Resúmenes de la semana del 13 al 19 de Junio, 2002
Journal of Pain and Symptom Management: Including Supportive and Palliative Care, Vol. 23 (6) (2002) pp. 517-525
© 2002 Published by Elsevier Science Ireland Ltd. All rights reserved.
PII: S0885-3924(02)00401-3
Special article
Euthanasia in Palliative Care Journals
Maaike A. Hermsen MA * and Henk A.M.J. ten Have MD, PhD
Department of Ethics, Philosophy, and History of Medicine, University Medical Center Nijmegen, Nijmegen, The Netherlands
Accepted 8 August 2001
Abstract
With the growth of palliative care services, interest in moral issues also seems to be growing. The controversial issue of euthanasia significantly provokes moral reflection on the care for dying patients. This article presents an analysis of the moral issue of euthanasia as it is discussed by the palliative care community in the professional journals of palliative care. Initially, the analysis will focus on describing the characteristics of the publications about euthanasia and the attitudes expressed in the articles towards this practice. Second, attention will be paid to the description of the uses of the term euthanasia in the various articles and also how frequently such uses occur. Third, the various arguments in support for or against a place for euthanasia in palliative care will be discussed.
Keywords: Ethics; morals; palliative care; euthanasia; journals of palliative care; qualitative and quantitative analysis
*Address reprint requests to: Maaike Hermsen, MA, Department of Ethics, Philosophy and History of Medicine, University Medical Center Nijmegen, University of Nijmegen, 232 EFG, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
Journal of Pain and Symptom Management: Including Supportive and Palliative Care, Vol. 23 (6) (2002) pp. 510-516
© 2002 Published by Elsevier Science Ireland Ltd. All rights reserved.
PII: S0885-3924(02)00393-7
Original article
Clinical Applications for Change-Point Analysis of Herpes Zoster Pain
Renee A. Desmond PhD a *, Heidi L. Weiss PhD a, Ramin B. Arani PhD b, Seng-jaw Soong PhD a, Martin J. Wood MD c, Paul A. Fiddian MD d, John W. Gnann MD e and Richard J. Whitley MD e
a Medical Statistics Section, Department of Medicine, Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
b Janssen Research Foundation, Titusville, NJ, USA
c Departments of Infection and Tropical Medicine, Birmingham Heartlands Hospital, Birmingham, UK
d Sandiway, UK
e Department of Pediatrics, Children's Hospital, University of Alabama at Birmingham, Birmingham, AL, USA
Accepted 4 September 2001
Abstract
Pain is the most frequent and disabling complication of herpes zoster. The analysis of pain severity data is complicated by the nonlinear rate of resolution. Further, three distinct phases characterize pain resolution acute, subacute, and chronic. Using two clinical trial datasets as the bases for analyses, the rates of baseline pain resolution were computed across each of three phases and compared for age, severity of pain at onset, and number of lesions at baseline. The results defined transition points of 24.4 ± 3.34 for the subacute phase and 110.3 ± 11.9 days for the chronic phase. The model demonstrated a treatment effect of valiciclovir (VACV) during the subacute phase as compared to acyclovir (ACV) (P = 0.006) and supports effects of age, baseline pain and number lesions on pain cessation rates in the acute phase. This model verifies three phases of zoster pain and delineates the impact of treatment and other factors on the phase-specific rates of pain cessation.
Keywords: Herpes zoster; bootstrap; piece-wise exponential distribution; survival analysis
*Address reprint requests to: Renee A. Desmond, PhD, Biostatistics Unit, Comprehensive Cancer Center, 1824 Sixth Avenue South, WTI 153, Birmingham, AL 35294-3300, USA
Intranasal Mupirocin to Prevent Postoperative Staphylococcus aureus Infections
Trish M. Perl, M.D., Joseph J. Cullen, M.D., Richard P. Wenzel, M.D., M. Bridget Zimmerman, Ph.D., Michael A. Pfaller, M.D., Deborah Sheppard, Jennifer Twombley, R.N., Pamela P. French, M.D., M.P.H., Loreen A. Herwaldt, M.D., and the Mupirocin and the Risk of Staphylococcus aureus Study Team
N Engl J Med Volume 346:1871-1877 June 13, 2002 Number 24
ABSTRACT
Background Patients with nasal carriage of Staphylococcus aureus have an increased risk of surgical-site infections caused by that organism. Treatment with mupirocin ointment can reduce the rate of nasal carriage and may prevent postoperative S. aureus infections.
Methods We conducted a randomized, double-blind, placebo-controlled trial to determine whether intranasal treatment with mupirocin reduces the rate of S. aureus infections at surgical sites and prevents other nosocomial infections.
