Clinical suggestions for management of stimulant treatment in adolescents

Children with attention-deficit hyperactivity disorder (ADHD) do not typically outgrow this condition in adolescence, which is a challenging period of development. Management of ADHD in adolescence requires specific accommodations. These include providing adolescents with as much control over treatment as possible, so that they perceive treatment to be widening their autonomy rather than limiting it. Wherever possible, medication needs to be long-acting to facilitate compliance and to minimize problems with rebound misbehaviour and moodiness. Comorbid psychiatric symptoms and syndromes need to be evaluated carefully both pre- and posttreatment. Ongoing psychoeducation and support can help to restructure the demands that an adolescent with ADHD faces at home and school so that they are more manageable. With active treatment it may be possible to prevent the serious morbidity associated with ADHD during this period and to lay a foundation for adulthood.

Adult attention deficit hyperactivity disorder and the dopamine D4 receptor gene

Attention deficit hyperactivity disorder (ADHD) is a prevalent psychiatric condition in children and follow up studies have indicated that 22-33% of patients continue to suffer from ADHD during late adolescence and adulthood. Convincing evidence supports the contribution of genetic factors in the etiology of ADHD, and the interaction of the psychostimulants with the dopamine system suggests that dopamine is involved in the pathophysiology. The 7-repeat allele of the 48 base pair repeat of the dopamine D4 receptor gene (DRD4) has been reported, with several replications, to be associated with ADHD in children. We tested for the presence of association between the DRD4 48 base repeat and adult ADHD in two independent samples: one comprised of cases and ethnically matched controls, and the second made up of nuclear families. Each case was assessed using a battery of adult ADHD assessment instruments. The analysis of the 66 cases and 66 controls showed a significantly higher presence of the 7-repeat in the adult ADHD patients vs. controls (chi(2) = 5.65; df = 1; P = 0.01). In the analysis of transmission of DRD4 alleles in 44 nuclear families with the transmission disequilibrium test, a trend was observed toward a increased transmission of the 7-repeat from the heterozygous parents to the affected offspring (chi(2) = 2.00; df = 1; P = 0.15). When the two samples were combined, the overall significance was stronger (N = 110; z = 2.68; P = 0.003). The results of our study suggest a role of the 7-repeat allele in adult subjects suffering from ADHD. This finding is an important continuation of the group of studies that together strongly suggest the involvement of DRD4 in ADHD.

Curriculum renewal in child psychiatry

OBJECTIVE

To ensure uniform design and evaluation of a clerkship curriculum for child and adolescent psychiatry teaching common disorders and problems in an efficient manner across 5 teaching sites and to include structures for continuous improvement.

METHOD

The curriculum committee selected for course inclusion disorders and problems of child psychiatry that were commonly encountered by primary care physicians. Instruction methods that encouraged active student learning were selected. Course coordination across sites was encouraged by several methods: involving faculty, adopting a centralized examination format, and aligning teaching methods with examination format. Quantitative and qualitative methods were used to measure students' perceptions of the course's value. These evaluative results were reviewed, and course modifications were implemented and reevaluated.

RESULTS

The average adjusted student return rate for course evaluation questionnaires for the 3-year study period was 63%. Clerks' ratings of course learning value demonstrated that the course improved significantly and continually across all sites, according to a Scheffé post-hoc analysis. Analysis of student statements from focus-group transcripts contributed to course modifications, such as the Brief Focused Interview (BFI).

CONCLUSIONS

Our curriculum in child psychiatry, which focused on common problems and used active learning methods, was viewed as a valuable learning experience by clinical clerks. Curriculum coordination across multiple teaching sites was accomplished by including faculty in the process and by using specific teaching and examination strategies. Structures for continuous course improvement were effective.

Five-factor personality traits in patients with seasonal depression: treatment effects and comparisons with bipolar patients

BACKGROUND

Increasingly, the Five Factor Model (FFM) of personality is being used to assess personality characteristics of patients with Axis I disorders. Recent study indicates that patients with the seasonal subtype of major depression (SAD) may differ meaningfully from other depressed patients. In the present study, we further examined this finding, with attention to the stability of personality characteristics across treatment.

