129 RE-THINKING THE MEMORY CONSENSUS MEETING: A QUALITY IMPROVEMENT INITIATIVE

Background

As part of our memory clinic service, weekly consensus meetings are held to allow for multidisciplinary diagnostic evaluation of new cases. As part of a local Quality Improvement (QI) initiative, we reviewed how this meeting could be streamlined to maximise efficiency and improve diagnostic accuracy in light of increasing referrals and patient complexity. Here we describe the development and initial implementation of this QI project.

Methods

A structured QI approach was taken to develop SMART (Specific, Measurable, Achievable, Realistic, Timely) goals. All professional stakeholders (from disciplines including geriatric medicine, neurology and psychiatry of later life) who attend the weekly consensus meeting were surveyed anonymously with a response rate of 80% (n=8). Information was gathered on areas that worked well, areas that needed improvement and suggestions for meeting enhancement. In addition, participants were asked at a single meeting to subjectively rate the complexity of eleven cases presented into the following categories: low, medium and high. Data were collated and presented to the memory clinic staff for further refinement.

Results

Four key actions were identified for implementation: formal allocation of a meeting chair, improvement of access to imaging from outside hospitals, revision of current proforma to streamline case discussions, and proposal to discuss patients in order of new assessment, return assessment and review of significant results. During the rating of case complexity, there was substantial variation among respondents.

Conclusion

This initial phase has been used to develop SMART goals to improve the consensus meeting structure. We identified that patient complexity would be an inefficient method to order case discussion. Implementation of action steps are ongoing, with positive feedback from staff to date.

Outcomes of a residential respite service for homeless people with tuberculosis in London, UK: a cross-sectional study

BACKGROUND

Many countries are seeking to eliminate tuberculosis (TB), but incidence remains high in socially excluded groups such as people experiencing homelessness. There is limited research into the effectiveness of residential respite services (RRS), which provide accomodation and social and clinical support for homeless people with active TB.

METHODS

We used a register of all cases of TB diagnosed in London between 1 January 2010 and 3 October 2019 to compare characteristics and outcomes of patients treated in an RRS with patients receiving standard care. The primary outcome was successful treatment completion. We used logistic regression to compare likelihood of completing treatment, and simulation to estimate the absolute change in treatment completion resulting from this service.

RESULTS

A total of 78 homeless patients finished an episode of TB treatment at the RRS. Patients treated in the RRS were more likely than patients treated in standard care to have clinical and social risk factors including drug resistance, history of homelessness, drug or alcohol use, and need for directly observed therapy. After adjusting for these factors, patients treated in the RRS had 2.97 times the odds of completing treatment (95% CI = 1.44-6.96). Treatment ended in failure for 8/78 patients treated in the RRS (10%, 95% CI = 5%-20%). We estimated that in the absence of the RRS, treatment would have ended in failure for 17/78 patients (95% CI = 11-25).

CONCLUSION

The residential respite service for homeless TB patients with complex social needs was associated with better treatment outcomes.

A Randomized, Crossover Trial of a Nutritional Intervention for Rheumatoid Arthritis

To investigate the effects of a dietary intervention on arthritis pain and disease severity, 44 adults previously diagnosed with rheumatoid arthritis were randomly assigned to a Diet phase (vegan diet for 4 weeks, elimination of additional foods for 3 weeks, and then reintroduction of the eliminated foods individually over 9 weeks) or a Supplement (placebo) phase for 16 weeks. After a 4-week washout, they then switched to the opposite phase. The Disease Activity Score-28 (DAS28) decreased from 4.5 to 2.5 (P < .001) in the Diet phase and from 3.2 to 2.9 (P = .41) in the Supplement phase (between-group P = .01). The mean number of swollen joints decreased from 7.0 to 3.3 in the Diet phase (P = .03) and increased from 4.7 to 5 in the Supplement phase (P = .63; between-group P = .047).

In a subanalysis excluding individuals who increased medications during the study, DAS28 decreased 1.9 points in the Diet phase (P = .003) and .4 points in the Supplement phase (P = .27; between-group P = .04). In a further subanalysis limited to participants making no medication changes, DAS28 decreased 1.5 points in the Diet phase (P = .009) and .3 points in the Supplement phase (P = .40, between-group P = .11). We conclude that the dietary intervention was associated with symptomatic improvements. TRIAL REGISTRATION: Clinicaltrials.gov NCT01544101, NCT01700881, NCT03417648, and NCT03580681

Ketogenic Diets and Chronic Disease: Weighing the Benefits Against the Risks

Very-low-carbohydrate ketogenic diets have been long been used to reduce seizure frequency and more recently have been promoted for a variety of health conditions, including obesity, diabetes, and liver disease. Ketogenic diets may provide short-term improvement and aid in symptom management for some chronic diseases. Such diets affect diet quality, typically increasing intake of foods linked to chronic disease risk and decreasing intake of foods found to be protective in epidemiological studies. This review examines the effects of ketogenic diets on common chronic diseases, as well as their impact on diet quality and possible risks associated with their use. Given often-temporary improvements, unfavorable effects on dietary intake, and inadequate data demonstrating long-term safety, for most individuals, the risks of ketogenic diets may outweigh the benefits.