Results Of 4030 enrolled patients who underwent general, gynecologic, neurologic, or cardiothoracic surgery, 3864 were included in the intention-to-treat analysis. Overall, 2.3 percent of mupirocin recipients and 2.4 percent of placebo recipients had S. aureus infections at surgical sites. Of the 891 patients (23.1 percent of the 3864 who completed the study) who had S. aureus in their anterior nares, 444 received mupirocin and 447 received placebo. Among the patients with nasal carriage of S. aureus, 4.0 percent of those who received mupirocin had nosocomial S. aureus infections, as compared with 7.7 percent of those who received placebo (odds ratio for infection, 0.49; 95 percent confidence interval, 0.25 to 0.92; P=0.02).
Conclusions Prophylactic intranasal application of mupirocin did not significantly reduce the rate of S. aureus surgical-site infections overall, but it did significantly decrease the rate of all nosocomial S. aureus infections among the patients who were S. aureus carriers.
Source Information
From the University of Iowa Colleges of Medicine and Public Health, Iowa City (T.M.P., J.J.C., R.P.W., M.B.Z., M.A.P., D.S., J.T., L.A.H.); the University of Iowa Hospitals and Clinics, Iowa City (L.A.H.); GlaxoSmithKline, Collegeville, Pa. (P.P.F.); and the Johns Hopkins Medical Institutions, Baltimore (T.M.P.).
Address reprint requests to Dr. Perl at the Johns Hopkins Medical Institutions, Division of Infectious Diseases and Department of Hospital Epidemiology and Infection Control, 425 Osler, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 212
Anaesthesia
Volume 57 Issue 7 Page 649 - July 2002A comparison between midazolam co-induction and propofol predosing for the induction of anaesthesia in the elderlyN. A. Jones,1 S. Elliott2 and J. Knight1
Summary In a prospective, double-blind, randomised, placebo-controlled trial, we have compared the effects of midazolam co-induction with propofol predosing on the induction dose requirements of propofol in elderly patients. We enrolled 60 patients aged >70 years, attending for urological surgery. The patients were allocated randomly to one of three groups, to receive either midazolam 0.02mg.kg1, propofol 0.25mg.kg1, or normal saline 2ml (placebo) 2min prior to induction of anaesthesia using propofol 1 infusion at 300ml.h1 . The propofol dose requirements for induction were recorded for two end-points (loss of verbal contact and insertion of an oropharyngeal airway). Cardiovascular parameters were recorded at 1-min intervals for each patient until induction was complete. The midazolam group showed a significant reduction in propofol dose requirements for induction (p = 0.05) compared to the placebo group. The propofol group did not show a significant dose reduction compared to placebo. There were no demonstrable differences in terms of improved cardiovascular stability between groups. We conclude that propofol predosing does not significantly reduce the induction dose of propofol required in the elderly, and there were no cardiovascular benefits to either midazolam co-induction or propofol predosing in the elderly.
Anaesthesia
Volume 57 Issue 7 Page 690 - July 2002ForumThe effect of dexamethasone upon patient-controlled analgesia-related nausea and vomitingY. Lee,1 Y. S. Lin2 and Y. H. Chen3
Summary Ninety female patients were enrolled in this randomised, double-blind, placebo-controlled study to compare the anti-emetic effect of intravenous dexamethasone 8 mg with saline control in preventing patient-controlled analgesia-related nausea and vomiting following major orthopaedic surgery. The prophylactic administration of dexamethasone 8mg significantly reduced the overall incidence of patient-controlled analgesia-related nausea and vomiting (p0.001) and the need for rescue anti-emetics (p 0.01). Furthermore, patients who received dexamethasone showed a higher incidence of complete responses (no vomiting or need for rescue anti-emetic for a 24-h postoperative period) than those who received saline (p0.05). We conclude that dexamethasone 8 mg may be valuable for preventing patient-controlled analgesia-related nausea and vomiting in women undergoing major orthopaedic surgery.
Chest. 2002;121:2000-2008.)
© 2002 American College of Chest Physicians
Predicting Fluid Responsiveness in ICU Patients*
A Critical Analysis of the Evidence
Frédéric Michard, MD, PhD and Jean-Louis Teboul, MD, PhD
* From the Medical ICU, CHU de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, Université Paris XI, France.
Correspondence to: Frédéric Michard, MD, PhD, Service de Réanimation Médicale, CHU de Bicêtre, Université Paris XI, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre cedex, France; e-mail:
Study objective: To identify and critically review the published peer-reviewed, English-language studies investigating predictive factors of fluid responsiveness in ICU patients.
Design: Studies were collected by doing a search in MEDLINE (from 1966) and scanning the reference lists of the articles. Studies were selected according to the following criteria: volume expansion performed in critically ill patients, patients classified in two groups (responders and nonresponders) according to the effects of volume expansion on stroke volume or on cardiac output, and comparison of responder and nonresponder patients’ characteristics before volume expansion.
