[Guided discontinuation of antidepressants: approach and first results of a Dutch multidisciplinary outpatient clinic]. / Werkwijze en eerste resultaten van multidisciplinaire afbouwpoli anti-depressiva.

BACKGROUND: Discontinuation of antidepressant medication can be difficult due to withdrawal symptoms and relapse risk. Scientific evidence on the questions of who, when, and how to stop antidepressants is limited. In Amsterdam a multidisciplinary outpatient clinic was started to provide advice and guidance. AIM: To substantiate the design of the clinic. Central questions relate to knowing which patients are referred, the background of their request, and their experiences with the outpatient clinic. METHOD: The first 51 patients of the clinic were described on the basis of file research, in addition a survey was conducted into patient experiences. RESULTS: Half of the patients (55%) actually started discontinuation, 39% were advised not to do so (yet). Patients at the clinic had used antidepressants for an average of 10 years, and 76% had previously attempted to stop. 21% had now successfully stopped and 25% were satisfied with a lower dose. One patient relapsed during tapering. CONCLUSION: So far, patients with long-term antidepressant use and multiple quit attempts have been referred. Our experiences are aimed at helping individual patients but can also result in more knowledge about who can stop at what moment, and how this should be done.

High dose propofol enhances red cell antioxidant capacity during CPB in humans.

PURPOSE: To compare low vs. high dose propofol and isoflurane on red cell RBC antioxidant capacity in patients during aortocoronary bypass surgery (ACBP). METHODS: Twenty-one patients, for ACBP, were anesthetized with sufentanil 0.5-10 microg x kg(-1) and isoflurane 0-2%; ISO = control; n = 7), or sufentanil 0.3 microg x kg(-1), propofol 1-2.5 mg x kg(-1) bolus then 100 microg x kg(-1) min(-1) before, and 50 microg x kg(-1) x min(-1) during CPB (LO; n = 7), or sufentanil 0.3 microg x kg(-1), propofol 2-2.5 mg x kg(-1) bolus then 200 microg x kg(-1) x min(-1) (HI; n = 7). Venous blood was drawn pre- and post-induction, after 30 min CPB, 5, 10, and 30 min of reperfusion, and 120 min post-CPB to measure red cell antioxidant capacity (malondialdehyde (MDA) production in response to oxidative challenge with t-butyl hydrogen peroxide) and plasma propofol concentration. Pre- induction blood samples were analyzed for antioxidant effects of nitrates on red cells. The tBHP concentration response curves for RBC MDA in ISO, LO and HI were determined. RESULTS: Preoperative nitrate therapy did not effect RBC MDA production. Perioperative RBC MDA production was similar in ISO and LO groups. Sustained intraoperative decrease in RBC MDA was seen with propofol 8.0+/-2.4 - 11.8+/-4.5 microg x ml(-1) in HI (P<0.05-0.0001). MDA production vs. log plasma propofol concentration was linear in HI dose. CONCLUSIONS: During CPB, RBC antioxidant capacity is enhanced and maintained with HI dose propofol. Propofol, at this dose, may prove useful in protecting against cardiopulmonary ischemia-reperfusion injury associated with ACBP.

Cost-effectiveness of prophylactic dolasetron or droperidol vs rescue therapy in the prevention of PONV in ambulatory gynecologic surgery.

PURPOSE: To assess the cost-effectiveness of prophylactic therapy (1.25 mg droperidol or 50 mg dolasetron i.v.) vs no prophylaxis (rescue therapy) for the prevention of post-operative nausea and vomiting (PONV) from a Canadian hospital perspective. DESIGN: A predictive decision analytic model using previously published clinical and economic evaluations, and costs of medical care in Canada. SUBJECTS: Ambulatory gynecology surgery patients. INTERVENTIONS: Three strategies administered prior to emergence from anesthesia were compared: 1.25 mg droperidol i.v., 50 mg dolasetron i.v.; and no prophylaxis (rescue therapy). RESULTS: The base case mean cost per patient receiving dolasetron prophylaxis was $28.08 CAN compared with $26.88 CAN per patient receiving droperidol prophylaxis, resulting in a marginal cost of $1.20 CAN. This difference translated in an additional cost of $12.00 CAN for the dolasetron strategy per adverse event avoided over the droperidol strategy. The base case mean cost per patient not receiving prophylaxis was $26.92 resulting in marginal costs of $1.16 CAN and $0.04 CAN when compared to dolasetron and droperidol, respectively. Compared with the no prophylaxis strategy, dolasetron prophylaxis resulted in an incremental cost-effectiveness ratio of $5.82 CAN per additional PONV-free patient. The mean costs incurred per PONV-free patient were calculated to be $48.41 for the dolasetron strategy, $46.34 for the droperidol strategy and $70.83 for the no prophylaxis strategy. CONCLUSIONS: Dolasetron and droperidol given intraoperatively were more cost-effective than no prophylaxis for PONV in patients undergoing ambulatory gynecologic surgery. The difference between the two agents was small and favoured droperidol. The model was robust to plausible changes through sensitivity analyses.

