Metabolic profile of human coelomic fluid.

AIM: Till now there is very limited knowledge on the molecular content of coelomic fluid and cells. This study presents the first attempt to elucidate the metabolic profile of such samples. METHODOLOGY: Samples were collected via coelocentesis from 41 women during the first trimester of gestation. Metabolic content was assessed using four different analytical platforms. For targeted analysis a hydrophilic interaction chromatography ultra high performance LC-MS/MS method was applied. Holistic analysis performed by GC-MS, NMR spectroscopy and ion cyclotron ultra-high resolution MS (FT-ICR-MS) instrumentation. RESULTS & CONCLUSIONS: Our observations suggest coelomic fluid and cells as promising biosamples, rich in metabolites with potential use in mammalian system biology studies.

Incidence of advanced intravenous access in 2 urban EDs.

BACKGROUND: In an emergency department (ED), intravenous (IV) access is frequently accomplished by inspection and palpation of peripheral veins. Failure of these methods indicates severe IV access difficulty and necessitates advanced techniques. Here, we estimate the incidence of advanced IV access in 2 urban EDs with varying resident coverage. METHODS: In this multiple-cohort study, we enrolled data from 2 neighboring urban EDs-a tertiary care ED and a community hospital affiliate. The 2 have similar volumes but the tertiary care ED has more resident coverage (112 vs 20 hours/d). In a prospective data collection (April 2012-2013), we enrolled consecutive patients during hours of scheduled shifts for research assistants. In a retrospective data collection (March 2011-2012), we reviewed charts of a random sample of patients from each ED for similar outcomes. We calculated the incidence of advanced IV access by dividing the number requiring advanced techniques by the number requiring IV access. RESULTS: We determined IV outcomes for 790 patients in the prospective cohort and 669 patients in the retrospective cohort. Between groups, there was no difference in the incidence of advanced IV access in the prospective collection (P = .08) or in the retrospective collection (P = .7). Pooling data from both cohorts and both hospitals, the overall incidence was 3.2 [95% confidence interval, 1.9-5.2] per 100 attempts. CONCLUSION: Advanced IV access is needed in 3.2% of IV attempts in 2 urban EDs with varying levels of resident coverage. We found similar incidence in both EDs.

Porosity and mechanically optimized PLGA based in situ hardening systems.

Goal of the present study was to develop and to characterize in situ-hardening, porous PLGA-based systems for their future application as bone grafting materials. Therefore, we investigated the precipitation behavior of formulations containing PLGA and a water-miscible solvent, DMSO, PEG 400, and NMP. To increase porosity, a pore forming agent (NaCMC) was added and to enhance mechanical properties of the system, an inorganic filler (α-TCP) was incorporated. The behavior upon contact with water and the influence of the prior addition of aqueous media on the morphology of the corresponding hardened implants were investigated. We proved cell-compatibility by live/dead assays for the hardened porous polymer/ceramic-composite scaffolds. The IsHS formulations can therefore be used to manufacture hardened scaffolds ex vivo by using molds with the desired shape and size. Cells were further successfully incorporated into the IsHS by precultivating the cells on the α-TCP-powder prior to their admixing to the formulation. However, cell viability could not be maintained due to toxicity of the tested solvents. But, the results demonstrate that in vivo cells should well penetrate, adhere, and proliferate in the hardened scaffolds. Consequently, we consider the in situ hardening system being an excellent candidate as a filling material for non-weight-bearing orthopedic indications, as the resulting properties of the hardened implant fulfill indication-specific needs like mechanical stability, elasticity, and porosity.

High-dose buprenorphine: perioperative precautions and management strategies.

