Inhaled fentanyl as a method of analgesia

A study was undertaken to investigate the use of fentanyl by aerosol for postoperative analgesia. Seven patients had placebo, six received fentanyl 100 micrograms and seven were given fentanyl 300 micrograms. A significant improvement in postoperative pain, as assessed by linear visual analogue scale, was achieved in the higher dose group, and in both fentanyl groups the time to alternative analgesia was significantly longer than in the control group. Serum fentanyl levels after inhalation of 100 micrograms reached a plateau around 0.04 ng/ml and after 300 micrograms at around 0.1 ng/ml after 15 minutes. Inhaled fentanyl may have a useful analgesic effect despite these low serum levels; this supports the hypothesis that the mode of analgesia from inhaled opioids may be different from that after other routes of administration. There were no adverse effects such as respiratory depression, bronchospasm, nausea or drowsiness.     

Chronic renal failure: factors influencing nephrology referral

Factors influencing referral of all 304 patients who developedpersistent renal failure during one year were studied in thestable Grampian population. The annual incidence of chronicrenal failure (CRF) (creatinine     

Computer-Assisted Instruction Improves Clinical Reasoning Skills of Dietetics Students

Objective The effects of a computer-assisted instruction (CAI) tutorial program on learning clinical reasoning skills were compared in undergraduate dietetics students.Design A drill-and-practice program to control for time on task, a tutorial program, and a simulation program, as the test vehicle, were developed. The tutorial and simulation programs presented data on a patient with cardiovascular disease.Setting Subjects were tested in 30 undergraduate dietetics programs.Subjects Participants were 413 undergraduate diet therapy students enrolled in a coordinated program in dietetics (CPD) or a didactic program in dietetics (DPD).Intervention After completion of lectures on cardiovascular disease, subjects were given the drill-and-practice program plus a simulation test (group 1), the tutorial plus a simulation test (group 2), or the simulation test only (group 3).Main outcome measures Scores on the simulation test were compared. Variables included type of CAI, dietetics program, year in school, computer experience, and experience using a medical chart. Mastery of objectives related to lower- and higher-level clinical reasoning skills introduced in the tutorial program was compared.Statistical analysis One-way analysis of variance and Student-Newman Keuls tests were conducted to determine any differences among the three groups. Reliability was determined using the Kuder-Richardson Formula 20.Results The reliability coefficient of the simulation test was 0.93. Group 2 scored higher on the simulation test than group 1 or group 3. As a group, the CPD students scored higher than the DPD students. When CPD and DPD students were divided into the three experimental groups, there was no significant difference between the CPD and DPD student simulation scores. Group 2 mastered all objectives for lower-level reasoning skills and the higher-level decision-making objective better than groups 1 and 3.Applications/conclusions A computer tutorial program enhanced clinical reasoning skills in undergraduate dietetics students. This type of program could be used to supplement many topics taught in diet therapy and provide DPD students with experiential learning before their clinical intern practicums. J Am Diet Assoc. 1995; 95:868–873.     

Comparison of desflurane and fentanyl-based anaesthetic techniques for coronary artery bypass surgery

We have compared, in 51 ASA II and III patients undergoing coronaryartery bypass surgery, an inhaled anaesthetic technique basedon desflurane, supplemented with low-dose (10 µg kg^–1)fentanyl, with an i.v. technique using high-dose (50 µgkg^–1) fentanyl with midazolam for induction. Satisfactoryrecords were available for analysis in 50 patients. There wereno differences between groups in operating time, cardiopulmonarybypass time, aortic cross-clamp time or duration of stay inthe intensive care unit after surgery. Desflurane maintainedmean systemic arterial pressure at the awake level during incisionand sternotomy (end-tidal concentrations 3.7% and 4.6%, respectively)but decreased it significantly at all other times. With fentanyl,mean systemic arterial pressure was unchanged from a wake valuesduring induction and laryngoscopy but increased significantlyat incision and sternotomy by 8% and 12.8%, respectively, toexceed the desflurane group at sternotomy by 20 mm Hg (P <0.001). With desflurane, heart rate remained at 60–67beat min^–1 at all times before cardiopulmonary bypass.This was always lower than the fentanyl group by 5–15beat min^–1 and the difference was significant at induction,during skin preparation and before aortic cannulation. In comparisonwith the desflurane group, cardiac index was significantly greaterin the fentanyl group at induction, laryngoscopy and duringskin preparation, but was significantly less before aortic cannulation.The need for vasodilator intervention was significantly morecommon in the fentanyl group before, during and after cardiopulmonarybypass and for ß adrenoceptor block before cardiopulmonarybypass. At the time of sternotomy, 10 patients in the fentanylgroup were receiving glyceryl trinitrate compared with one inthe desflurane group. There were no deaths during the periodin hospital or any cases of awareness under anaesthesia. Desfluranesupplemented with lowdose fentanyl produced a controlled haemodynamicstate suitable for patients at risk of myocardial ischaemiawithout recourse to large end-tidal concentrations. (Br. J.Anaesth. 1994; 72: 430–438)     

Evaluating the effectiveness of the coronary care nurses' role in smoking cessation

Summary

• ? The aim of this small-scale study was to assess the feasibility and impact of an individualized smoking cessation intervention among clients admitted to a coronary care unit with severe angina or a first time myocardial infarction.
• ? The intervention involved in-depth nursing assessment interviews related to client beliefs, motivation and experiences of smoking, culminating in an individualized cessation plan. Participants were offered follow up support during the first year post-intervention.
• ? The findings are highly encouraging with a 77% smoking cessation rate for surviving clients within the intervention group at the end of the first year, and with 75% continued successful smoking cessation amongst surviving clients 2 years post-intervention.

     

Clinical and histological features of'mechanic's hands' in a patient with antibodies to Jo-1—a case report

The clinical and histological features of‘mechanic's hands' are described in a patient with polymyositis characterized serologically b6y antibodies to histidyl t RNA synthetase (Jo-1). Although distinctive cutaneous lesions have only recently been associated with the ‘anti-synthetase syndrome’. It is becoming apparent that recognition of subsets within the spectrum of polymyositis/dermatomyositis characterized by certain clinical and serological features not only have prognostic significance, but also may provide insights into mechanisms of disease.     

Acute effects of atrial natriuretic peptide on left ventricular diastolic function: A pulsed wave Doppler study in man

Doppler echocardiographic indices of diastolic function andsystemic haemodynamics were studied in response to infusionsof atrial natriuretic peptide (0.5, 1, 2, 5 pmol.kg^–1.min^–1)and placebo (0.9%(w/v) saline) in ten normal male subjects.Compared with placebo, atrial natriuretic peptide infusion produceda significant and dose-related reduction in the isovolumic relaxationtime [(mean and 95% CI) –5.9 (–9.2 To –2.6)ms (P<0.01) at 5pg. kg^–1 min^–1 and a significantincrease in the ratio between early and late transmitral peakvelocities [0.46 (0.02 to 0.89) (P<0.05) at 5 pg. kg^–1min^–1]. No significant changes in heart rate, blood pressureor aortic stroke distance were observed with infusion of atrialnatriuretic peptide compared with placebo. These data suggestthat pathophyisological plasma concentrations of atrial natriureticpeptide improve diastolic function by increasing the rate ofmyocardial relaxation.