Effects of a 48-h fast on heart rate variability and cortisol levels in healthy female subjects.

BACKGROUND/OBJECTIVES: The physiological changes that occur during fasting are not completely understood, regardless of the cause for fasting (for example, medical, lifestyle, religious, political or famine). The purpose of this study was to examine the effects of a 48-h fast on heart rate variability (HRV) and cortisol levels in healthy young female volunteers. SUBJECTS/METHODS: A total of 16 young healthy female volunteers underwent 48 h of total fasting under 24-h medical surveillance. Psychological (subjective feeling of hunger) as well as physiological data (HRV, diurnal cortisol profiles) were measured upon admission (Day 1), and after 24 (Day 2) and 48 h (Day 3) of fasting. RESULTS: There was a measured weight loss from Day 1 to Day 3 that resulted in significant body mass index (BMI) reduction across all subjects (P<0.001). The slope of the diurnal cortisol profile significantly shifted towards lower values from baseline to the end of experiment (P=0.002). HRV during resting showed a significant (P<.001) decrease in standard deviation of the normal-to-normal interval (SDNN) and root mean square of successive differences (RMSSDs) from Day 1 to Day 3 of the experiment, with a small increase after 24 h that did not reach statistical significance. A 48 h of fasting also induced a significant (P<.001) decrease of mean interbeat intervals (IBIs), SDNN, RMSSD and log high-frequency (HF) power during head-up tilt testing. CONCLUSIONS: An acute (48 h) total fast induced parasympathetic withdrawal with simultaneous sympathetic activation. These changes appear to reflect stress. Further studies are needed to demonstrate the specificity of these changes to fasting.

[Anesthesia for carotid paraganglioma exeresis. Report of 3 cases]. / Implicaciones anestesiológicas de la exéresis de paragangliomas carotídeos. A propósito de tres casos clínicos.

This report of carotid paraganglioma excision in three patients discusses differential diagnosis, preoperative assessment, preoperative embolization of the tumor, monitoring of anesthesia including cerebral oximetry, and postoperative complications. We consider cerebral protection to be essential during carotid paraganglioma surgery. Such protection may be provided by drugs such as sodium thiopental and by temporarily shunting the internal carotid artery. Preoperative angiography is also important for evaluating retrograde circulation through Willis's polygon and to examine the arteries irrigating the tumor. Information thus obtained helps establish the need for presurgical embolization of the tumor, thereby possibly reducing the risks, such as obstructive hematoma that are inherent to the procedure. Finally, in our opinion, full monitoring should include cerebral oximetry so that possible complications can be detected and resolved.

Implicaciones anestesiológicas de la exéresis de paragangliomas carotídeos. A propósito de tres casos clínicos / Anesthesia for carotid paraganglioma exeresis. A report of three cases

Presentamos 3 casos clínicos de paragangliomas carotídeos que fueron extirpados quirúrgicamente, en los que se analiza el diagnostico diferencial, el estudio preoperatorio, la embolización preoperatoria del tumor, la monitorización anestésica, incluyendo la oximetría cerebral, la estrategia anestesiológica y las posibles complicaciones postoperatorias.Consideramos que durante la exéresis del paraganglioma carotídeo es necesario garantizar la protección cerebral intraoperatoria, que puede proporcionarse, sobre todo, mediante fármacos como el tiopental sódico y mediante un cortocircuito transitorio de la arteria carótida interna. La angiografía preoperatoria es importante para evaluar la circulación retrograda, a través del polígono de Willis, así como la irrigación del tumor; esto último puede servir para indicar la realización de una embolización preoperatoria del tumor, que parece reducir los riesgos inherentes a este tipo de cirugía, como el hematoma transfixiante; por último, en nuestra opinión, la monitorización peroperatoria de estos paciente debe ser muy completa, incluyendo también la oximetría cerebral, con la finalidad de prevenir y resolver los posibles problemas que puedan presentarse (AU)

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Eficacia analgésica de alfentanilo administrado por vía epidural lumbar vs torácica / Analgesic efficacy of alfentanyl administered by lumbar epidural versus thoracic route

