Descriptions of three new species of Strattis Pascoe, 1883 (Coleoptera: <br />Curculionidae: Cryptorhynchinae) from the Indian subcontinent

The cryptorhynchine genus Strattis Pascoe originally described from Sri Lanka is recorded from India with the descriptions of three new species: S. pascoei sp. nov., S. maculatus sp. nov., and S. srilankaiensis sp. nov. from the Indian subcontinent. Strattis biguttatus is designated as type species for the genus. A key to species is provided. The character of a presumable stridulatory structure between the meta-femur and the first abdominal ventrite is discussed.

Effect of no-tillage and tillage on the ecology of mite, Acarina (Oribatida) in two different farming systems of paddy field in Cachar district of Assam

The present investigation was carried out in Cachar district of Assam over a period of one year (January 2011 - December 2011) to understand the seasonal ecology of Acarina (Oribatida) in rice (Oryza sativa L.) cultivated fields. Population of Oribatida was found to be maximum during August 2011, both in no-tillage (6.32 ± 0.66 No./m2 x 100(2)) and tillage (5.30 ± 0.71 No./M2 x 100(2)) sites in Dorgakona area whereas the peak was recorded during August 2011, both in no-tillage (5.38 ± 0.75 No./m(2) x 100(2)) and tillage (4.69 ± 0.77 No./m2 x 100(2)) in Durby area of study sites. Least population was encountered during January 2011, in both no-tillage (0.98 ± 0.28 ± No./m2 x 100(2)) and tillage (0.98 ± 0.30 No/m2 x 100(2)) sites in Dorgakona area whereas the same was found during November 2011 in no-tillage (0.57 ± 0.31 No.m/2 x 100(2)) and in February 2011 in tillage (0.45 ± 0.21 No./m2 x 100(2)) sites of Durby area. Linear regression analysis with all the environmental variables showed positive and significant influence on the population dynamics whereas relative humidity (R2 = 0.26 p > 0.05) in Dorgakona no-tillage and tillage (R2 = 0.19 P > 0.05) sites and relative humidity in tillage site (R2 = 0.27 P > 0.05) in Durby area showed no influence. Multiple regression analysis showed that the combined effect of climatic variables having a significant influence (p < 0.05) on the oribatid mite population in no-tillage and tillage systems in both the study sites. Rainfall, relative humidity and temperature facilitated the soil moisture, microbial activity and litter decomposition, which in turn may favour the reproduction and growth rate of the species. Among microclimatic conditions all the parameters showed positive and significant influence (P < 0.05) on the population in no-tillage and tillage system on both the sites except pH which showed negative correlation with the population. One way ANOVA revealed significant difference (F = 6.53, P < 0.01) of the Oribatid population between the systems.

Seasonal distribution of Isotomina thermophilan in a secondary succession and a homegarden in Cachar, Assam

Present investigation was carried out in Cachar district of Assam over a period of two years (May 2007-April 2009) to understand the seasonal ecology of Isotomina thermophila (Axelson, 1900) in secondary succession and homegarden ecosystems. Population was found to be maximum during July 2008 (7949.05 No. m(-2)) and September 2008 (7949.05 No. m(-2)) in homegarden whereas the peak was recorded in secondary succession during September 2008 (13656.05 No. m(-2)). Least population was encountered during March 2008 (1222.93 No. m(-2)) and April 2008 (1630.57 No. m(-2)) in homegarden and secondary succession, respectively. It may be due to the fact that, vital activity of this species effected in the dry period or migrate towards lower soil profile in search of food and moisture. Linear regression analysis established the hypothesis that all the environmental variables showed positive and significant influence on the population dynamics whereas in homegarden, rainfall (r = 0.36, p > 0.05) did not show any influence. In multiple regression analysis positive and significant influences (p < 0.05) were recorded for both the investigated sites. Rainfall, relative humidity and temperature facilitated the soil moisture, microbial activity, litter decomposition may favour the reproduction and growth rate of the species. Among microclimatic conditions except soil pH all other parameters exhibited significant correlations (p < 0.05) with population. Based on the present investigation, it can be concluded that I. thermophilia does not differ much with the general ecology of collembolans in this sub humid climate.

