Buspirone and meperidine synergistically reduce the shivering threshold.

UNLABELLED: Mild hypothermia (i.e., 34 degrees C) may prove therapeutic for patients with stroke, but it usually provokes shivering. We tested the hypothesis that the combination of buspirone (a serotonin 1A partial agonist) and meperidine synergistically reduces the shivering threshold (triggering tympanic membrane temperature) to at least 34 degrees C while producing little sedation or respiratory depression. Eight volunteers each participated on four randomly-assigned days: 1) large-dose oral buspirone (60 mg); 2) large-dose IV meperidine (target plasma concentration of 0.8 microg/mL); 3) the combination of buspirone (30 mg) and meperidine (0.4 microg/mL); and 4) a control day without drugs. Core hypothermia was induced by infusion of lactated Ringer's solution at 4 degrees C. The control shivering threshold was 35.7 degrees C +/- 0.2 degrees C. The threshold was 35.0 degrees C +/- 0.8 degrees C during large-dose buspirone and 33.4 degrees C +/- 0.3 degrees C during large-dose meperidine. The threshold during the combination of the two drugs was 33.4 degrees C +/- 0.7 degrees C. There was minimal sedation on the buspirone and combination days and mild sedation on the large-dose meperidine day. End-tidal PCO2 increased approximately 10 mm Hg with meperidine alone. Buspirone alone slightly reduced the shivering threshold. The combination of small-dose buspirone and small-dose meperidine acted synergistically to reduce the shivering threshold while causing little sedation or respiratory toxicity. IMPLICATIONS: Mild hypothermia may be an effective treatment for acute stroke, but it usually triggers shivering, which could be harmful. Our results indicate that the combination of small-dose buspirone and small-dose meperidine acts synergistically to reduce the shivering threshold while causing little sedation or respiratory toxicity. This combination may facilitate the induction of therapeutic hypothermia in stroke victims.

A randomized, controlled trial of advanced care planning discussions during preoperative evaluations.

BACKGROUND: Although many patients and physicians support the concept of advance care planning, only a small percentage of patients actually have the necessary discussion with health care providers. Hospital-based physicians other than primary care providers often are needed to increase physician, patient, and proxy communication about advanced directives. This study evaluated the effectiveness of a 5-10-min discussion designed to foster dialogue between patients and their proxies in a preoperative evaluation clinic. The discussions were lead by anesthesiologists. METHODS: A randomized controlled trial was conducted from September 1998 through May 1999 in a preoperative evaluation clinic at University of California, San Francisco, a tertiary care center. English-speaking patients aged 65 yr or older who were scheduled for elective surgery were randomized to receive a short information session stressing the importance of communication about end-of-life care between the patients and their proxies. Patients randomized to the control group received the standard preoperative anesthesia screening. An admitting counselor questioned all patients (control and intervention) about whether they have an advanced directive as part of the registration process before their arrival in clinic. RESULTS: The intervention significantly increased discussions about end-of-life care between patients and their proxies. Eighty seven percent of patients reported having discussions with their proxies as compared with only 66% of control patients (P = 0.001). The intervention also increased durable power of attorney completion rate to 27% as compared with 10% completion rate by controls. CONCLUSIONS: The preoperative evaluation period can be an opportunity to encourage patient and proxy communication about end-of-life care.

Increased neutrophil numbers and IL-8 levels in airway secretions in acute severe asthma: Clinical and biologic significance.

The inflammatory events in the airways at the time of acute respiratory failure from acute severe asthma are poorly understood. To determine the patterns of cellular inflammation in the airways in acute severe asthma, we analyzed tracheal aspirates collected within 12 h of intubation from patients intubated emergently for acute severe asthma (n = 10) and from patients intubated electively for nonpulmonary surgery (n = 14). The number of neutrophils in tracheal aspirates from asthma patients was 10 times higher than normal (4.2 [0.6 to 335.0] [median, range] versus 0.4 [0.009 to 9.4] x 10(6)/ml, p = 0.001), and there was a strong trend for a positive relationship between neutrophil number and duration of intubation (r(s) = 0.64, p = 0.06). Although eosinophil numbers were also significantly higher than normal (0.5 [0.0 to 23.3] versus 0.0 [0.0 to 0.1] x 10(6)/ml, p = 0.003), the numbers of eosinophils were 8-fold less than neutrophils, and there was no significant correlation between eosinophil number and duration of intubation (r(s) = 0.4, p = 0.26). Interleukin-8 (IL-8), a chemoattraction for neutrophils, was 19 times higher than normal in tracheal aspirates from asthmatic patients (75.0 [9.0 to 168.0] versus 4.0 [0.08 to 24.0] ng/ml, p < 0. 05) and correlated significantly with the neutrophil number (r(s) = 0.77, p = 0.03). Furthermore, the IL-8 levels correlated positively with the duration of mechanical ventilation (r(s) = 0.74, p = 0.03). Surprisingly, the number of neutrophils increased significantly during the period of intubation in the asthmatic subjects, possibly because of intravenous corticosteroid treatment. We conclude that neutrophils are the dominant inflammatory leukocyte characterizing airway inflammation in acute severe asthma that requires mechanical ventilation, and that IL-8 is an important mediator of this neutrophilia.