Objetivos: El objetivo ha sido evaluar la eficacia de tres pautas de analgesia en el dolor postoracotomía. Material y métodos: Estudio a doble ciego y aleatorizado de 45 pacientes ASA I-IV separados en tres grupos (n=15) sometidos a toracotomía (lobectomías o neumonectomías). Previamente se insertó un catéter epidural torácico en T5-7 (grupo T) o lumbar en L2-3 (grupo L y C). Se administró inicialmente un bolo de alfentanilo (L y T) o ClNa 0,9 por ciento (C), prosiguiéndose con una infusión epidural de 400 µg . h- 1 de alfentanilo más 50 mg.h- 1 de lidocaína (T), 400 µg . h- 1 de alfentanilo (L) o ClNa 0,9 por ciento (C) durante la cirugía y postoperatorio, complementados con una PCA endovenosa. Se registraron las siguientes variables: escala analógica visual del dolor (EVA ) , requerimientos de analgésicos, parámetros hemodinámicos, gasometrías arteriales, incidencia de atelectasias y efectos secundarios. El análisis estadístico consistió en los tests de ANOVA, Scheffé y Chi cuadrado (p 0,05). Resultados : En el grupo T el alivio del dolor fue mejor y los requerimientos de analgesia de rescate fueron menores con respecto a los otros grupos, y también en el grupo L con respecto al C. La PaO2 fue significativamente mayor en el grupo T con respecto a los otros grupos (6 y 18 horas) ( p 0,05). La incidencia de atelectasia fue mayor en el grupo C que en el T. La presión arterial y frecuencia cardiaca fueron más elevadas en el grupo C. Conclusiones: La analgesia epidural torácica mendiante alfentanilo y lidocaína fue mejor que las otras dos pautas analgésicas (AU)

Acid resistance of enterohaemorrhagic and generic Escherichia coli associated with foodborne disease and meat.

As part of the Australia New Zealand Food Authorities (ANZFA) food standards code, salami manufacturers are required to demonstrate that their process is capable of achieving a 3-log reduction in Escherichia coli. Non-pathogenic E. coli strains with similar or greater acid resistance to enterohaemorrhagic E. coli (EHEC) are needed if industry is to conduct challenge studies to demonstrate compliance with the standard. In the present study, E. coli isolates from sheep and beef carcasses and meat were shown to have wide-ranging acid resistance in broth when preadapted to growth in acidic conditions. Times required for a 3-log reduction in E. coli ranged from less than I day to more than 28 days. Variable acid resistance was observed in both EHEC strains associated with foodborne outbreaks and generic E. coli strains. Generic E. coli strains with the greatest acid resistance were assessed for pathogenicity markers and their survival in fermented meat compared with EHEC strains. It was demonstrated that generic E. coli strains could be used for challenge studies to determine compliance with or validate performance standards designed for the control of EHEC.

[Outpatient care of upper gastrointestinal hemorrhage not related to portal hypertension]. / Seguridad del control ambulatorio de la hemorragia digestiva alta no relacionada con hipertensión portal.

BACKGROUND: The handling of upper gastrointestinal hemorrhage (UGH) usually includes the hospitalization of all patients, regardless of severity and prognosis. The aim of this paper is to assess the security of the outpatient control of some UGH, after their assessment in the hospital emergency room. PATIENTS AND METHODS: Prospective cohort of 533 patients who attended over 1994 and 1995 hospital emergency room for an episode of UGH not linked to portal hypertension. After clinical and endoscopical assessment in the emergency department, 422 cases (79%) were admitted and 111 (21%) discharged for outpatient care. An analysis is presented of the characteristics of both groups, their clinical outcomes and a multivariate analysis to assess the factors associated with the decision to admit the patient. RESULTS: Outpatients were young, with less comorbidity and better haemodynamic status than hospitalized patients. Most of outpatient cases UGH was due to gastroduodenitis, oesophagitis and Mallory-Weiss syndrome, as opposed to the greater importance of peptic ulcer in those admitted. All outpatients presented clean lesions or haematic remains. 25 (5.9%) hospitalized patients presented rebleeding, vs. only 1 (0.9%) outpatient (p < 0.05). When more severity cases were excluded from hospital group, the differences were not significant. All cases with active bleeding, severe haemodynamic repercussion or without endoscopy were admitted. For the remainder, the decision to admit was associated with the presence of bleeding stigmata, haemodynamic repercussion, some causes of hemorrhage, older age, and urea levels. CONCLUSIONS: Although the scarce sample do not permit definitive conclusions, results guide towards that a substantial part of UGH not linked to portal hypertension may be monitored without hospitalizing the patient, thereby minimizing care costs and increasing the productive capacity of the hospital, without increasing risks for the patient.

