Comparison of a blind and an ultrasound-guided technique for Retrobulbar anesthesia in dogs undergoing unilateral subconjunctival enucleation

OBJECTIVE

This study compared the quality of retrobulbar anesthesia using a blind inferior-temporal palpebral approach (ITP) with an ultrasound-guided supratemporal (ST) technique in dogs undergoing unilateral enucleation.

ANIMAL STUDIED

Twenty-one client-owned dogs were undergoing enucleation.

PROCEDURES

Dogs were randomly assigned to receive ITP (n = 10) or ST (n = 11) with 0.5% ropivacaine at 0.1 mL/cm of neurocranial length. The anesthetist was blinded to the technique. Intraoperative data included cardiopulmonary variables, inhalant anesthetics requirement, and requirement for rescue analgesia (intravenous fentanyl 2.5 mcg/kg). Postoperative data included pain scores, sedation scores, and need for intravenous hydromorphone (0.05 mg/kg). Treatments were compared using Wilcoxon's rank sum test or Fisher's exact test as appropriate. Comparison of variables over time were tested using a mixed effect linear model on rank. Significance was set at p = 0.05.

RESULTS

Intraoperative cardiopulmonary variables and inhalant requirements were not different between groups. Dogs receiving ITP required median (interquartile range, IQR) 1.25 (0, 2.5) mcg/kg intraoperative fentanyl while those receiving ST required none (p < 0.01). Intraoperative fentanyl was required in 5/10 and 0/11 of dogs in the ITP and ST groups, respectively (p = 0.01). Postoperative analgesia requirements were not significantly different between groups; 2/10 and 1/10 dogs in the ITP and ST groups, respectively. Sedation score negatively affected pain score (p < 0.01).

CONCLUSIONS

The ultrasound-guided ST technique was more effective at decreasing intraoperative opioid requirements than the blind ITP approach in dogs undergoing unilateral enucleation.

A Public Health Grid (PHGrid): Architecture and value proposition for 21st century public health

PURPOSE

This manuscript describes the value of and proposal for a high-level architectural framework for a Public Health Grid (PHGrid), which the authors feel has the capability to afford the public health community a robust technology infrastructure for secure and timely data, information, and knowledge exchange, not only within the public health domain, but between public health and the overall health care system.

METHODS

The CDC facilitated multiple Proof-of-Concept (PoC) projects, leveraging an open-source-based software development methodology, to test four hypotheses with regard to this high-level framework. The outcomes of the four PoCs in combination with the use of the Federal Enterprise Architecture Framework (FEAF) and the newly emerging Federal Segment Architecture Methodology (FSAM) was used to develop and refine a high-level architectural framework for a Public Health Grid infrastructure.

RESULTS

The authors were successful in documenting a robust high-level architectural framework for a PHGrid. The documentation generated provided a level of granularity needed to validate the proposal, and included examples of both information standards and services to be implemented. Both the results of the PoCs as well as feedback from selected public health partners were used to develop the granular documentation.

CONCLUSIONS

A robust high-level cohesive architectural framework for a Public Health Grid (PHGrid) has been successfully articulated, with its feasibility demonstrated via multiple PoCs. In order to successfully implement this framework for a Public Health Grid, the authors recommend moving forward with a three-pronged approach focusing on interoperability and standards, streamlining the PHGrid infrastructure, and developing robust and high-impact public health services.

Hyperparathyroidism and psychosis: possible prelude to murder

The authors present a case of a middle aged attorney who suffered from hyperparathyroidism and a psychotic disorder. It is possible that the hyperparathyroidism may have precipitated an acute psychotic delusional rage leading to an attempted mass murder. They discuss the relationship between hyperparathyroidism and neuropsychiatric symptoms in consideration of available research.

Refusing care to emergency department of patients: evaluation of published triage guidelines

STUDY OBJECTIVE

To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care.

DESIGN

Historical cohort study.

SETTING

A public hospital ED.

TYPE OF PARTICIPANTS

All patients triaged during a one-week period who were not in the most acute triage category.

MEASUREMENTS

Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patient's outcome.

MAIN RESULTS

Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized.