Amrinone versus dobutamine in cardiac surgical patients with severe pulmonary hypertension after cardiopulmonary bypass: a prospective, randomized double-blinded trial.

We compared the relative effects of dobutamine (5 micrograms/kg/min) and amrinone (1.0 mg/kg bolus followed by 10 micrograms/kg/min) on right and left ventricular function and pulmonary arterial pressures during weaning from cardiopulmonary bypass in patients with a mean preoperative pulmonary pressure > 30 mmHg. Twenty patients scheduled for mitral valve replacement were studied in a prospective, randomized, double-blind trial. Patients receiving amrinone had a greater increase in cardiac index (CI) of 1.38 (+/-0.95) litre/min/m2 at separation vs 0.69 (+/-0.63) litre/min/m2 in the dobutamine group (P < 0.05). The amrinone group also had a greater increase in right ventricular ejection fraction (0.15 +/- 0.08 at separation from cardiopulmonary bypass versus an increase of 0.04 +/- 0.11 in those receiving dobutamine; P < 0.005). Amrinone produced a larger decrease in pulmonary artery wedge pressure 8.0 (+/-4.4) mmHg vs 0.75 (+/-6.6) mmHg at separation; pulmonary artery systolic and diastolic pressures also were reduced more in the amrinone group. There were no differences in heart rate, mean arterial pressure, central venous pressure and right ventricular stroke work index between patient groups. In the doses chosen, the use of amrinone compared to dobutamine was associated with a reduction in pulmonary arterial pressures and an increase in cardiac index and right ventricular ejection fraction after separation from bypass in patients with severe preoperative pulmonary hypertension.

On line ST-segment analysis for detection of myocardial ischaemia during and after coronary revascularization.

PURPOSE: A paucity of information exists to validate the accuracy and reliability of ECG monitoring in the operating room or ICU. The purpose of this study was to determine the accuracy, sensitivity, specificity, and predictive values of the Marquette ECG monitor for detection of perioperative myocardial ischaemia (PMI) as measured by ST segment changes in a high risk population. METHODS: Monitoring for PMI in 28 patients scheduled for aortocoronary bypass surgery was done with the Cardiodata PR ambulatory continuous electrocardiography (ACECG) monitor lead V5, and compared with lead V5 of the Marquette Series 7000 ECG/Surgical operating room monitor, and ECG/Resp ICU monitor. The Marquette lead V5 was evaluated using current criteria for the assessment of diagnostic tests including concordance, sensitivity, specificity, positive and negative predictive values, false positive and false negative rates and compared with the ACECG monitor which served as the reference or "gold standard." Agreement beyond chance between the two methods was assessed using the Kappa statistic. RESULTS: Of the 53 observation data points, 27 were defined as ischaemic episodes by ACECG. Concordance between lead V5 in each system was 83% (44/53 episodes). Discordance was 17% (9/53 episodes), predominantly in the postbypass interval (77%, 7/9; P = 0.0184). The incidences of false negatives and false positives for Marquette lead V5 was 26% (7/27) and 7.7% (2/26), respectively. The sensitivity and specificity of the Marquette was 0.74 and 0.92. Positive predictive value was 0.91, negative predictive value was 0.77, and Kappa statistic was 66%. CONCLUSION: Automated ST segment analysis with the Marquette Series 7000 monitoring system demonstrates good diagnostic accuracy, moderate sensitivity, and high specificity. However, clinically significant false negative and false positive rates of ischaemia detection are associated with its use, especially in the postoperative period.