Prophylactic percutaneous sealing of lumbar postdural puncture hole with fibrin glue to prevent cerebrospinal fluid leakage in swine.

UNLABELLED: We explored the effect of fibrin glue injection at the site of dural puncture on cerebrospinal fluid (CSF) leakage in a swine model. Pigs were subjected to a lumbar dural CSF puncture in the sitting position with a 17-gauge Tuohy needle. Fibrin glue 1.4 mL was injected through the same needle into the epidural space. Evans blue dye was infused through the cisterna magna 15 min later, and the appearance of dyed CSF through the skin puncture and along the needle trajectory to the dura was inspected and categorized. In seven of eight animals, the CSF leak was sealed with fibrin glue. Control animals were injected with 1.4 mL saline. A sham operation group of animals underwent cisternal dye infusion without a lumbar puncture. CSF pressure at the cisterna magna was recorded throughout the procedure. No significant differences in the leakage indicators were found between the fibrin glue-injected and sham-operated group, whereas both groups showed significant differences with respect to the control group. The fibrin glue seal was effective against CSF pressures of 24.5 [17-31] cm H(2)O. We conclude that percutaneously injected fibrin glue is effective in stopping CSF leaks after dural puncture in this animal model. IMPLICATIONS: In this swine study, we repaired a cerebrospinal fluid leak after a dural puncture by percutaneously injecting tissue adhesive. The technique of percutaneous injection of fibrin glue seems promising for the prophylaxis of headache associated with cerebrospinal fluid leakage, and may be an alternative to an epidural blood patch.

Epidural and subarachnoidal pneumocephalus after epidural technique.

Iatrogenic pneumocephalus is an uncommon complication observed after using the 'loss-of-resistance' technique with an air filled syringe. We report and review two cases of pneumocephalus: one subarachnoid and the other epidural.

Usefulness of alanine and aspartate aminotransferases in the diagnosis of microlithiasis in idiopathic acute pancreatitis.

CONCLUSION: Serum increases of aminotransferases, especially alanine aminotransferase (ALT), were suggestive of microlithiasis in idiopathic acute pancreatitis, particularly when assessed early after the onset of abdominal pain. BACKGROUND: It has been shown that biochemical laboratory values only are useful parameters in distinguishing gallstone from nongallstone acute pancreatitis. We assessed the diagnostic usefulness of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) for identification of occult microlithiasis in idiopathic acute pancreatitis. METHODS: Ninety-one patients with idiopathic acute pancreatitis who underwent microscopic examination of stimulated duodenal bile sediments were retrospectively studied. According to earliness of ALT and AST assay after the onset of abdominal pain, patients were divided into two groups: group A, within the first 24 h (n = 56) and group B, between 24 and 72 h (n = 35). RESULTS: ALT and AST values expressed as number of elevations of the upper limits of normal were higher in group A patients with positive biliary drainage than in group B. Median (range) ALT and AST values were 2.5 (0.1-18.1) vs 0.4 (0.1-8.6) and 3 (0.3-17.4) vs 0.5 (0.3-11.9), respectively. In the univariate analysis and receiver operating characteristic (ROC) curves, ALT within the first 24 h showed a sensitivity of 73%, specificity of 86%, and positive predictive value of 92% for a cutoff of 1.2 elevations of the upper limit of normal. These values were slightly higher, although without statistically significant differences, than those of AST (73, 80, and 89%, respectively).