METHODS

We used the NEO-FFM to assess the personality characteristics of two samples of depressed outpatients: patients with SAD and patients with bipolar disorder. Assessment was repeated in the SAD patients after light therapy.

RESULTS

Consistent with previous research, we found elevated scores on the Openness domain in the SAD patients. SAD patients also scored significantly lower on Neuroticism and significantly higher on the Conscientiousness and Extroversion domains than patients with bipolar disorder. Scores on the Openness domain remained elevated after treatment of SAD; this occurred in the context of significant decreases in Neuroticism and increases in Extroversion scores.

LIMITATIONS

These results were obtained in a relatively small-sample study. Although our sample of bipolar patients were taking mood stabilizers, it is unlikely that medication effects could explain our results.

CONCLUSIONS

Our findings are consistent with those reported by Bagby et al. (Major depression and the five-factor model of personality. J. Pers. Disord. 1995;9:224-234) and suggests that Neuroticism and Extroversion are the FFM domains most responsive to treatment for depression. Our results also suggest that elevations on the Openness domain do not change with treatment and may be an enduring characteristic of patients with SAD.

Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary artery bypass grafting. The Institutions of the Multicenter Study of Perioperative Ischemia (McSPI) Research Group

OBJECTIVES

No data exist regarding "the best" hematocrit value after coronary artery bypass graft surgery. Transfusion practice varies, because neither an optimal hematocrit value nor a uniform transfusion trigger criterion has been determined.

METHODS

To investigate the optimal hematocrit value, we studied 2202 patients undergoing coronary bypass. The hematocrit value on entry into the intensive care unit (IHCT) was categorized into three groups: high (> or = 34%), medium (25% to 33%), and low (< or = 24%). Characteristics and adverse events (outcomes) were compared, and the effect of IHCT on the risk of myocardial infarction was determined by logistic regression.

RESULTS

High IHCT (> or = 34%) was associated with an increased rate of myocardial infarction (8.3% vs 5.5% vs 3.6%; p < or = 0.03, high, medium vs low) and with more severe left ventricular dysfunction (11.7% vs 7.4% and 5.7%; p=0.006, high, medium vs low). Mortality rate increased with higher IHCT when all the high-risk subgroups were combined (8.6% vs 4.5% vs 3.2%; p < 0.001, high, medium vs low). By multivariate analysis, IHCT remained the most significant predictor of adverse outcomes (relative risk high vs low 2.22, 95% confidence interval: 1.04 to 4.76). No characteristic, event, medication, or transfusion therapy confounded the relationship between IHCT and outcome.

CONCLUSION

High IHCT is associated with a higher rate of myocardial infarction and is an independent predictor of infarction. On the basis of the risk of myocardial infarction, there is no rationale for transfusion to an arbitrary level after coronary artery bypass grafting.

Prevalence of fragile X(A) syndrome in mentally retarded children at a genetics referral centre in Delhi, India

The usefulness of the clinical score based on Turner 5-trait scale prior to undertaking cytogenetic or molecular tests for the diagnosis of the fragile X(A) syndrome was evaluated. Mean clinical score in fragile X positive patients was significantly higher than in fragile X negative patients (7.06 +/- 1.85 vs 2.98 +/- 1.6, P < 0.0001). Of 1206 children with mental retardation 360 (29.8%) boys fulfilled defined clinical criteria to be screened for fragile X syndrome by chromosomal studies. Twenty three (6.38%) of them were found to be positive for fragile X syndrome using cytogenetic techniques. Molecular confirmation in 21 affected boys (two were lost to follow up) showed full mutation in 19 (5.27%). Two patients showed a normal 5.2 kb band on southern blot. This frequency (5.27%) of fragile X(A) patients among children with non-specific mental retardation is comparable to the results of studies in the West. Routine use of the clinical score, and the selection of patients with a score > or = 5 for diagnostic tests would reduce the laboratory load, especially in countries with limited facilities.

Wave recognition and use of the intraoperative unipolar esophageal electrocardiogram

STUDY OBJECTIVES

To evaluate the automated determination of onset and offset times and amplitudes of all the PQRST waves from simultaneously recorded surface electrocardiogram (SECG) and unipolar esophageal ECG (EsECG). The occurrence of ST segment deviation is also examined.