Buprenorphine has been in clinical use in anaesthesia for several decades. Recently, the high-dose sublingual formulation (Subutex, Reckitt Benckiser, Slough, U.K.) has been increasingly used as maintenance therapy in opioid dependence, as an alternative to methadone and other pharmacological therapies. Buprenorphine has unique pharmacological properties making it well suited for use as a maintenance therapy in opioid dependence. However, these same properties may cause difficulty in the perioperative management of pain. Buprenorphine is a partial opioid agonist, attenuating the effects of supplemental illicit or therapeutic opioid agonists. As a result of its high receptor affinity, supplemental opioids do not readily displace buprenorphine from the opioid receptor in standard doses. High-dose buprenorphine has an extended duration of action that prolongs both of these effects. The perioperative management of patients stabilized on high-dose buprenorphine and undergoing surgery requires consideration of the likely analgesic requirements. Where possible the buprenorphine should be continued. Pain management should focus on maximizing non-opioid analgesia, local anaesthesia and non-pharmacological techniques. Where pain may not be adequately relieved by these methods, the addition of a full opioid agonist such as fentanyl or morphine at appropriate doses should be considered, accompanied by close monitoring in a high dependency unit. In situations where this regimen is unlikely to be effective, preoperative conversion to morphine or methadone may be an option. Where available, liaison with a hospital-based alcohol and drug service should always be considered.

Awake fibreoptic intubation under remifentanil and propofol target-controlled infusion.

We present the first report of the use of remifentanil and propofol target-controlled infusion to sedate a patient with a difficult airway undergoing awake fibreoptic intubation. This regimen was rapidly titratable, aided suppression of airway reflexes, maintained patient comfort and cooperation and did not compromise spontaneous respiration. The literature regarding infusion rates and potential complications of this technique is reviewed.

The ability of pulse oximetry to screen for hypoxemia and hypercapnia in patients breathing room air.

This study was designed to determine whether high room-air pulse oximetry can rule out hypoxemia or moderate hypercapnia. Based on retrospective analysis of 513 arterial blood gas results, oxygen saturation cutpoints were derived. Coincidentally, a room-air oxygen saturation (RAO2 sat) value of 96% was selected as a cutpoint to screen for both hypoxemia (PaO2 < 70 mm Hg) and moderate hypercapnia (PaCO2 > 50 mm Hg). These tests were validated prospectively by using a convenience sample of 213 Emergency Department patients in whom room-air arterial blood gas sampling was ordered. To detect hypoxemia, the sensitivity of RAO(2) sat < or = 96% was 1.0 [0.95-1.0, 95% confidence interval (CI)] and specificity was 0.54 (0.45-0.64, 95% CI). To detect hypercapnia, the sensitivity of RAO(2) sat < or = 96% was 1.0 (0.7-1.0) and specificity was 0.31 (0.25-0.38, 95% CI). We concluded that RAO(2) sat > or = 97% rules out hypoxemia and may also rule out moderate hypercapnia.

A comparison of emergency medicine ultrasound training with guidelines of the Society for Academic Emergency Medicine.

STUDY OBJECTIVES: To compare the current state of emergency medicine residency ultrasound training with guidelines for that training from the Society for Academic Emergency Medicine (SAEM). METHODS: A brief questionnaire was sent to program directors from 119 emergency medicine residency programs in the United States. Responses were compared with the SAEM guidelines for clinical experience (150 total ultrasounds) and didactic experience (40 hours of didactic instruction). RESULTS: The overall response rate was 92%. Seventy-six (69%) of the programs own an ultrasound machine (ownership defined as 24-hour availability and complete discretion over use). Of these, 12 (16%) indicated that their average 1998 graduate had done at least 150 total ultrasound scans during residency, although none of the programs had average numbers that exceeded the minimum guidelines for all 4 procedure categories. Information on didactic curriculum was available from 74 ultrasound-owning programs: the duration was 0 to 20 hours in 49 (66%), 20 to 40 hours in 19 (26%), and 40 to 100 hours in 6 (8%). Only 1 program's average graduate met or exceeded the SAEM guidelines for both didactic and clinical training. CONCLUSION: Most emergency medicine residency programs own at least 1 ultrasound machine, with more than half of these obtaining their first machine within the past 3 years. Only 1 program currently meets SAEM training guidelines.

Does exogenous melatonin improve day sleep or night alertness in emergency physicians working night shifts?