The effect of fibrin glue patch in an in vitro model of postdural puncture leakage.

UNLABELLED: We studied the possibility of stopping a continuing transdural leakage with fibrin glue, a biologic adhesive, in an in vitro model. The model was made by sealing the bottom of a tube filled with saline to a height of 50 cm with a human lyophilized dural specimen. Dural punctures were performed with a 17-gauge Tuohy needle. The needle was then withdrawn, and 0.8 mL of fibrin glue was injected through the same needle to seal the defect. The column was refilled 3 min after sealing. The pressure in the intrathecal chamber was measured during the procedure. Macroscopic and microscopic histological studies of the dura and the fibrin plug were performed. In the five cases studied, the leak was sealed by the fibrin plug at closing pressures of 25-35 cm H2O, and no further leakage was detected after refilling. The dural specimens showed a fibrin glue plug stuck at the edges of the hole. We conclude that fibrin glue stops leakage of fluid from dural holes created by a 17-gauge Tuohy needle in an in vitro pressurized model. IMPLICATIONS: We explored the possibility of repairing a cerebrospinal fluid leak produced by an accidental dural puncture during epidural anesthesia by percutaneously injecting tissue adhesive in vitro. This technique seems promising for the prophylaxis and treatment of the headache associated with this leakage but requires further study in vivo.

[Our experience with the Univent tube]. / Nuestra experiencia con el tubo Univent.

INTRODUCTION: We describe our experience in managing single lung ventilation (SLP) with the Univent bronchial blocker tube from 1993 to the present. PATIENTS AND METHOD: Patients were grouped based on the following criteria: use of a double lumen tube as an alternative to SLP (group 1), use of SLP and tracheotomy (group 2), or difficult or dangerous orotracheal intubation (group 3). RESULTS: The mean age of the 32 patients (22 men and 10 women) studied was 45.7 +/- 12.2 years. Mean weight was 67.9 +/- 13.4 kg. Ten patients were physical status ASA I, 10 were ASA II, 10 were ASA III and 2 were ASA IV. Group 1 contained 28 patients (18 receiving right SLP and 10 receiving left SLP; use of SLP failed to collapse the lung in 4 patients [14.3%]). Group 2 consisted of 5 patients and group 3 contained 11. The Univent tube was used in 4 patients in group 3 who did not require use of SLP but whose intubation was considered difficult and in whom laryngoscopic findings were consistent with a Cormack-Lehane group III classification. The Univent bronchial blocker tube was used as a guide, such that intubation was achieved on the first try. The tube was removed from 3 patients (8%) in the intensive care recovery ward. The remaining 29 tracheas were extubated in the operating room. No side effects attributable to the Univent tube were recorded. CONCLUSIONS: The advantages and disadvantages of this new tool for the management of SLP mean that it may be useful for specific situations (such as for SLP with difficult intubation or in patients with tracheotomies or aneurysms of the descending thoracic aorta), but that it does not replace conventional methods. We believe that the Univent bronchial blocker tube should be available as part of operating room equipment.

Influence of alcohol consumption on the initial development of chronic pancreatitis.

The aim of our study was to analyze the influence of alcohol consumption on the early clinical manifestations of alcoholic chronic pancreatitis of the 517 patients in whom chronic pancreatitis was initially suspected, 158 were diagnosed with this disease; of these, alcohol was considered the cause in 136 (86.1%). Alcohol was considered a major etiologic factor when mean consumption was > or = 60 grams per day for at least 4 years. Alcohol consumption, initial clinical manifestations and time of onset were considered up until the moment of diagnosis in all patients. The sex distribution was 133 men (97.8%) and 3 women (2.2%). The average age was 22 +/- 6.5 years at onset of alcoholism, 38 +/- 9.4 years at onset of clinical features, and 44 +/- 9.4 years at diagnosis. The interval between the onset of alcoholism and the initial clinical manifestations was 15.8 +/- 8.8 years, and the interval between the latter and diagnosis was 6.1 +/- 4.9 years. Average alcohol consumption was 162 +/- 8 grams/day and total consumption was 1312 +/- 1017 kg. A statistically significant relationship was found only for mean alcohol consumption and abdominal pain. We found a higher frequency of acute pancreatitis outbreaks, calcifications, steatorrhea and diabetes until the moment of diagnosis in the higher alcohol consumption groups, although the relationship was not statistically significant.