DESIGN

Prospective, observational study.

SETTING

University hospital.

PATIENTS

30 patients undergoing coronary artery bypass graft (CABG) surgery.

INTERVENTIONS

SECG and two-lead unipolar EsECG were recorded after induction of anesthesia and before cardiopulmonary bypass (CPB).

MEASUREMENTS AND MAIN RESULTS

The amplitudes of the P and T waves and the ST segment deviation were measured. EsECG had more noise than SECG. Slight movement of the esophageal electrodes occasionally caused substantial changes in the wave amplitudes and ST segment deviation in the unipolar EsECG. The maximum P wave amplitude in EsECG was, on average, 97% greater than the maximum P wave amplitude in SECG, ST segment deviation in EsECG was observed in the absence of ST segment deviation in SECG and vice versa.

CONCLUSIONS

The recognition and measurement of all the PQRST waves can be improved and automated by simultaneous use of EsECG and SECG. The P wave amplitude is greater in EsECG than in SECG, which may faciliate the identification of supraventricular versus ventricular arrhythmias. ST segment deviation in the unipolar EsECG may not be suitable for the routine detection of ischemia.

Electrocardiographic and hemodynamic changes and their association with myocardial infarction during coronary artery bypass surgery. A multicenter study. Multicenter Study of Perioperative Ischemia (McSPI) Research Group

BACKGROUND

Electrocardiographic (ECG) changes during coronary artery bypass graft surgery have not been described in detail in a large multicenter population. The authors describe these ECG changes and evaluate them, along with demographic and clinical characteristics and intraoperative hemodynamic alterations, as predictors of myocardial infarction (MI) as defined by two sets of criteria.

METHODS

Data from 566 patients at 20 clinical sites, collected as part of a clinical trial to evaluate the efficacy of acadesine for reducing MI, were analyzed at core laboratories. Perioperative ECG changes were identified using continuous three-lead Holter ECG. Systolic blood pressure, diastolic blood pressure, and heart rate were recorded each minute during operation. The occurrence of MI by Q wave or myocardial fraction of creatine kinase (CK-MB) or autopsy criteria, and by (Q wave and CK-MB) or autopsy criteria was determined.

RESULTS

During perioperative Holter monitoring, episodes of ST segment deviation, major cardiac conduction changes > or = 30 min, or use of ventricular pacing > or = 30 min occurred in 58% patients, primarily in the first 8 h after release of aortic occlusion. Of the 25% patients who met the Q wave or CK-MB or autopsy criteria for MI, 19% had increased CK-MB as well as ECG changes. (Q wave and CK-MB) or autopsy criteria for MI were met by 4% of patients. The CK-MB concentration generally peaked by 16 h after release of aortic occlusion. In patients with (n = 187) and without a perioperative episode of ST segment deviation, the incidence of MI was 36% and 19%, respectively (P < 0.01), by Q wave or CK-MB or autopsy criteria, and 6% and 3%, respectively (P = 0.055), by (Q wave and CK-MB) or autopsy criteria. Multiple logistic regression analysis showed that intraoperative ST segment deviation, intraventricular conduction defect, left bundle branch block, duration of hypotension (systolic blood pressure < 90 mmHg) after cardiopulmonary bypass, and duration of cardiopulmonary bypass are independent predictors of Q wave or CK-MB or autopsy MI. The independent predictors of (Q wave and CK-MB) or autopsy MI are intraoperative ST segment deviation and duration of aortic occlusion.

CONCLUSIONS

Major ECG changes occurred in 58% of patients during coronary artery bypass graft surgery, primarily within 8 h after release of aortic occlusion. Multicenter data collection revealed a substantial variation in the incidence of MI and an overall incidence of up to 25%, with most MI occurring within 16 h after release of aortic occlusion. Intraoperative monitoring of ECG and hemodynamics has incremental value for predicting MI.

Multicenter study of target-controlled infusion of propofol-sufentanil or sufentanil-midazolam for coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group

BACKGROUND

The use of target-controlled infusions of anesthetics for coronary artery bypass graft surgery has not been studied in detail. The effects of target-controlled infusions of propofol or sufentanil, supplemented by infusions of sufentanil or midazolam, respectively, were evaluated and compared.

