An interface to display special physiologic signals on patient monitors

Objective. The objective of this study was to develop an interface to allow special physiologic signals (e.g., in a research setting) to be displayed on the invasive pressure channel of conventional clinical monitors. The interface accepts single-ended high-level signals for display using the pressure channel of patient monitors, which use strain-gauge transducers employing direct current (DC) excitation.Methods. By studying the electronic circuitry common to most clinical invasive pressure measurement systems (Wheatstone bridge, differential input instrumentation amplifier) it was possible to develop an interface to convert high-level single-ended signals into the low-level differential signal needed for input to an invasive pressure channel.Results and Conclusions. The device is useful when it is desired to display signals from special transducers on regular patient monitors. Schematic diagrams and sample results are provided.     

Difficult or Impossible Ventilation after Sufentanil-induced Anesthesia Is Caused Primarily by Vocal Cord Closure

Introduction: Opioid-induced rigidity often makes bag-mask ventilation difficult or impossible during induction of anesthesia. Difficult ventilation may result from chest wall rigidity, upper airway closure, or both. This study further defines the contribution of vocal cord closure to this phenomenon.

Methods: With institutional review board approval, 30 patients undergoing elective cardiac surgery participated in the study. Morphine (0.1 mg/kg) and scopolamine (6 micro gram/kg) given intramuscularly provided sedation along with intravenous midazolam as needed. Lidocaine 10% spray provided topical anesthesia of the oropharynx. A fiberoptic bronchoscope positioned in the airway photographed the glottis before induction of anesthesia. A second photograph was obtained after induction with 3 micro gram/kg sufentanil administered during a period of 2 min. A mechanical ventilator provided 10 ml/kg breaths at 10/min via mask and oral airway with jaw thrust. A side-stream spirometer captured objective pulmonary compliance data. Subjective airway compliance was scored. Pancuronium (0.1 mg/kg) provided muscle relaxation. One minute after the muscle relaxant was given, a third photograph was taken and compliance measurements and scores were repeated. Photographs were scored in a random, blinded manner by one investigator. Wilcoxon signed rank tests compared groups, with Bonferroni correction. Differences were considered significant at P <0.05.

Results: Twenty-eight of 30 patients exhibited decreased pulmonary compliance and closed vocal cords after opioid induction. Two patients with neither objective nor subjective changes in pulmonary compliance had open vocal cords after opioid administration. Both subjective and objective compliances increased from severely compromised values after narcotic-induced anesthesia to normal values (P = 0.000002) after patients received a relaxant. Photo scores document open cords before induction, progressing to closed cords after the opioid (P = 0.00002), and opening again after a relaxant was administered (P = 0.00005).     

Nonsteroidal anti-inflammatory drug use and increased risk for peptic ulcer disease in elderly persons

OBJECTIVE: To evaluate the relative risk for peptic ulcer disease that is associated with the use of nonaspirin nonsteroidal anti-inflammatory drugs. DESIGN: Nested case-control study. SETTING: Tennessee Medicaid program. PARTICIPANTS: Medicaid enrollees 65 years of age or older were included in the study. The 1415 case patients had been hospitalized for confirmed peptic ulcer disease at some point from 1984 through 1986. The 7063 control persons represented a stratified random sample of other Medicaid enrollees. MEASUREMENTS AND MAIN RESULTS: The estimated relative risk for the development of peptic ulcer disease among current users of nonaspirin nonsteroidal anti-inflammatory drugs, compared with that among nonusers, was 4.1 (95% CI, 3.5 to 4.7). For current users, the risk increased with increasing dose, from a relative risk of 2.8 (CI, 1.8 to 4.3) for the lowest to a relative risk of 8.0 (CI, 4.4 to 14.8) for the highest dose category. The risk was greatest in the first month of use (relative risk, 7.2; CI, 4.9 to 10.5). If the association is fully causal, 29% of peptic ulcers in the study sample resulted from the use of these drugs, and the excess risk associated with such use was 17.4 hospitalizations for ulcer disease per 1000 person-years of exposure. CONCLUSIONS: These data support other findings indicating that a clinically significant risk for serious ulcer disease is associated with the use of nonaspirin nonsteroidal anti-inflammatory drugs. The data show that this risk increases with dose and recency of use and that use of these drugs may be responsible for a large proportion of peptic ulcer disease among elderly persons.     

Nonoperative treatment ofacromioclavicular joint injuries

Nonoperative treatment is generally the choice for Type I and II acromioclavicular (AC) joint injuries. The situation issomewhat more controversial when Type III AC dislocations are considered, particularly with respect to athletes and heavy laborers. A number of recent studies have supported conservative treatment in these groups. There is general consensus as to the need for surgical intervention for Type IV, V, and VI AC injuries. Integral to any form of management, nonoperative or operative, is a rehabilitation program that addresses range of motion, strength, and neuromuscular control. We describe our program, which is divided into four phases: (1) Pain control and immediate protected range of motion and isometric exercises; (2) strengthening exercises using isotonic contractions and proprioceptive neuromuscular facilitation (PNF) exercises; (3) Unrestricted functional participation with the goal of increasing strength, power, endurance, and neuromuscular control; and (4) return to activity with sport specific functional drills. An athlete is ready to return to competitive sports once the following criteria are met: full range of motion (ROM), no pain or tenderness, satisfactory clinical exam, and demonstration of adequate strength on isokinetic testing. The unique considerations in a throwing athlete with an AC injury are also addressed. The primary goal of the nonoperative treatment protocol is to return the athlete to full activities as quickly and as safely as possible.