STUDY OBJECTIVE: To determine whether exogenous melatonin improves day sleep or night alertness in emergency physicians working night shifts. METHODS: In a double-blind, placebo-controlled crossover trial, emergency physicians were given 10 mg sublingual melatonin or placebo each morning during one string of nights and the other substance during another string of nights of equal duration. During day-sleep periods, subjective sleep data were recorded. During night shifts, alertness was assessed with the use of the Stanford Sleepiness Scale. Key outcome comparisons were visual analog scale scores for gestalt night alertness and for gestalt day sleep for the entire string of nights. RESULTS: We analyzed data from 18 subjects. Melatonin improved gestalt day sleep (P = .3) and gestalt night alertness (P = .03) but in neither case was the improvement statistically significant. Of 13 secondary comparisons, 9 showed a benefit of melatonin over placebo; none showed a benefit of placebo over melatonin. CONCLUSION: Exogenous melatonin may be of modest benefit to emergency physicians working night shifts.

Laboratory testing in ethanol, methanol, ethylene glycol, and isopropanol toxicities.

Toxicity from ethanol, methanol, ethylene glycol, and isopropyl alcohol varies widely, and appropriate use of the available laboratory tests can aid in timely and specific treatment. Available testing includes direct measurements of serum levels of these alcohols; however, these levels often are not available rapidly enough for clinical decision making. This article discusses the indications and methods for both direct and indirect testing for ethanol, methanol, ethylene glycol, and isopropanol toxicity. Also discussed are the costs, availability, and turn-around times for these tests.

Orthostatic change in shock index: comparison with traditional tilt test definitions.

OBJECTIVE: To determine whether the orthostatic change in the shock index or published tilt test criteria better discriminated normal individuals from those with moderate acute blood loss. METHODS: Postural vital signs were recorded in a standardized manner before and after an elective 450-mL phlebotomy associated with blood donation in healthy volunteers. Paired comparisons of the sensitivity of each of 3 published tilt test criteria were made against the sensitivity of an orthostatic change in shock index (OCSI) at the threshold for OCSI yielding the same specificity. Subjects were prospectively divided into group 1 (age < 65 years) and group 2 (age > or = 65 years). RESULTS: A total of 336 healthy euvolemic adult blood donors were studied over a 1-year period (group 1 = 292; group 2 = 44). For each published criterion for a positive tilt test (for both groups), OCSI had the same or higher sensitivity for a chosen specificity. No sensitivity difference was statistically significant. An OCSI > or = 0 was 99%/98% sensitive and 10%/10% specific (group 1/group 2) for a 450-mL blood loss; whereas an OCSI > or = 0.25 was 28%/23% sensitive and 92%/100% specific (group 1/group 2). CONCLUSION: The OCSI discriminates normal individuals from those with acute moderate blood loss as well as previously published tilt test definitions do.

Renal papillary necrosis following emergency department treatment of migraine.

New medications have lessened the need for narcotic medications in the acute treatment of migraine. Some of these new medications include parenteral dihydroergotamine (DHE), sumatriptan, and ketorolac. Treatment failures still occur, though, and some cases necessitate adding a second agent to one that has been ineffective. We report a case of a 46-year-old man who suffered renal papillary necrosis 12 days after receiving parenteral DHE, sumatriptan, and ketorolac for treatment of a severe migraine headache. There were no signs of an adverse drug reaction at the time of his emergency department visit. The case illustrates a potential hazard of this combination in the acute treatment of migraine.

Thrombotic thrombocytopenic purpura presenting as a sudden headache with focal neurologic findings.

We report a case of thrombotic thrombocytopenic purpura presenting as a sudden headache with associated neurologic deficits. The diagnosis of this rare disorder is discussed, with special attention given to a potential pitfall in evaluation and treatment--platelet transfusion.

Defining the positive tilt test: a study of healthy adults with moderate acute blood loss.