METHODS

At 14 clinical sites, 329 patients were given a target-controlled infusion of propofol (n = 165) to produce effect-site concentration (Ce) of > or = 3-micrograms/ml or a target-controlled infusion of sufentanil (n = 164). Sufentanil or midazolam, respectively, also were infused. Systolic hypertension, hypotension, tachycardia, and bradycardia were assessed by measuring heart rate and blood pressure every minute during operation. Myocardial ischemia was assessed perioperatively by monitoring ST segment deviation via continuous three-lead Holter electrocardiography, and it was evaluated during operation by monitoring left ventricular wall motion abnormality via transesophageal echocardiography.

RESULTS

The measured cardiovascular parameters were satisfactory and usually similar for the patients receiving propofol-sufentanil or sufentanil-midazolam. The primary endpoint of the percentage of patients with intraoperative ST segment deviation (23 +/- 6% vs. 24 +/- 6%, P = 0.86) did not differ significantly between the two groups. The incidence of left ventricular wall motion abnormality shown on transesophageal echocardiography before (19 +/- 4% vs. 26 +/- 4%, P = 0.25) and after (23 +/- 4% vs. 31 +/- 5%, P = 0.32) cardiopulmonary bypass also did not differ significantly for the two groups. Changes in intraoperative target concentration were more frequent with propofol-sufentanil anesthetic than with sufentanil-midazolam (11.7 +/- 7.1 vs. 7.3 +/- 3.6, P < 0.001). The incidence of intraoperative hypotension (77% vs. 55%, P < 0.001), the use of inotropic/vasopressor medications (93% vs. 84%, P = 0.01), and the administration of crystalloids (2.8 +/- 1.4 L vs. 2.4 +/- 1.2 L, P < 0.001) were significantly greater in the propofol-sufentanil group. Conversely, the incidence of intraoperative hypertension (43% vs. 54%, P = 0.05) and the use of antihypertensive/vasodilator medications (70% vs. 90%, P < 0.001) were significantly less in the propofol-sufentanil group.

CONCLUSIONS

Target-controlled infusions of propofol or sufentanil, supplemented by infusions of sufentanil or midazolam, respectively, were suitable to provide anesthesia for coronary artery bypass graft surgery. Continuous monitoring revealed a high prevalence of hemodynamic abnormalities. Despite greater hypotension in the propofol-sufentanil group and greater hypertension in the sufentanil-midazolam group, episodes of myocardial ischemia were similar for both groups and were not temporally related to episodes of hemodynamic abnormalities.

Cardiovascular responses during sedation after coronary revascularization. Incidence of myocardial ischemia and hemodynamic episodes with propofol versus midazolam. Institutions of the McSPI Research Group

BACKGROUND

Propofol sedation offers advantages for titration and rapid emergence in the critically ill patient, but concern for adverse hemodynamic effects potentially limits its use in these patients. The current study compares the cardiovascular effects of sedation with propofol versus midazolam during the first 12 h after coronary revascularization.

METHODS

Three hundred fifty-one patients undergoing coronary revascularization were anesthetized using a standardized sufentanil/midazolam regimen, and assigned randomly to 12 h of sedation with either propofol or midazolam while tracheally intubated. The incidence and characteristics of hemodynamic episodes, defined as heart rate less than 60 or greater than 100 beats/min or systolic blood pressure greater than 140 or less than 90 mmHg, were determined using data electronically recorded at 1-min intervals. The presence of myocardial ischemia was determined using continuous three-channel Holter electrocardiography (ECG) and of myocardial infarctions (MI) using 12-lead ECG (Q wave MI, Minnesota Code) or creatine kinase isoenzymes (CK-MB) analysis (non-Q wave MI, peak CK-MB > 70 ng/ml, or CK-MB > 70 IU/I).