A survey of health agencies' responses to non-English-speaking women's health needs in south Australia.

Evidence from the literature points to the disadvantages encountered by migrant women from non-English-speaking backgrounds in obtaining access to health services. In May 1994, a survey of 31 health units in the metropolitan area and two country areas was conducted in South Australia. The study investigated the services available to women of non-English-speaking background, their level of usage, the factors that affected the use of health services by the women, and the strategies developed by the service providers to overcome the barriers. The study found sexual and reproductive health to be the most important, and occupational health and safety the least important issue for women of non-English-speaking background attending the state's health units. The main problems were English language deficiencies, lack of culturally appropriate services and inadequate knowledge and awareness of the existing services. From the service providers' point of view, language (79 per cent), culture (87 per cent), and information or awareness about health units (78 per cent) were the most important factors affecting the use of health services by women of non-English-speaking background. Women of non-English-speaking background have different linguistic and cultural needs from English-speaking women, and as a result, require specifically designed services.

Patient-controlled lumbar epidural fentanyl compared with patient-controlled intravenous fentanyl for post-thoracotomy pain.

Thirty-four patients undergoing thoracotomy were entered into a randomized, double-blind, placebo-controlled study to compare the effects of patient-controlled, lumbar epidural (PCA-E) fentanyl with patient-controlled intravenous (PCA-i.v.) fentanyl with respect to drug requirements, analgesic efficacy and respiratory function. Prior to chest closure patients received fentanyl 2 micrograms.kg-1 by the epidural or i.v. route. In the recovery room further doses of epidural or i.v. fentanyl, 50 micrograms, were administered by the patients who controlled two PCA pumps. Background fentanyl infusion rates were increased by 10 micrograms.hr-1 each time the patient administered a drug bolus and were decreased by 10 micrograms.hr-1 whenever visual analogue scale (VAS) pain scores were less than 2 on a maximum 10 scale. Twenty-nine patients completed the study. Patients in the PCA-E group (n = 14) required less total fentanyl than those in the PCA-i.v. (n = 15) group (1857 +/- 693 micrograms vs 2573 +/- 890 micrograms respectively, P less than 0.05). Fentanyl infusion rates were lower in the PCA-E group at most measurement times. There were no differences between groups in respiratory rates, PaCO2, VAS pain scores or changes in pulmonary function as measured by FVC and FEV1. It is concluded that satisfactory patient-controlled analgesia can be achieved with both epidural and i.v. fentanyl after thoracotomy but that fentanyl requirements are less when given via the epidural route. This supports a direct spinal cord site of action for lumbar epidural fentanyl.

The influence of temperature on the behaviour of mixed bacterial contamination of the shell membrane of the hen's egg.

The inner membrane of the air cell of hens' eggs was inoculated with Pseudomonas putida, Staphylococcus xylosus, Enterococcus faecalis, Escherichia coli and Salmonella enteritidis. The first mentioned eventually dominated the contamination of the albumen of eggs stored at 4, 15, and 20 degrees C. The last mentioned did so in eggs stored at 37 degrees C. The interval between inoculation of the membrane and gross contamination of the albumen was markedly influenced by site of contamination relative to yolk movement.

Activity of some antiseptics against urinary tract pathogens growing as biofilms on silicone surfaces.

The activity of chlorhexidine, mandelic acid and a mandelic/lactic mixture were tested against biofilms of four species of gram-negative nosocomial organisms that commonly infect the catheterized urinary tract. Cells growing on silicone discs were exposed to concentrations of agents used in bladder instillation. Citrobacter diversus biofilms proved to be sensitive to all three agents. Pseudomonas aeruginosa, Proteus mirabilis and Klebsiella pneumoniae all survived well in chlorhexidine but their viability was significantly reduced by the mandelic acid formulations. These results suggest that bladder instillations of mandelic acid or mandelic/lactic acids would be more effective than chlorhexidine in eliminating biofilms from catheter surfaces.

Activity of antiseptics against Escherichia coli growing as biofilms on silicone surfaces.