Tracheal intubation in the critically ill: a multi-centre national study of practice and complications

BACKGROUND

Complications associated with tracheal intubation may occur in up to 40% of critically ill patients. Since practice in emergency airway management varies between intensive care units (ICUs) and countries, complication rates may also differ. We undertook a prospective, observational study of tracheal intubation performed by critical care doctors in Scotland to identify practice, complications, and training.

METHODS

For 4 months, we collected data on any intubation performed by doctors working in critical care throughout Scotland except those in patients having elective surgery and those carried out before admission to hospital. We used a standardized data form to collect information on pre-induction physical state and organ support, the doctor carrying out the intubation, the techniques and drugs used, and complications noted.

RESULTS

Data from 794 intubations were analysed. Seventy per cent occurred in ICU and 18% occurred in emergency departments. The first-time intubation success rate was 91%, no patient required more than three attempts at intubation, and one patient required surgical tracheostomy. Severe hypoxaemia ( <80%) occurred in 22%, severe hypotension (systolic arterial pressure <80 mm Hg) in 20%, and oesophageal intubation in 2%. Three-quarters of intubations were performed by doctors with more than 24 months formal anaesthetic training and all but one doctor with <6 months training had senior supervision.

CONCLUSIONS

Tracheal intubation by critical care doctors in Scotland has a higher first-time success rate than described in previous reports of critical care intubation, and technical complications are few. Doctors carrying out intubation had undergone longer formal training in anaesthesia than described previously, and junior trainees are routinely supervised. Despite these good results, further work is necessary to reduce physiological complications and patient morbidity.

Effect of spinal anaesthesia on plasma concentrations of glutathione S-transferase

BACKGROUND

Plasma glutathione S-transferase (GST) concentration measurement is a sensitive and specific index of hepatocellular injury. GST concentration increases after anaesthesia with most volatile anaesthetic agents, but not after propofol. Such increases are thought to result from reduced liver blood flow. The effect on GST concentration of spinal (subarachnoid) anaesthesia, which might also reduce liver blood flow, is not known.

METHODS

We studied the effects of spinal anaesthesia on GST concentrations measured by specific radioimmunoassay in 33 patients undergoing intermediate orthopaedic, general or gynaecological surgery. GST concentrations were measured before anaesthesia and 3, 6 and 24 h after induction of anaesthesia. Hypotension (systolic blood pressure <70% of pre-induction value) was rapidly corrected with i.v. ephedrine.

RESULTS

Mean duration of surgery was 41 min (range 11-80). No increase in GST concentration was observed at any time, but at 24 h GST concentration was significantly reduced (P<0.05). One patient in whom hypotension was not treated developed a greatly increased GST concentration at 3 h.

CONCLUSION

We found no association between spinal anaesthesia and disturbance of hepatocellular integrity when hypotension does not occur or is rapidly corrected.

The coagulative and cardiorespiratory responses to reamed intramedullary nailing of isolated fractures

We measured the changes during operation in seven markers of coagulation in a prospective series of 84 patients with fractures of the tibia or femur who were undergoing reamed intramedullary nailing. All patients were also continually monitored using transoesophageal echocardiography to assess marrow embolism. In a subset of 40 patients, intraoperative cardiopulmonary function was monitored, using pulmonary and systemic arterial catheterisation. The procedure produced a significant increase in prothrombin time, activated partial thromboplastin time, the level of prothrombin fragments F1+2 and D-dimers, and a decrease in the fibrinogen level, suggesting activation of both the coagulation and fibrinolytic pathways. There was evidence of both platelet hyper-reactivity and depletion, as estimated by an increase in beta-thromboglobulin levels and a decrease in the platelet count. In the patients who had invasive monitoring there was an incremental increase in mean pulmonary arterial pressure, with the changes being greatest during insertion of the guide-wire and reaming. The change in markers of coagulation, pulmonary artery pressure and arterial oxygen partial pressures correlated with the intraoperative embolic response. Greater changes in these parameters were observed during stabilisation of pathological fractures and in those patients in whom surgery had been delayed for more than 48 hours. Seven patients with pathological fractures developed more severe hypoxic episodes during reaming, which were associated with significantly greater arterial hypoxaemia, a fall in the right ventricular ejection fraction and an increase in the mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure and the pulmonary vascular resistance index. These changes suggested that the patients had transient intraoperative right heart strain. Eight patients developed significant postoperative respiratory compromise. They all had severe intraoperative embolic responses and, in the three who had invasive monitoring, there was a significantly greater increase in pulmonary artery pressure and alveolar-arterial oxygen gradient, and a fall in the ratio of arterial partial pressure of oxygen to the inspired oxygen concentration. Operative delay, intraoperative paradoxical embolisation and the scores for the severity of the coagulative and embolic responses were predictive of the development of postoperative respiratory complications on univariate logistic regression analysis. On multivariate analysis, however, only the embolic and coagulative scores were significant independent predictors of respiratory complications.