STUDY OBJECTIVES: To define a set of orthostatic vital signs that minimize the frequency of false-positives among healthy individuals while maximizing sensitivity in detecting acute moderate blood loss and to determine the sensitivity and specificity of this optimized tilt test in detecting acute moderate blood loss. DESIGN AND INTERVENTION: Postural vital signs were recorded in a standardized manner before and after 450-mL phlebotomy. Paired comparisons were done for a variety of criteria for a positive tilt test using receiver-operating characteristic curves. SETTING AND TYPE OF PARTICIPANTS: Three hundred forty-five healthy euvolemic adult volunteer blood donors were tested at three community blood donation centers over a one-year period. Subjects were prospectively divided into group 1 (less than age 65; 301) and group 2 (age 65 or older; 44). MEASUREMENTS AND MAIN RESULTS: For each combination of pulse and blood pressure in group 1, a change in pulse alone had the same or higher sensitivity with at least the same specificity. Pulse alone was similarly superior in group 2 compared with previously published combinations of pulse and blood pressure. Even the optimized tilt test had limited sensitivity in detecting acute moderate blood loss with high specificity. CONCLUSION: In applying the tilt test to young adults without cardiovascular disease, pulse measurement usually is all that is necessary.

Intrathecal diamorphine (heroin) for obstetric analgesia.

Intrathecal diamorphine (heroin, diacetyl morphine) 2.5 mg in isotonic saline 2.5 ml was given to 13 patients in labour through a 26 gauge Quincke needle. Three patients were given epidural bupivacaine at a mean of 295 min after injection of diamorphine and a further 2 used 50% nitrous oxide during the second stage of labour. Eight patients needed no additional analgesia for labour although 1 received a pudendal nerve block for forceps delivery. No neonatal complications attributable to diamorphine were observed. There was a high incidence of post partum headache (6/13 cases). The use of a Sprotte needle and a fine spinal catheter might overcome the limitations of spinal headache and limited duration of action respectively.

Acute carbon monoxide exposure and cerebral blood flow in rabbits.

Carbon monoxide (CO) 1% was administered to anaesthetised rabbits for 15 minutes. Despite a 28% +/- 5.8 (SEM) fall in mean arterial blood pressure during the CO exposure, cerebral blood flow increased by 236% +/- 36.5 in the left and 287% +/- 28.9 in the right cortex. Cerebrovascular resistance was reduced by 70.6% +/- 2.8 in the left and by 76.2% +/- 3 in the right cortex. These changes were accompanied by an increase in intracranial pressure, a drop in body temperature and ventilation requirement, and a metabolic acidosis. When the CO was withdrawn all these parameters returned to normal over three hours. Hence, these vascular effects are reversible and consistent with the natural history of CO intoxication in humans. Carboxyhaemoglobin levels correlated well with hemispheric cerebral blood flow (r = 0.90; r = 0.98) and cerebrovascular resistance (r = 0.87; r = 0.97).

Lumbar epidural diamorphine following thoracic surgery. A comparison of infusion and bolus administration.

Twenty-two patients received a single dose of diamorphine 5 mg through a lumbar epidural catheter before thoracic surgery. The patients were transferred after surgery to a high dependency unit where they were allocated randomly to receive either an infusion of epidural diamorphine at a rate of 1 mg/hour (group 1) or bolus doses of epidural diamorphine 5 mg on demand (group 2). There was no statistically significant difference between the groups in visual analogue pain scores in the first 18 postoperative hours. Arterial carbon dioxide tension was elevated in both groups and was consistently higher in group 1 than in group 2, with a statistically significant intergroup difference 12 hours after operation. Respiratory rate was not a useful index of respiratory depression. The commonest nonrespiratory side effect was urinary retention, but the incidences of this and other minor side effects were similar in the two groups.

The stability of atracurium in clinical practice.

Atracurium has an unusual intrinsic Hofmann elimination which is increased by an alkaline environment and increased temperature. Normally the relaxant is stored at pH 3.3 and kept at a temperature of 4 degrees C. However, it is convenient to have a reasonable quantity available within the operating theatre. This study examined the rate of degradation of atracurium in the operating theatre environment of 20 degrees C. Atracurium within one month of its expiry date was placed in the drawer for anaesthetic drugs in each of three operating theatres. At the end of each month, further drug was added to the stock. At the end of the study, atracurium which had been stored continuously at 4 degrees C, was at 102.9% of nominal strength, having started with 113.5% at manufacture. Atracurium which had been at room temperature for one, two and three months respectively retained 99%, 95% and 92% strength respectively. These results show that even three months' exposure to room temperature does not cause enough deterioration to be clinically significant.