Results: Twelve studies were analyzed in which the parameters tested were as follows: (1) static indicators of cardiac preload (right atrial pressure [RAP], pulmonary artery occlusion pressure [PAOP], right ventricular end-diastolic volume [RVEDV], and left ventricular end-diastolic area [LVEDA]); and (2) dynamic parameters (inspiratory decrease in RAP [RAP], expiratory decrease in arterial systolic pressure [down], respiratory changes in pulse pressure [PP], and respiratory changes in aortic blood velocity [Vpeak]). Before fluid infusion, RAP, PAOP, RVEDV, and LVEDA were not significantly lower in responders than in nonresponders in three of five studies, in seven of nine studies, in four of six studies, and in one of three studies, respectively. When a significant difference was found, no threshold value could discriminate responders and nonresponders. Before fluid infusion, RAP, down, PP, and Vpeak were significantly higher in responders, and a threshold value predicted fluid responsiveness with high positive (77 to 95%) and negative (81 to 100%) predictive values.
Conclusion: Dynamic parameters should be used preferentially to static parameters to predict fluid responsiveness in ICU patients.
Key Words: arterial pressure • cardiac output • cardiac preload • fluid responsiveness • left ventricular end-diastolic area • pulmonary artery occlusion pressure • right atrial pressure • right ventricular end-diastolic volume • stroke volume • volume expansion
Foot and Ankle Surgery
Volume 8 Issue 2 Page 95 - June 2002Peripheral or central nerve blocks for foot surgery: a prospective, randomized clinical comparisonA. CASATI1, C. GRISPIGNI2, G. ALDEGHERI1, F. VINCIGUERRA1, A. SCIASCIA1, G. FRASCHINI2 & G. FANELLI1
The efficacy of surgical anaesthesia and postoperative analgesia after elective orthopaedic foot surgery was evaluated in 200 healthy patients, randomly allocated to receive either a bilateral spinal anaesthesia (group BSA, n=50), a unilateral spinal anaesthesia (group USA, n=50), or a combined sciatic-femoral nerve block performed with 2 mepivacaine (group SFM, n=50) or 0.75 ropivacaine (group SFR, n=50). Similar duration of surgery was reported in the four groups (median 50min, range 20-90min), without differences in times of thigh tourniquet. Surgeon satisfaction was 92 in group SFM and 90 in group SFR, 94 in group BSA and 94 in group USA (P =0.18). Tourniquet pain during surgery was reported in two SFM patients and three SFR patients, while two patients in each group required anaesthetic implementation. No urinary retention was reported in SFM and SFR groups, but seven BSA patients (14) and one USA patient (2) required bladder catheterization (P=0.005). Postoperative analgesia was longer in group SFR (13.4h) than in the SFM (4.6h), BSA (3.1h), and USA (3.2h) groups (P=0.0005), with reduced analgesic consumption (P =0.0005). When providing anaesthesia for foot and ankle procedures, the combination of sciatic and femoral nerve blocks is as effective and safe as spinal anaesthesia with less urinary retention. Longer postoperative analgesia is provided by ropivacaine than mepivacaine.
Anaesthesia
Volume 57 Issue 7 Page 690 - July 2002ForumPatient feedback on the anaesthetist's performance during the pre-operative visitJ. Carnie
Summary A questionnaire was devised from guidelines published by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland for the conduct of the pre-operative interview and conduct of anaesthesia. The responses to the questionnaire formed the basis of an accumulative record of patient feedback on individual anaesthetist's performance and used as one component of annual appraisal. The median desired answer and overall dissatisfaction percentages, and the desired:undesired answer ratio for consultants and non-training grade doctors from 835 patients at a large Acute District General Hospital were 92, 0.6 and 12:1, respectively.
Canadian Journal of Anesthesia 49:545-553 (2002)
© Canadian Anesthesiologists' Society, 2002
General Anesthesia
Serious intraoperative problems – a five-year review of 83,844 anesthetics
[Problèmes peropératoires graves – une revue de 83 844 anesthésies sur cinq ans]
Sigurd Fasting, MD and Sven E. Gisvold, MD PhD
From the Department of Anesthesia and Intensive Care, St. Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway.
Address correspondence to: Dr. Sigurd Fasting, Department of Anesthesia and Intensive Care, St. Olav's Hospital, University Hospital of Trondheim, N-7006 Trondheim, Norway. Phone: +47-73868108; Fax: +47-73868117; E-mail:
Purpose: The low incidence of mortality and major morbidity in anesthesia makes it difficult to study the pattern of potential accidents and to develop preventive strategies. Anesthetic ‘near-misses’, however, occur more frequently. Using data from a simple routine-based system of problem reporting, we have analyzed the pattern and causes of serious non-fatal problems, in order to improve preventive strategies.