The coagulative and cardiorespiratory responses to reamed intramedullary nailing of isolated fractures

We measured the changes during operation in seven markers of coagulation in a prospective series of 84 patients with fractures of the tibia or femur who were undergoing reamed intramedullary nailing. All patients were also continually monitored using transoesophageal echocardiography to assess marrow embolism. In a subset of 40 patients, intraoperative cardiopulmonary function was monitored, using pulmonary and systemic arterial catheterisation.

The procedure produced a significant increase in prothrombin time, activated partial thromboplastin time, the level of prothrombin fragments F1+2 and D-dimers, and a decrease in the fibrinogen level, suggesting activation of both the coagulation and fibrinolytic pathways. There was evidence of both platelet hyper-reactivity and depletion, as estimated by an increase in β-thromboglobulin levels and a decrease in the platelet count. In the patients who had invasive monitoring there was an incremental increase in mean pulmonary arterial pressure, with the changes being greatest during insertion of the guide-wire and reaming.

The change in markers of coagulation, pulmonary artery pressure and arterial oxygen partial pressures correlated with the intraoperative embolic response. Greater changes in these parameters were observed during stabilisation of pathological fractures and in those patients in whom surgery had been delayed for more than 48 hours.

Seven patients with pathological fractures developed more severe hypoxic episodes during reaming, which were associated with significantly greater arterial hypoxaemia, a fall in the right ventricular ejection fraction and an increase in the mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure and the pulmonary vascular resistance index. These changes suggested that the patients had transient intraoperative right heart strain.

Eight patients developed significant postoperative respiratory compromise. They all had severe intraoperative embolic responses and, in the three who had invasive monitoring, there was a significantly greater increase in pulmonary artery pressure and alveolar-arterial oxygen gradient, and a fall in the ratio of arterial partial pressure of oxygen to the inspired oxygen concentration. Operative delay, intraoperative paradoxical embolisation and the scores for the severity of the coagulative and embolic responses were predictive of the development of postoperative respiratory complications on univariate logistic regression analysis. On multivariate analysis, however, only the embolic and coagulative scores were significant independent predictors of respiratory complications.

Stress and coping with scoliosis: psychological effects on adolescents and their families

The psychological, functional, and family impact of brace treatment for idiopathic scoliosis was assessed in a cross-sectional follow-up study. Eighty-four percent of parents described the initial bracing period in stressful terms. Establishing a daily routine facilitated coping with bracewear treatment. While bracewear did not necessarily affect participation in many common activities, subjects perceived limitations in sports, physical activities, and social events. There was no evidence of overt psychopathology among the subjects, although the initial bracewear period was associated with lower levels of self-esteem. Recommendations that can minimize the stresses attendant to bracewear treatment are given.

Serum thyroxine binding capacity-dependent bias in an automated free thyroxine assay

The magnitude of serum thyroxine (T4) binding capacity (sBC) dependent bias in the AXSYM free thyroxine (FT4) assay was assessed using two recently described tests. One of the tests uses a direct equilibrium dialysis (ED) FT4 assay as the reference method. The results obtained with the AXSYM method were compared with those obtained by the ED FT4 method in patient sera having a wide range of sBC. The other test involves comparison of the FT4 results obtained following dilution of sera by an inert buffer, to theoretically derived FT4 results. As serum dilution causes a predictable decrease in sBC, the demonstration of a negative bias whose magnitude increases in parallel to the dilution, is indicative of an sBC-dependent bias. The AXSYM FT4 assay exhibited a significant sBC-dependent bias. This sBC-dependent bias is likely to have been caused by the presence of significant amounts of T4 binding proteins in the assay reagents.