RESULTS

Ninety-three percent of patients in both treatment groups had at least one hemodynamic episode during the period of postoperative sedation. Propofol sedation resulted in a 17% lower incidence of tachycardia (58% vs. 70%, propofol vs. midazolam; P = 0.04), a 28% lower incidence of hypertension (39% vs. 54%; P = 0.02), and a greater incidence of hypotension (68% vs. 51%; P = 0.01). Despite these hemodynamic effects, the incidence of myocardial ischemia did not differ between treatment groups (12% propofol vs. 13% midazolam; P = 0.66), nor did its severity, as measured by ischemic minutes per hour monitored (8.7 +/- 5.8 vs. 6.2 +/- 4.6 min/h, propofol vs. midazolam; P = 0.19) or ischemic area under the curve (6.8 +/- 4.0 vs. 5.3 +/- 4.2; P = 0.37). The incidence of cardiac death (one per group), Q wave MI (propofol, n = 7; midazolam, n = 3; P = 0.27), or non Q wave MI (propofol, n = 16; midazolam, n = 18; P = 0.81) did not differ between treatment groups.

CONCLUSIONS

Hemodynamic episodes occur frequently in the first 12 h after coronary revascularization. Compared with a standard sedation regimen (midazolam), propofol sedation appears to modulate postoperative hemodynamic responses by reducing the incidence and severity of tachycardia and hypertension and increasing the incidence of hypotension. Both sedation regimens appear similarly safe with respect to myocardial ischemia. These findings indicate that propofol infusion provides effective sedation without deleterious hemodynamic effects in patients recovering from cardiac surgery.

Caring for the ICU patient receiving propofol

This article, the first in the new DCCN department for acute-care nurse practitioners, clinical nurse specialists, and advanced practice nurses, focuses on the pharmacodynamics of propofol. The advanced practice nurse working in the ICU is likely to institute propofol protocols, teach staff about the drug, and collaborate with the bedside nurse on the patient's outcome to this treatment.

An electrocardiographic lead system for coronary artery bypass surgery

STUDY OBJECTIVES

To identify the optimal subset of two electrocardiographic (ECG) leads for monitoring of ischemic ST depression and elevation during coronary artery bypass grafting (CABG) surgery.

DESIGN

Prospective observational clinical study.

SETTING

University hospital cardiac surgery operating room.

PATIENTS

120 patients undergoing primary surgery or reoperation for CABG.

INTERVENTIONS

All six ECG limb leads and a precordial matrix of four leads were recorded intraoperatively approximately every 3 minutes. The limb leads were placed on the torso in modified Mason-Likar positions. The precordial leads were placed at V4, V5, and one interspace below them.

MEASUREMENTS AND MAIN RESULTS

New ischemic 1 mm ST depression and elevation episodes were determined. New ST deviation episodes attributed to nonischemic causes such as cooling at the onset of cardiopulmonary bypass (CPB), defibrillation at the end of CPB, new cardiac conduction changes after CPB, and postoperative pericarditis were excluded. Fixed ST deviation that did not change by 1 mm in the perioperative period was also excluded. Leads V5 and III constituted the best two-lead set. These leads recorded 15 of the 16 ischemic ST elevation episodes and all 8 ischemic ST depression episodes. One ST elevation episode was not recorded intraoperatively but was recorded in lead V1 in the immediate postoperative ECG. Leads V5 and II recorded 13 of the 16 ischemic ST elevation episodes and all 8 ischemic ST depression episodes. Lead V5 alone missed 8 episodes of ischemic ST elevation and one episode of ischemic ST depression.

CONCLUSIONS

For monitoring of ischemia during CABG, leads V5 and III are preferable to other two-lead sets, including the commonly used V5 and II. No single lead is adequate. Lead V5 alone missed approximately one half the episodes of ST elevation that were recorded by lead III or another inferior lead.

Myocardial injury during reoperation for coronary artery bypass surgery

OBJECTIVES

To determine the incidence, triggers, and timing of myocardial injury during reoperation for coronary artery bypass surgery.

DESIGN

Prospective observational.

SETTING

One tertiary care university hospital.

PARTICIPANTS

15 patients undergoing reoperation.

INTERVENTIONS

Multilead electrocardiographic monitoring approximately every 3 minutes during surgery.