[Oxygen consumption during anaphylactic shock]. / Consumo de oxígeno durante un shock anafiláctico.

We report the case of a 49-year-old man who suffered anaphylactic/anaphylactoid shock within the first few minutes of reaching the recovery room after unremarkable coronary surgery and revascularization. Adequate monitoring permitted differential diagnosis and establishment of specific treatment Monitoring also allowed us to document hemodynamic changes and oxygen consumption during this instance of anaphylactic/anaphylactoid shock. Anaphylactic/anaphylactoid shock caused significant vasoparalysis with decreases in arterial pressures, reduction of oxygen consumption and discrete changes in oxygen exchange. The reposition of volume and administration of adrenaline were insufficient. Appropriate management of noradrenaline perfusion, which was made possible by complete monitoring, was essential for reestablishing normal hemodynamic and oximetric readings and preventing myocardial ischemia.

Total intravenous anaesthesia for caesarean section in a patient with Marfan's syndrome.

The case is described of a pregnant patient with Marfan's syndrome scheduled at 39 weeks' gestation for elective caesarean section carried out for the first time by total intravenous anaesthesia (TIVA) with continuous intravenous (i.v.) infusion of propofol. The diagnosis was based on a positive family history, classic phenotype, scoliosis, arachnodactyly, high narrow palate, hyperextensible joints, ectopia lentis and mitral valve prolapse, with a secondary low mitral insufficiency. Maternal and fetal surveillance did not detect complications during the course of pregnancy. Elective caesarean section was performed at 39 weeks due to high-risk pregnancy and to avoid the risk of haemodynamic alterations that take place during labour and delivery. The patient was given general anaesthesia with continuous i.v. infusion of propofol and boluses of atracurium and fentanyl after delivery. The haemodynamics and oxygen saturation remained stable during surgery. Apgar scores were 9 at 1 and 5 min. The post-delivery course was unremarkable and post partum echocardiography showed no changes from before caesarean section. The cardiovascular problems of Marfan's syndrome, the risk of haemodynamic changes associated with pregnancy and delivery, its anaesthetic implications and the possible advantages of TIVA with continuous i.v. infusion of propofol in the anaesthetic management of caesarean section in patients with this disease are discussed.

Diagnosis of chronic pancreatitis: presenting features and diagnostic delay.

The diagnosis of chronic pancreatitis continues to present difficulties. The nonspecific nature of the symptomatology, its low prevalence and the limited value of morphological and functional tests in the early stages are the most common causes of delay in diagnosis. Our aim was to analyze the most significant clinical manifestations and the diagnostic features of chronic pancreatitis, distinguishing between alcoholic and nonalcoholic etiologies. We studied 158 patients, 136 (86.1%) with alcoholic and 22 (13.9%) with nonalcoholic chronic pancreatitis. The initial symptomatology, the age at diagnosis, the delay in diagnosis from the onset of the clinical signs and the type of diagnosis (incidental or suspected) were considered for each patient. Men predominated in both the alcoholic and the nonalcoholic pancreatitis groups (97.8% and 68.2%, respectively). The mean ages at onset and diagnosis were 38 and 50.6 years, respectively, in alcoholic chronic pancreatitis and 44 and 55 years in the nonalcoholic group; the differences between the two parameters were statistically significant. The most common clinical signs in alcoholic chronic pancreatitis were abdominal pain (81.6%) and episodes of acute pancreatitis (64%), while patients with nonalcoholic pancreatitis presented abdominal pain (59%), diarrhea (40.9%) and weight loss (36.4%). The delay in diagnosis from the onset of the clinical manifestations was 5.8 years (6.1 years in alcoholic and 4.3 years in nonalcoholic pancreatitis. The diagnosis was incidental in 34% of cases of alcoholic chronic pancreatitis and in 50% of cases in the nonalcoholic group.