Assessment of serum thyroxine binding capacity-dependent biases in free thyroxine assays

BACKGROUND

Free thyroxine (FT4) assays may exhibit biases that are related to serum T4 binding capacity (sBC). We describe two tests that can be used to assess the presence and magnitude of sBC-dependent biases in FT4 assays.

METHODS

We used a direct equilibrium dialysis FT4 assay as the reference method and compared the results obtained with those of the FT4 assays under investigation, in patient sera having a wide range of sBC. We then compared the expected and observed FT4 results for sera diluted with an inert buffer. Because serum dilution causes a predictable decrease in sBC, an increasingly negative bias on progressive dilution is indicative of a sBC-dependent bias.

RESULTS

The automated FT4 assay investigated (Vitros FT4) showed no demonstrable sBC-dependent bias by either test.

CONCLUSION

These two tests can be used to screen for sBC-dependent biases in FT4 assays.

Effect of sevoflurane anaesthesia on plasma concentrations of glutathione S-transferase

To assess the effect of sevoflurane anaesthesia on hepatocellular integrity, we measured plasma concentrations of glutathione S-transferase (GST) before anaesthesia and 1, 3, 6 and 24 h after the end of anaesthesia in 41 healthy, Japanese patients undergoing elective, body surface surgery. Sevoflurane (approximately 1.0 MAC) was delivered in 50-66% nitrous oxide in oxygen via a circle system, with a fresh gas flow of 6 litre min-1. Ventilation was spontaneous in all patients. Mean duration of anaesthesia was 101 min. Concentrations of GST increased significantly 1 h after the end of anaesthesia (P = 0.0075), but this was not significantly different from preoperative concentrations at 3, 6 and 24 h. Three patients developed a large secondary increase in GST concentrations at 24 h. The increase observed at 1 h was probably a result of reduced total liver blood flow; the mechanism for the secondary increase at 24 h is unclear but the possibility that products of sevoflurane biotransformation are responsible cannot be excluded.

Relationship of admission thyroid function tests to outcome in critical illness

One hundred and eighty patients had serum thyrotropin, total triiodothyronine and free thyroxine concentrations measured within 3 h of admission to the Intensive Therapy Unit to assess whether thyroid function tests could predict outcome in critical illness. Overall mortality was 30.6%. Nonsurvivors were older (p = 0.001), and had higher APACHE II scores (p < 0.001) and predicted mortalities (p < 0.001). There was no difference in the median values of thyrotropin, total triiodothyronine and free thyroxine concentrations between survivors and nonsurvivors. Thyrotropin concentration was subnormal in 15 patients, normal in 152 and elevated in 13 patients. In contrast, 80 patients had subnormal triiodothyronine concentration. Free thyroxine was subnormal in five patients. Thyrotropin, total triiodothyronine and free thyroxine concentrations were not related to outcome (p = 0.360, p = 0.622, p = 0.726, respectively). No variable independently predicted death. Total triiodothyronine concentrations were lower in patients who received dopamine before admission to the intensive therapy unit than those who did not (p = 0.008); thyrotropin and free thyroxine concentrations were not influenced by dopamine administration. Serum concentrations of thyrotropin, total triiodothyronine and free thyroxine measured within 3 h of admission to the intensive therapy unit are not predictive of outcome.