A comparison of two reading interventions for children with reading disabilities.

This study compared the effectiveness of two reading interventions in a public school setting. Forty-five second-grade children with reading disabilities were randomly assigned to a 6-week phonological awareness, word analogy, or math-training program. The two reading interventions differed from each other in (a) the unit of word analysis (phoneme versus onset-rime), (b) the approach to intervention (contextualized versus decontextualized), and (c) the primary domain of reading instruction (oral versus written language). Results indicate that children in both reading programs achieved significant gains in beginning reading skills, learning the specific skills taught in their respective programs, and applying what they had learned to uninstructed material on several transfer-of-learning measures, in comparison to children in the control group. For children in both reading intervention groups, the most significant mediator of growth in oral reading fluency was a child's initial level of word identification skill. Implications of these findings are that systematic, high quality reading intervention can occur in a small group, public school setting and that there are several different paths to the remediation of children with reading disabilities.

Status asthmaticus.

Despite improved understanding of the pathophysiology and treatment of asthma, significant morbidity and mortality exist for both the pediatric and adult patient. The critical care practitioner must understand the chronic as well as the acute nature of the condition in order to provide effective intervention. This article reviews the epidemiology and pathophysiology of asthma, clinical assessment, management principles, therapeutic modalities, and future approaches to the management of asthma.

Cardiovascular collapse after laparoscopic liver biopsy.

We describe a unique complication of laparoscopic liver biopsy. The increased intra-abdominal pressure associated with carbon dioxide pneumoperitoneum produced haemodynamic stability by tamponading a trochar-induced retroperitoneal haemorrhage. After deflation of the abdomen, release of the tamponade resulted in acute cardiovascular collapse. Other complications associated with laparoscopic surgery are also discussed.

Does Acute Physiologic and Chronic Health Evaluation (APACHE II) scoring predict need for prolonged support after coronary revascularization?

Significant intensive care unit (ICU) resources are allocated to patients recovering from coronary artery bypass graft (CABG) procedures, suggesting that a system to identify patients at risk for prolonged ICU therapy would help to enhance the use of this resource. To test the hypothesis that post-CABG patients likely to require prolonged ICU stay could be identified at the time of admission using the Acute Physiologic and Chronic Health Evaluation (APACHE II) system for scoring the severity of illness, we retrospectively reviewed the length of ICU stay for all patients recovering from CABG procedures over 1 yr, comparing the APACHE II scores assigned to patients requiring the longest stay with scores for patients with the briefest stay to determine whether a difference in score corresponded with the difference in length of stay. All medical records were reviewed and the physiologic variables (n = 12) used to assess acute physiologic status were recorded. Perioperative therapeutic interventions having significant impact on the physiologic variables used to derive the APACHE II score also were recorded. The study group was defined as patients requiring ICU care lasting between 14 and 84 days (n = 20); a control group of 23 patients was randomly selected from 124 patients having an ICU stay of 48 h or less. The overall APACHE II scores, and the component scores used to derive the overall scores, were calculated for both groups and were compared. The mean APACHE II score for the study group was 23.5 compared with 13.2 (P < 0.001) for the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving teenage attitudes toward children, child handicaps, and hospital settings: a child development curriculum for potential parents.

The recent increase in teenage pregnancies increases the risk of of low-birth-weight premature infants born to young mothers. Facilitative child-rearing practices, aimed at overcoming effects of perinatal stress, are being taught to middle-grade students before they become parents. Students participating in the program score higher than controls on measures of positive attitudes toward and knowledge of normal and handicapped children, hospitals, and child development.