A new respiratory rate monitor: development and initial clinical experience

The need for continous, noninvasive, and reliable respiratory rate monitoring during recovery from general anesthesia has long been recognized. Alternative principles can be grouped into those detecting the respiratory effort, and those detecting the actual result, i.e. the respiratory gas flow. The second category is of greatest interest for patient monitoring. In this paper, we report the development and initial clinical experience with a new acoustic air-flow sensor. By differential, multipoint detection of the air-flow in the mouth and nose region, the sensor can easily discriminate against different kinds of interference, including motion arterfacts. The sensor is nonexpensive, rugged, simple to apply, and inherently safe. An instrument with continous display of respiratory rate, and an audiovisual apnea alarm has been designed and built.The complete system has been tested on patients during recovery after general anesthesia. In 16 patients, the respiratory rate displayed by the instrument has been correlated against that visually observed. A good correlation was obtained. Minor discrepancies can be explained from the fact that visual observation corresponds to the respiratory effort, whereas the sensor detects the actual air flow. In 12 patients, 24 hour simultaneous recordings were made of respiratory rate with the new sensor, with simultaneous recording of the oxygen saturation and the heart rate with a pulse oximeter. It was found that the new sensor reliabley recorded respiratory depression and apnea. Such events may in some patients be as frequent as one incident per hour. One case of Ondine's curse provided clear evidence that pulse oximetry has a low sensitivity to respiratory disorders.     

Paraplegia after thoracotomy--not caused by the epidural catheter

BACKGROUND: Paraplegia and peripheral nerve injuries may arise after general anaesthesia from many causes but are easily ascribed to central block if the latter has been used. CASE REPORT: A 56-yr-old woman, with Bechterev disease but otherwise healthy, was operated with left-sided thoracotomy to remove a tumour in the left lower lobe. She had an epidural catheter inserted in the mid-thoracic area before general anaesthesia was started. Bupivacaine 0.5% 5 ml was injected once and the infusion of bupivacaine 0.1% with 2 micrograms/ml fentanyl and 2 micrograms/ml adrenaline (5 ml/h) started at the end of surgery. The patient woke up with total paralysis in the lower limb and sensory analgesia at the level of T8, which remained unchanged at several observations. Laminectomy, performed 17 h after the primary operation, showed a large piece of a haemostatic sponge (Surgicel) compressing the spinal cord, which was then decompressed but the motor and sensory deficit remained virtually unchanged both then and a year later. CONCLUSIONS: This case shows--once again--that although central blocks may cause serious neurological complications and paraplegia, other causes are possible and have to be considered. However, all patients with an epidural catheter must be monitored for early signs and symptoms of an intraspinal process and the appropriate treatment has to be instituted instantly.     

Recombinant Human Erythropoietin and Hemoglobin Concentration at Operation and during the Postoperative Period: Reduced Need for Blood Transfusions in Patients Undergoing Colorectal Surgery—Prospective Double-blind Placebo-controlled Study

p < 0.05). On postoperative days 3 and 7 the values were 7.2 (5.3–8.2) and 7.5 (5.4–9.4) mmol/L, respectively, in the erythropoietin group compared to 6.7 (5.2–7.8) and 6.9 (5.1–8.6) mmol/L in the placebo group ( p < 0.01). At discharge the hemoglobin concentration was 7.8 (5.9–8.8) mmol/L in the erythropoietin group and 7.2 (5.4–8.6) mmol/L in the placebo group ( p < 0.002). The blood loss during operation was similar in the two groups. In the erythropoietin group the median value was 280 ml (range 25–2000 ml), with the lower and upper quartiles 150 and 500 ml, respectively. In the placebo group the blood loss was median 300 ml (range 50–1800 ml), with the lower and upper quartiles 200 and 750 ml, respectively. The number of blood transfusions given was significantly lower in the erythropoietin group, with a mean of 0.3 (range 0–6) units compared to 1.6 (0–9) units in the control group ( p < 0.05). In conclusion, the hemoglobin concentration at the time of surgery and during the week following surgery was significantly higher in the group of patients receiving r-HuEPO perioperatively compared to the placebo group together with a significant lower use of blood transfusions in the r-HuEPO group. However, the clinical implications of these findings has yet to be proven.RID=" ID=" <E5>Correspondence to:</E5> N. Qvist, M.D., D.Sci.     

Ngaka ya setswana, ngaka ya sekgoa or both? Health seeking behaviour in Batswana with pulmonary tuberculosis

The health seeking behaviour of tuberculosis (TB) patients, and their beliefs and attitudes with regard to the disease, was studied in 212 Batswana with smear-positive pulmonary TB during 1993/94. There is an apparent resemblance between traditional ideas of disease being caused by pollution (breaking of taboos) and modern theories of spread via germs. TB may be regarded as a 'European disease' or as a 'Tswana disease' and this has implications for health behaviour. Patients who regard TB as a 'Tswana disease' may use modern medicine for symptom relief but traditional medicine to treat what they consider the cause of the disease. All patients were eventually diagnosed and initiated specific antituberculous treatment in a modern health facility. The median number of health facility visits was two, and the median delay period was 12 weeks. 95% of patients visited a modern health facility as their first step of action. Before start of specific treatment one or more alternative treatments was tried by 52% of patients during the delay period. After starting modern treatment, 47% of patients visited, or planned to visit, a traditional healer or a faith healer. Traditional explanations of disease seemed less prevalent in 1993/94 than in a study conducted among TB patients in Botswana ten years earlier, but few patients had a thorough understanding of TB from a biomedical point of view. More knowledge about patients' health seeking behaviour and perceptions would be useful for health workers. The findings of this study could offer suggestions for improvement in the area of health education.     