Biological variation and the effect of fasting and halothane anesthesia on plasma glutathione S-transferase concentrations

Using a specific RIA, we have investigated in patients and volunteers whether fasting, diminished hepatic clearance, hemoconcentration, or within-day biological variation might be responsible for the transient increases in plasma glutathione S-transferase (GST) concentration observed after anesthesia. GST concentration was measured in 44 healthy volunteers after an overnight fast and at 3, 6, and 24 h after the fasting sample. The concentration was significantly lower at 3 and 6 h after than in the fasting sample (P = 0.0019 and P = 0.015, respectively). The change in GST concentration caused by fasting was examined in 30 subjects by comparing pre- and postfasting values. Fasting had no significant effect on GST concentration overall (P = 0.4721), but two individuals showed a marked increase in GST concentration after fasting overnight. In a separate study of 10 patients, plasma amylase activity and plasma concentrations of GST and albumin were measured immediately before and 3 h after induction of halothane anesthesia. Although GST concentration was increased at 3 h in each of the 10 patients, plasma amylase activity and plasma albumin concentration were significantly decreased in all patients (P = 0.002). Apparently, increases in GST concentration after anesthesia do not result from incidental factors.

Medullary lavage reduces embolic phenomena and cardiopulmonary changes during cemented hemiarthroplasty

We randomised 24 patients before they had a cemented hemiarthroplasty for hip fracture to receive either thorough or minimal saline lavage of the femoral canal. We then determined the effect in each group on the thromboembolic and cardiopulmonary responses to the pressurised insertion of cement, using transoesophageal echocardiography to show the echogenic embolic response. We found a statistically significant reduction in both the duration of the response and the number of large emboli in patients who had had thorough lavage as compared with the control group with minimal lavage. There was also less disturbance of pulmonary function, as assessed by the change in end-tidal CO2 levels and oxygen saturation, in patients who had thorough lavage. Three patients had a significant fall in blood pressure during cement insertion; all had only minimal lavage. We consider that thorough lavage should be an essential part of the preparation of the proximal femur before cement insertion.

Biological variation and the effect of fasting and halothane anesthesia on plasma glutathione S-transferase concentrations

Using a specific RIA, we have investigated in patients and volunteers whether fasting, diminished hepatic clearance, hemoconcentration, or within-day biological variation might be responsible for the transient increases in plasma glutathione S-transferase (GST) concentration observed after anesthesia. GST concentration was measured in 44 healthy volunteers after an overnight fast and at 3, 6, and 24 h after the fasting sample. The concentration was significantly lower at 3 and 6 h after than in the fasting sample (P = 0.0019 and P = 0.015, respectively). The change in GST concentration caused by fasting was examined in 30 subjects by comparing pre- and postfasting values. Fasting had no significant effect on GST concentration overall (P = 0.4721), but two individuals showed a marked increase in GST concentration after fasting overnight. In a separate study of 10 patients, plasma amylase activity and plasma concentrations of GST and albumin were measured immediately before and 3 h after induction of halothane anesthesia. Although GST concentration was increased at 3 h in each of the 10 patients, plasma amylase activity and plasma albumin concentration were significantly decreased in all patients (P = 0.002). Apparently, increases in GST concentration after anesthesia do not result from incidental factors.

Effects of perceived responsibility on help-seeking decisions among elderly persons

This study sought to clarify why elderly adults underutilize mental health services. One hundred ten elderly individuals were asked to imagine experiencing symptoms described in a vignette and to appraise their responsibility for the problem and for its solution, their willingness to seek help, and their preference among sources of help. Results indicated that perception of problems as either medical or psychological significantly affected how elders appraised responsibility. Although attributions were unrelated to help-seeking for medical problems, elderly persons feeling responsible for psychological problems were more likely to seek help for them. Perceived responsibility predicted the sources of help (e.g., social network, physicians, mental health workers) selected by elders who believed that their problems were medical, but not for problems thought to be psychological. A discussion of the reasons for their underutilization of mental health services is presented, with an emphasis on the practical implications of the results.

Halothane hepatitis

The historical background, clinical features, morphology, epidemiology and aetiology of halothane hepatitis have been presented. Animal models of halothane hepatotoxicity have been described, although their application to humans is of doubtful significance. Two, probably distinct, forms of liver damage associated with halothane have been identified. The much more common mild form may result from reductive biotransformation of halothane, possibly influenced by genetic factors, or reduced liver oxygenation, whereas the rare fulminant form is most likely to be immune-mediated. The role of altered calcium homeostasis has not yet been established. In addition, a common mechanism for liver dysfunction associated with halogenated volatile anaesthetic agents has been proposed. The hepatotoxicity of enflurane cannot be excluded; while hepatic dysfunction after isoflurane or nitrous oxide is considered unlikely, further attention is necessary. It is too soon to comment on the hepatotoxic potential of sevoflurane or desflurane.