CONCLUSION

When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

Thermoregulatory vasoconstriction during propofol/nitrous oxide anesthesia in humans: threshold and oxyhemoglobin saturation

To determine the thermoregulatory effects of propofol and nitrous oxide, we measured the threshold for peripheral vasoconstriction in seven volunteers over a total of 13 study days. We also evaluated the effect of vasoconstriction on oxyhemoglobin saturation (SpO2). Anesthesia was induced with an intravenous bolus dose of propofol (2 mg/kg), followed by an infusion of 180 micrograms.kg-1 x min-1 for 15 min, and maintained with 60% nitrous oxide and propofol (80-160 micrograms.kg-1 x min-1). Central and skin surface temperatures and SpO2 (using two different pulse oximeters) were measured continuously; plasma propofol concentrations and arterial PO2 were measured at 15-min intervals. Volunteers were cooled with a circulating water blanket until definitive peripheral vasoconstriction was detected. The tympanic membrane temperature triggering vasoconstriction was considered the thermoregulatory threshold. Vasoconstriction developed on seven study days during propofol/nitrous oxide anesthesia at a central temperature of 33.3 +/- 1.0 degrees C (mean +/- SD) and plasma propofol concentration of 3.9 +/- 1.1 micrograms/mL. The thresholds during anesthesia were significantly lower than those during the control period (36.7 +/- 0.3 degrees C), but the correlation between plasma propofol concentrations and vasoconstriction thresholds was poor. On the remaining six study days, vasoconstriction did not develop despite central temperatures ranging from 32.1 to 32.7 degrees C. Corresponding propofol concentrations were 4.1-10.9 micrograms/mL. These data suggest that anesthesia with propofol, in typical clinical concentrations, and 60% nitrous oxide substantially inhibits thermoregulatory vasoconstriction. Vasoconstriction increased SpO2 by approximately 2% without a significant concomitant change in PO2. The observed increase in SpO2 probably reflects decreased transmission of arterial pulsations to venous blood in the finger.

Emergency computerized tomography of tracheoesophageal fistula in lung adenocarcinoma

Malignant tracheoesophageal fistula occurs infrequently in patients with irradiated esophageal and lung cancer, uncommonly in patients with untreated mediastinal malignancies, infection, or trauma, and rarely in primary adenocarcinoma of the lung. The natural progression of this entity leads to rapid deterioration and death from overwhelming pulmonary infection.Definitive treatment depends on the demonstration and localization of the fistula. Computerized tomography (CT) chest scanning with dilute oral contrast is the ideal means of identification of the fistula. CT scanning without contrast may outline sufficiently the pathology to avoid the usage and side effects of contrast media in the lungs.A review of one case of tracheoesophageal fistula due to pulmonary adenocarcinoma is presented where emergency CT scanning without contrast resulted in rapid and accurate diagnosis, leading to prompt and appropriate management.

Occult mucous airway obstruction in diabetic ketoacidosis

Four patients with diabetes mellitus and no underlying clinical pulmonary disease were found to have extensive unilateral mucous occlusion of a major central bronchus. None of the patients had significant auscultatory findings suggestive of pulmonary secretions, and chest roentgenographic films were normal. Arterial blood gas evaluation failed to reveal the usual hypocapnia during ketoacidosis, thus prompting bronchoscopic examination or deep airway suctioning. These interventions disclosed and resolved the mucous obstruction of the compromised bronchus. Antibiotic therapy, based upon bronchial secretion Gram stain and culture, was successfully instituted in all patients. Lethargy and autonomic neuropathy are proposed as contributing factors responsible for occult mucous plugging in diabetic patients in ketoacidosis. The absence of hypocapnia in this setting may be the only clue to silent mucous plugging of airways.

Bacteroidosis

Bacteroides infection frequently complicates surgery, instrumentation, or trauma to the alimentary, upper respiratory, and female genitourinary tracts. Bacteroides sp, alone or with other organisms, also may cause infections in the ear, nose, and throat, and other tissues where defeneses are lowered. Foul-smelling pus, sinus drainage, material from an abscess or infected traumatic wound, or a blood culture made because of a suspected anaerobic complication should be subjected to anaerobic study in the laboratory. Treatment of clinical bacteroidosis consists of specific antibiotics, surgery, oxygen under pressure, and appropriate local dressings. Treatment is often more effective if at least two antibiotics are given concurrently, and antibiotic sensitivity tests are recommended to select the best combination.