The activity of chlorhexidine, acetic, lactic and mandelic acids were examined against biofilms of Escherichia coli established on silicone discs and against the test strain growing in suspension in urine. The results showed that the concentrations of chlorhexidine and acetic acid normally used for bladder instillations to control infections in patients with indwelling catheters failed to eliminate cells from the biofilm in exposure periods of up to 2 h. Lactic acid (1% v/v) had a bactericidal effect on planktonic cells but poor activity against cells in the biofilm. Mandelic acid (1% v/v), and mandelic (1% v/v) and lactic acid (1% v/v) mixtures eliminated organisms from both suspensions and biofilms. It is suggested that these solutions be considered as alternatives to acetic acid and chlorhexidine for the washing of catheterized bladders.

Comparative hemodynamic effects of propofol and thiamylal sodium during anesthetic induction for myocardial revascularization.

The safety and efficacy of propofol, a new intravenous anesthetic agent, have been demonstrated in healthy patients. Twenty-one patients, ASA III-IV, undergoing elective myocardial revascularization, were randomly chosen to receive either propofol, 2.5 mg/kg, or thiamylal, 4 mg/kg. for the induction of anesthesia. Hemodynamics were recorded at one and three minutes after drug administration during spontaneous respiration. After the addition of halothane and pancuronium with controlled ventilation, measurements were made immediately prior to and one minute after intubation. Five patients were dropped from the study, four due to airway problems and one due to severe hypotension following an induction dose of propofol. Statistics were done using data from the remaining 16 patients, eight in each group. Administration of propofol resulted in significant decreases in mean arterial pressure (MAP), systemic vascular resistance (SVR), and left ventricular stroke work index (LVSWI); as well as an increase in heart rate (HR). These changes were further accentuated by the addition of halothane and pancuronium prior to intubation. Patients in the thiamylal group experienced no significant hemodynamic changes until halothane and pancuronium were added and controlled ventilation was instituted. With these additions, the thiamylal group showed significant decreases in MAP and LVSWI immediately prior to intubation. Both groups experienced significant increases in HR following intubation, but no evidence of myocardial ischemia was seen in either group. All other parameters returned toward control values. Propofol appeared to be safe and effective for the induction of anesthesia in this group of patients, although its hemodynamic effects were greater than those of thiamylal.

The effect of temperature, mean arterial pressure, and cardiopulmonary bypass flows on somatosensory evoked potential latency in man.

Median nerve somatosensory evoked potentials were recorded in 21 patients undergoing cardiac surgical procedures utilizing cardiopulmonary bypass, in order to establish the effects of hypothermia, reductions in mean arterial pressure, and alterations in cardiopulmonary bypass flows on evoked potential latency. Induction and maintenance of anesthesia with fentanyl caused a significant prolongation of latency of the first cortical peak. Temperature changes were linearly correlated with changes in latency for peaks recorded from Erb's point (r = -0.843, p less than 0.01) and the contralateral cortex (r = 0.843, p less than 0.01). There was no significant effect of mean arterial pressure or cardiopulmonary bypass flow reductions on latencies under the conditions of this study. Our results emphasize the importance of monitoring peripheral and first cortical peak latencies in evaluating somatosensory evoked potentials. It is suggested that peak latency prolongations beyond those predicted by temperature alterations may be indicative of hypoperfusion.

Myocardial ischaemic/reperfusion injury in the anaesthetized rabbit: comparative effects of halothane and isoflurane.

The effects of halothane and isoflurane anaesthesia on myocardial injury in rabbits subjected to coronary artery ligation and subsequent reperfusion were analyzed. Although halothane and isoflurane (at inspired concentrations of 1.0 and 1.5 per cent, respectively) exerted comparable effects on cardiovascular status during ischaemic and reperfusion phases, greater preservation of subcellular integrity (as assessed by mitochondrial and sarcoplasmic reticular ATPase activities and myocardial ionic alterations) and a lower incidence of ventricular fibrillation and severe hypotension occurred with halothane. Our results indicate that in studies of experimental myocardial ischaemia anaesthetics may, independently of cardiovascular actions, influence the nature and extent of resulting injury, possibly by virtue of their differing effects on subcellular membrane systems.