Effect of adrenaline on plasma concentrations of bupivacaine following lower limb nerve block

Twenty-two patients undergoing total knee arthroplasty received combined sciatic plus femoral "3 in 1" blocks as adjuncts to general anaesthesia. Eleven patients received 0.375% bupivacaine 45 ml (168.75 mg) with adrenaline 1 in 200,000 and the remaining 11 received plain solution according to a previously prepared, randomized list. The mean maximum plasma bupivacaine concentration was significantly greater with plain solution than when adrenaline was added (1.66 micrograms ml-1 compared with 0.98 micrograms ml-1) (P less than 0.05). Bupivacaine concentrations were greater at all times in the plain group compared with the group receiving adrenaline. These differences were statistically significant at 10, 15 and 20 min (P less than 0.05). The greatest peak concentration recorded was 3.13 micrograms ml-1 in one patient receiving plain bupivacaine. No patient developed signs of systemic toxic effects. Peak plasma concentrations were related inversely to body weight in patients receiving solution containing adrenaline (P less than 0.005), but no relationship existed in patients who received plain solution.

A disposable blood pressure cuff. An assessment of its accuracy

An empty 500-ml infusion bag was used as the cuff for a Lifestat 100 oscillotonometer. The systolic and mean blood pressures obtained in 40 subjects were not significantly different from those measured with a standard cuff. The diastolic pressure was unrelated between the two cuffs. The empty bag is a cheap and hygienic option in patients who present a high infection risk.

Preoperative cimetidine does not prevent subclinical halothane hepatotoxicity in man

To assess the influence of pretreatment with cimetidine on changes in hepatocellular integrity after halothane anaesthesia, 53 patients were allocated randomly to receive either cimetidine 1600 mg orally or placebo tablets before anaesthesia. Plasma concentrations of glutathione S-transferase (GST) were measured as an index of hepatic damage. Data from 45 patients were available for analysis. Plasma GST concentration increased significantly 3 h after induction of anaesthesia in both groups (P less than 0.01, both groups) and at 6 h in the cimetidine group (P less than 0.05). Pretreatment with cimetidine did not influence the magnitude of increase in GST concentration. There was no difference between the groups in the frequency of abnormal GST concentrations at any time. Cimetidine does not appear to prevent release of GST from the liver by halothane anaesthesia in man.

Effect of nicardipine infusion on the release of glutathione S-transferase following halothane anaesthesia

To assess the possible protective effect of calcium channel blockade on hepatic function after halothane anaesthesia, 80 patients were allocated randomly to receive an i.v. infusion of either nicardipine or normal saline. Plasma concentration of glutathione S-transferase B1 subunits (GST) was measured as a sensitive index of hepatic damage. Data from 53 patients were analysed. Plasma GST concentration increased significantly at 3 and 6 h after induction of anaesthesia in the placebo group (P less than 0.01), and at 3 h (P less than 0.01) and 6 h (P less than 0.05) in the nicardipine group. The administration of nicardipine resulted in a greater increase in plasma GST concentrations at 3 h than did placebo (P less than 0.05), mainly because of a greater increase in males than in females. The increase in GST at 3 h was related inversely to plasma concentration of nicardipine both at the end of the exponential infusion (P less than 0.01) and at 2 h after induction (P less than 0.05), when males had lower plasma nicardipine concentrations than females (P less than 0.05). Calcium channel blockade with nicardipine in the dose administered was not shown to reduce liver dysfunction after halothane anaesthesia.

Haemodynamic responses to nicardipine in humans anaesthetised with halothane

The haemodynamic effects of an infusion of nicardipine were studied noninvasively before, during and after halothane anaesthesia in man, using a simple technique to achieve constant plasma drug concentrations. Eighty patients were randomly allocated to receive an intravenous infusion of either nicardipine or normal saline. Systolic and diastolic arterial pressures were significantly lower and heart rate significantly higher throughout the infusion than before infusion (p less than 0.001, all variables) in those patients who received nicardipine. The hypotension induced by nicardipine was not affected by induction of anaesthesia; halothane significantly reduced the nicardipine-induced tachycardia (p less than 0.001). Nicardipine caused no cardiac rhythm disorders. This technique for the intravenous administration of nicardipine achieves appropriate stable plasma concentrations, is devoid of severe haemodynamic disturbance and appears to be safe to use during halothane anaesthesia in patients with normal left ventricular function.