Gemcitabine and ISIS-2503 for patients with locally advanced or metastatic pancreatic adenocarcinoma: a North Central Cancer Treatment Group phase II trial.

PURPOSE: Gemcitabine remains the standard therapy for metastatic pancreatic adenocarcinoma (ACA), but has limited activity. ISIS-2503 is an antisense compound directed against H-ras with preclinical activity against pancreatic ACA in tumor models. The combination of ISIS-2503 and gemcitabine has been evaluated in a prior phase I study. METHODS: Patients with metastatic or locally advanced pancreatic ACA not amenable to surgery or local radiation received gemcitabine 1,000 mg/m(2) intravenously over 30 minutes on days 1 and 8 and ISIS-2503 6 mg/kg/d as a continuous intravenous infusion over 14 days of an every-3-weeks cycle. Responses were monitored by radiologic imaging every 6 weeks. RESULTS: Forty-eight eligible patients were enrolled, 43 with metastatic disease. Median follow-up was 12.6 months (range, 2.2 to 16.8 months) for living patients. A median of four cycles of treatment was given (range, 1 to 18 cycles). All patients were assessable for response and toxicity. The 6-month survival percentage was 57.5% (95% CI, 44.9% to 73.5%) and the median survival was 6.6 months. The response rate was 10.4% (one complete response, four partial responses). Clinically significant toxicity was limited except for one fatal pulmonary embolism. CONCLUSION: This study shows a promising response rate to the combination of gemcitabine and ISIS-2503 in patients with pancreatic ACA. The observed 6-month survival rate in these patients met our protocol-defined criteria for success. This regimen is tolerable, but is of unclear benefit. Additional studies evaluating the role of gemcitabine and ISIS-2503 in the treatment of pancreatic ACA should be considered.     

Health-related quality of life parameters as prognostic factors in a nonmetastatic breast cancer population: an international multicenter study.

PURPOSE: The purpose of this research was to evaluate whether baseline health-related quality of life (HRQOL) parameters are prognostic factors for survival in locally advanced breast cancer patients. Although the literature highlights the important role of HRQOL parameters in predicting survival in advanced metastatic disease, little evidence exists for earlier stages. PATIENTS AND METHODS: The overall sample consisted of 448 patients randomly assigned to receive cyclophosphamide, epirubicin, and fluorouracil versus epirubicin, cyclophosphamide, and granulocyte colony-stimulating factor. Patients were enrolled in 12 countries. HRQOL baseline scores were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival. In addition, a bootstrap resampling technique was used to assess the stability of the outcomes. Bootstrap results were then applied for model averaging purposes as a means to account for the observed model selection uncertainty. RESULTS: The final multivariate model retained inflammatory breast cancer (T4d) as the only factor predicting overall survival (OS) with a hazard ratio of 1.375 (95% CI, 1.027 to 1.840; P =.03). The presence of inflammatory breast cancer lowers the median survival time from 6.6 to 4.2 years (36% reduction). None of the preselected HRQOL variables were prognostic for OS or disease-free survival, in either the univariate or multivariate analysis. CONCLUSION: Our findings suggest that baseline HRQOL parameters have no prognostic value in a nonmetastatic breast cancer population.     

Withholding or starting antibiotic treatment in patients with dementia and pneumonia: prediction of mortality with physicians' judgment of illness severity and with specific prognostic models.

BACKGROUND: To help decision makers plan treatment, the authors assessed clinical predictors of mortality from nursing home-acquired pneumonia in patients with dementia. METHODS: Pneumonia patients treated without (n = 165) or with antibiotics (n = 541) were enrolled in a prospective cohort study in 61 nursing homes. RESULTS: In both groups, clinical judgment of illness severity was a strong predictor for 1-week mortality. Despite large differences in frailty and mortality (83% in untreated patients and 15% in treated patients), separate multivariable logistic models included similar specific predictors. DISCUSSION: Despite profound differences between the 2 independent groups, predictors for short-term mortality were largely similar. We found that, when combined with physicians' clinical judgment, 3 readily assessed predictors (respiratory rate, fluid intake, and eating dependency) helped predict mortality. Our results, if confirmed in an independent population, can help make decision making about antibiotic treatment of pneumonia in patients with dementia more evidence-based.     

Treatment of scoliosis with spinal bracing in quadriplegic cerebral palsy

To evaluate the clinical results of the treatment and to assess the factors that influenced the rate of scoliosis progression, a retrospective study of spinal orthosis in 86 patients with spastic quadriplegic cerebral palsy was performed. The mean age of the patients was 13.8 years (range 5 to 33 years). Their scoliotic deformities were treated with custom-moulded, polypropylene thoraco-lumbar-sacral orthoses. Cobb angles were measured on radiographs taken in a sitting position before treatment, in orthosis, and during follow-up. The mean initial Cobb angle was 68.4 degrees (range 25 to 131 degrees). The mean correction in orthosis was 25 degrees (range 3 to 60 degrees). Seventy-two patients had a follow-up period of more than 2 years. At the latest follow-up, average 6.3 years (range 2 to 14 years) after the start of treatment, the mean Cobb angle without orthosis was 93.1 degrees (range 40 to 145 degrees). The mean progression per year was 4.2 degrees (range -3 to 21 degrees). Linear multiple regression revealed that age and initial correction in orthosis were the only variables that significantly influenced the rate of progression. Twenty-two patients had no progression or progression <1.0 degrees per year. Correction in orthosis was the only variable that predicted progression <1.0 degrees per year in both age groups (<15 years and > or =15 years). Of the 57 patients who were still alive and had not undergone surgical fusion, 72% used their orthoses at a mean age of 22 years. Parents and caregivers expressed satisfaction with the use of orthosis, mainly because of improved sitting stability which gave better overall function.