[Cardiocirculatory stability and early extubation in patients undergoing thoracic surgery with propofol as the single anesthetic agent]. / Stabilità cardiocircolatoria ed estubazione precoce nei pazienti sottoposti a chirurgia toracica utilizzando propofol come agente anestetico unico.

OBJECTIVE: To determine the efficiency of total intravenous anesthesia technique (TIVA) using propofol on maintaining cardio-circulatory stability and rapid recovery time in patients undergoing thoracotomy. DESIGN: Prospective study. SETTING: University General Hospital in Spain. PATIENTS: Twelve patients, undergoing elective thoracic surgery, including lung resection with one-lung ventilation with more than 120 minutes of anesthetic time. METHODS: ECG, blood pressure (BP), heart rate (HR), pulse oximetry (SpO2), end tidal CO2 (ETCO2) and muscular relaxation with Relaxograph were monitored. Anesthesia was performed with propofol 1.5-2.5 mg/kg i.v. and maintained with continuous propofol infusion 4 +/- 1.4 mg/kg/h. Fentanyl, 10 mg i.v., was administered in bolus. After succinylcholine 1 mg/kg i.v. or atracurium 0.5 mg/kg i.v., trachea was intubated with a double-lumen tube or a standard cuffed endotracheal tube. The patients were ventilated with air-oxygen mixture. Maintenance of muscular relaxation was obtained with atracurium 0.2 mg/kg i.v. RESULTS: No significative differences were registered in the values of heart rate, SpO2, ETCO2 and between intraoperative blood pressure and the postextubation blood pressure values. Recovery time, from discontinuation of the propofol until postoperative extubation, was 8.25 +/- 4.8 minutes. CONCLUSIONS: Performing a TIVA with propofol good cardiocirculatory stability was obtained. Continuous monitoring of relaxation, graphically recorded, knowing the bolus rate of muscle relaxant, allows us to antagonize it totally, facilitating patient recovery and its early postoperative extubation.

Catecholaminergic polymorphic ventricular tachycardia in children. A 7-year follow-up of 21 patients.

BACKGROUND: Primary ventricular tachyarrhythmias are rarely seen in children. Among them, catecholaminergic polymorphic ventricular tachycardia has a poor spontaneous outcome. Its diagnosis is often delayed after the first symptoms, which is unacceptable because treatment with the appropriate beta-blocker prevents sudden death. METHODS AND RESULTS: We observed 21 children (mean +/- SD age, 9.9 +/- 4 years) at the time of the diagnosis who had no structural heart disease and a normal QT interval on routine ECG. They were referred for stress- or emotion-induced syncope related to ventricular polymorphic tachyarrhythmias. The arrhythmia, consisting of isolated polymorphic ventricular extrasystoles followed by salvoes of bidirectional and polymorphic tachycardia susceptible to degeneration into ventricular fibrillation, was reproducibly induced by any form of increasing adrenergic stimulation. There was a familial history of syncope or sudden death in 30% of our patients. On receiving therapy with the appropriate beta-blocker, the patients' symptoms and polymorphic tachyarrhythmias disappeared. During a mean follow-up period of 7 years, three syncopal events and two sudden deaths occurred, probably due to treatment interruption. CONCLUSIONS: The entity of adrenergic-dependent, potentially lethal tachyarrhythmia with no structural heart disease deserves to be individualized. It may form a variant of the congenital long QT syndrome in which the ECG marker is lacking; this primary ventricular arrhythmia must be looked for in a pediatric patient with stress- or emotion-induced syncope because only beta-blocking therapy can prevent sudden death and therefore must be given for the patient's lifetime.