Continuous intravenous morphine for pain relief after abdominal surgery

We studied prospectively 247 consecutive patients given morphine by continuous intravenous infusion for 24 h to provide pain relief following elective abdominal surgery. Using a dose of 1 mg/kg supplemented by additional intramuscular morphine 5 mg as necessary, only 26% required more than two additional intramuscular doses for discomfort. In 71 patients, the infusion was discontinued temporarily, mostly because of low respiratory rates. These patients were older (P less than 0.01), and their mean respiratory rate over the 24 h was significantly less (P less than 0.001) than those in whom the infusion was continuous. The technique was inexpensive, easy to use in a general surgical ward, and safe provided certain rules were observed.

Plasma glutathione S-transferase concentration as a measure of hepatocellular integrity following a single general anaesthetic with halothane, enflurane or isoflurane

The plasma concentration of hepatic glutathione S-transferase (GST) was measured in matched groups of patients who received halothane, enflurane or isoflurane anaesthesia for elective minor surgery. The GST concentrations increased significantly at 3 h after anaesthesia in patients who received halothane or enflurane, but not in patients who were given isoflurane. A secondary increase in GST concentration, at 24 h, was seen in a small number of individuals who received halothane or enflurane. Abnormal GST concentrations were found in 50% of patients following halothane anaesthesia, 20% following enflurane and 11% after isoflurane. The small but significant increases in GST concentrations in patients receiving halothane or enflurane suggests an impairment of hepatocellular integrity following the administration of these anaesthetics. In contrast, isoflurane anaesthesia did not appear to be associated with this effect.

Hypokalemic paralysis associated with renal tubular acidosis

Patients with renal tubular acidosis may show hypokalemic paralysis. We report a case in which the symptoms of hypokalemia and the onset of paralysis were initially mistaken for the Guillain-Barré syndrome.

Psychiatric consultation in somatization disorder. A randomized controlled study

The per capita expenditure for health care of patients with multiple physical symptoms but no apparent physical disease (somatization disorder) is up to nine times the average per capita amount. We conducted a randomized controlled trial to determine whether psychiatric consultation would reduce the medical costs of these patients, without effecting a substantial change in patient outcome. Thirty-eight patients were randomly assigned to treatment or control groups and studied prospectively for 18 months. Treatment consisted of a psychiatric consultation and suggestions on management given to primary physicians. After nine months, the control group was crossed over to receive treatment with the same intervention. After the psychiatric consultation, the quarterly health care charges in the treatment group declined by 53 percent (P less than 0.05). In contrast, the charges in the control group showed wide variations but no overall change. The quarterly charges in the control group were significantly higher than those in the treatment group (P less than 0.05). After the control group was crossed over to receive treatment, their quarterly charges declined by 49 percent (P less than 0.05). The reductions in expenditures in both groups were due largely to decreases in hospitalization. We conclude that psychiatric consultation in the care of patients with somatization disorder reduced subsequent health care expenditures without inducing changes in health status or patients' satisfaction with their health care.

Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization

To define groups of patients with inappropriately high health care utilization better, we have studied a group of 41 chronically ill patients to determine their characteristics, symptoms, functional health status, and amount of health care utilization. This group had somatization disorder diagnosed by specific criteria. They can be easily recognized by primary care physicians by their multiple complaints, negative physical examination results, and a history of multiple medical examinations. We found them to be functionally disabled, spending an average of seven days ill in bed each month. They perceived themselves as severely ill and were willing to undergo multiple hospitalizations, diagnostic studies, and operations. Their health care charges were extraordinary, averaging $4,700 annually. The physician can most effectively treat these patients by scheduling regular visits, relying on physical examinations rather than diagnostic studies, and avoiding costly hospitalizations.