MEASUREMENTS AND MAIN RESULTS

The occurrence of a new ischemic ST elevation or depression on the electrocardiogram (ECG) was determined. A major deterioration in ventricular function after cardiopulmonary bypass (CPB) also was determined. Peak creatine kinase myocardial band (CK-MB) > or = 25 IU/L was considered to be the marker of myocardial injury. Seven patients demonstrated myocardial injury, all intraoperatively. Five of these patients had new ST elevation episodes before CPB. Three of the episodes were temporally associated with an abrupt increase in the heart rate. The other two episodes were temporally associated with surgical manipulation of the heart and the old grafts. The sixth patient had a significant deterioration of ventricular function during CPB. One of the patients who had ST elevation before CPB and the seventh patient developed ST elevation towards the end of protamine administration.

CONCLUSIONS

In patients undergoing reoperation, the intraoperative incidence of myocardial injury, especially before CPB, was found to be substantially higher than that previously reported.

Myocardial ischemia after cardiopulmonary bypass

Intraoperatively, myocardial ischemia is more common after cardiopulmonary bypass (CPB) than before CPB. Ischemia associated with coronary vasospasm and thrombosis may be much more common toward the end of surgery and early in the postoperative period than previously appreciated. This may be because the coagulation system is altered during CPB, and the coronary endothelium is damaged significantly as a result of cardioplegic arrest followed by reperfusion. In this milieu, vasospasm and thrombosis may be caused by the administration of protamine. Some of the ischemia observed in this period actually is not reversible and is associated with myocardial injury and infarction. It may be ameliorated by the administration of calcium channel blockers, aspirin, and anticoagulants. Electrocardiography may be the most suitable modality for the detection of ischemia after CPB and postoperatively. During this period, many episodes of ST deviation are of a nonischemic etiology, and the ECG needs careful interpretation. Transesophageal echocardiography is suitable for use intraoperatively and early on in the intensive care unit.

Voiding efficiency after ureteral reimplantation: a comparison of extravesical and intravesical techniques

The purpose of our study was to examine postoperative changes and recovery in voiding efficiency after intravesical and extravesical ureteral reimplantation. Retrospective review was performed of 188 cases. Inclusion criteria were the presence of primary vesicoureteral reflux and the absence of previous lower urinary tract surgery. Voiding efficiency after ureteral reimplantation was assessed based on post-void residual volume measurements. It was found that postoperative voiding efficiency of patients in the extravesical unilateral group was similar to that in the intravesical group, while the extravesical bilateral group had a statistically significantly higher proportion of patients with transient voiding inefficiency. A statistically higher proportion of those in the extravesical bilateral group also required some form of urinary catheter drainage for a longer period. However, on more prolonged followup all evaluable patients in the 3 groups fully regained voiding efficiency.

Voiding efficiency after ureteral reimplantation: a comparison of extravesical and intravesical techniques

The purpose of our study was to examine postoperative changes and recovery in voiding efficiency after intravesical and extravesical ureteral reimplantation. Retrospective review was performed of 188 cases. Inclusion criteria were the presence of primary vesicoureteral reflux and the absence of previous lower urinary tract surgery. Voiding efficiency after ureteral reimplantation was assessed based on post-void residual volume measurements. It was found that postoperative voiding efficiency of patients in the extravesical unilateral group was similar to that in the intravesical group, while the extravesical bilateral group had a statistically significantly higher proportion of patients with transient voiding inefficiency. A statistically higher proportion of those in the extravesical bilateral group also required some form of urinary catheter drainage for a longer period. However, on more prolonged followup all evaluable patients in the 3 groups fully regained voiding efficiency.

A clinical and cytogenetic study of Turner syndrome

Forty five case of Turner syndrome diagnosed in the Genetics Clinic, between January 1986 and December 1993, were analyzed. The most commonly observed karyotype was 45, X (44.4%), followed by 45, X/46, XX mosaicism (24.4%). Less frequently demonstrated karyotypes were 45, X/46, X, i (Xq) mosaicism and 46, X, i (Xq) (13.3%). Mosaicism for chromosome was seen in 6.7% of patients. Patients with 45, X karyotype had short stature (85%), dysmorphic facies (60%), delayed appearance of secondary sexual characters (100%) and primary amennorhea (100%). Those with 45, X/46, XX mosaicism were less often dysmorphic and presented with either primary or secondary amenorrhea. Patients with 45, X karyotype were younger at diagnosis and had a significantly shorter mean adult height than those with 45, X/46, XX mosaicism. The phenotype in patients with other karyotypic abnormalities was similar to the 45, X group. Short stature and primary or secondary amenorrhea occurring together in a female strongly suggests the possibility of Turner syndrome, which should be confirmed by chromosomal analysis.

Effects of perioperative dexmedetomidine infusion in patients undergoing vascular surgery. The Study of Perioperative Ischemia Research Group

BACKGROUND

Dexmedetomidine, a highly selective alpha 2-adrenergic agonist, increases perioperative hemodynamic stability in healthy patients but decreases blood pressure and heart rate. The goal of this study was to evaluate, in a preliminary manner, the hemodynamic effects of perioperatively administered dexmedetomidine in surgical patients at high risk for coronary artery disease.

METHODS

Twenty-four vascular surgery patients received a continuous infusion of placebo or one of three doses of dexmedetomidine, targeting plasma concentrations of 0.15 ng/ml (low dose), 0.30 ng/ml (medium dose), or 0.45 ng/ml (high dose) from 1 h before induction of anesthesia until 48 h postoperatively. All patients received standardized anesthesia and hemodynamic management. Blood pressure, heart rate, and Holter ECG were monitored; additional monitoring included continuous 12-lead ECG preoperatively, anesthetic concentrations and myocardial wall motion (echocardiography) intraoperatively, and cardiac enzymes postoperatively.

RESULTS

Preoperatively, there was a decrease in heart rate (low dose 11%, medium dose 5%, high dose 20%) and systolic blood pressure (low dose 3%, medium dose 12%, high dose 20%) in patients receiving dexmedetomidine. Intraoperatively, dexmedetomidine groups required more vasoactive medications to maintain hemodynamics within predetermined limits. Postoperatively, demedetomidine groups had less tachycardia (minutes/monitored hours) than the placebo group (placebo 23 min/h; low dose 9 min/h, P = 0.006; medium dose 0.5 min/h, P = 0.004; high dose 2.3 min/h, P = 0.004). Bradycardia was rare in all groups. There were no myocardial infarctions or discernible trends in the laboratory results.

CONCLUSIONS

Infusion of dexmedetomidine up to a targeted plasma concentration of 0.45 ng/ml appears to benefit perioperative hemodynamic management of surgical patients undergoing vascular surgery but required greater intraoperative pharmacologic intervention to support blood pressure and heart rate.

Poland anomaly with unusual associated anomalies: case report of an apparent disorganized defect

We report on a 2 1/2-year-old boy with absence of clavicular head of pectoralis major on the left side, ipsilateral upper limb anomalies, and anomalies of the lower limbs such as popliteal webbing, median cleft of right foot, bifid left hallux, syndactyly of toes, and toenail hypoplasia. Other anomalies included undescended testis, hairy nevus in the lumbosacral region, and a pedunculated finger-like tag on the right thigh. The pathogenesis of these associated anomalies cannot be explained on the basis of compromised local blood supply alone. A possible link with the disorganization mutation is discussed.

Cellular immunity in depressed, conduct disorder, and normal adolescents: role of adverse life events

OBJECTIVE

To determine whether adolescents with major depressive disorder have disturbances in their cellular immunity and to study whether the immunological changes detected are specific to depression or are general responses to stress.

METHOD

Twenty subjects with major depressive disorder, 17 nondepressed subjects with conduct disorder, and 17 normal adolescents were recruited. Subjects were assessed with a clinical interview for DSM-III-R and a modified version of the Coddington Life Events Checklist. Blood samples were drawn for total white blood cells, lymphocytes subsets, natural killer cell activity, lymphocyte proliferation response to phytohemagglutinin, and cortisol plasma levels.

RESULTS

Overall, there were no significant between-group differences in any of the cellular immune measurements. Natural killer cell activity was significantly negatively correlated with past year and lifetime adverse life events across all effector-target cell ratios. Controlling for diagnoses and socioeconomic status yielded similar results. There were no significant effects of age, sex, race, sleep, nutrition, cigarette use, menstrual cycle, or cortisol on any of the immunological variables.

CONCLUSIONS

In this sample of adolescents, we found that independent of the diagnoses and socioeconomic status, increases in adverse life events were associated with low natural killer cell activity.