The role of nutrition in asthma prevention and treatment

Asthma is a chronic respiratory condition characterized by airway inflammation and hyperreactivity. Prevalence has continued to rise in recent decades as Western dietary patterns have become more pervasive. Evidence suggests that diets emphasizing the consumption of plant-based foods might protect against asthma development and improve asthma symptoms through their effects on systemic inflammation, oxidation, and microbial composition. Additionally, increased fruit and vegetable intake, reduced animal product consumption, and weight management might mediate cytokine release, free radical damage, and immune responses involved in the development and course of asthma. The specific aim of this review paper is to examine the current literature on the associations between dietary factors and asthma risk and control in children and adults. Clinical trials examining the mechanism(s) by which dietary factors influence asthma outcomes are necessary to identify the potential use of nutritional therapy in the prevention and management of asthma.

Nationwide survey on training and device utilization during tracheal intubation in French intensive care units

Background

Intubation is a lifesaving procedure that is often performed in intensive care unit (ICU) patients, but leads to serious adverse events in 20–40% of cases. Recent trials aimed to provide guidance about which medications, devices, and modalities maximize patient safety. Videolaryngoscopes are being offered in an increasing range of options and used in broadening indications (from difficult to unremarkable intubation). The objective of this study was to describe intubation practices and device availability in French ICUs.

Materials and methods

We conducted an online nationwide survey by emailing an anonymous 26-item questionnaire to physicians in French ICUs. A single questionnaire was sent to either the head or the intubation expert at each ICU.

Results

Of 257 ICUs, 180 (70%) returned the completed questionnaire. The results showed that 43% of intubators were not fully proficient in intubation; among them, 18.8% had no intubation training or had received only basic training (lectures and observation at the bedside). Among the participating ICUs, 94.4% had a difficult intubation trolley, 74.5% an intubation protocol, 92.2% a capnography device (used routinely to check tube position in 69.3% of ICUs having the device), 91.6% a laryngeal mask, 97.2% front-of-neck access capabilities, and 76.6% a videolaryngoscope. In case of difficult intubation, 85.6% of ICUs used a bougie (154/180) and 7.8% switched to a videolaryngoscope (14/180). Use of a videolaryngoscope was reserved for difficult intubation in 84% of ICUs (154/180). Having a videolaryngoscope was significantly associated with having an intubation protocol (P = 0.043) and using capnography (P = 0.02). Airtraq^® was the most often used videolaryngoscope (39.3%), followed by McGrath^®Mac (36.9%) then by Glidescope^® (14.5%).

Conclusion

Nearly half the intubators in French ICUs are not fully proficient with OTI. Access to modern training methods such as simulation is inadequate. Most ICUs own a videolaryngoscope, but reserve it for difficult intubations.

Nutrition Interventions in Rheumatoid Arthritis: The Potential Use of Plant-Based Diets. A Review

Rheumatoid arthritis (RA), a chronic inflammatory autoimmune disease, affects roughly 1% of the world's population. RA pathogenesis remains unclear, but genetic factors account for 50–60% of the risk while the remainder might be linked to modifiable factors, such as infectious diseases, tobacco smoking, gut bacteria, and nutrition. Dietary triggers may play an inciting role in the autoimmune process, and a compromised intestinal barrier may allow food components or microorganisms to enter the blood stream, triggering inflammation. In addition, excessive body weight may affect pharmacotherapy response and the likelihood of disease remission, as well as the risk of disease mortality. Evidence suggests that changes in diet might play an important role in RA management and remission. Several studies have shown improvements in RA symptoms with diets excluding animal products. Studies have also shown that dietary fiber found in these plant-based foods can improve gut bacteria composition and increase bacterial diversity in RA patients, thus reducing their inflammation and joint pain. Although some of the trigger foods in RA patients are individualized, a vegan diet helps improve symptoms by eliminating many of these foods. This review examines the potential role of a plant-based diet in mediating RA symptoms. Further research is needed to test the effectiveness of plant-based diets on joint pain, inflammation, and quality of life in patients with RA.

Early identification of declining balance in higher functioning older adults, an inertial sensor based method

Higher functioning older adults rarely have their balance assessed clinically and as such early decline in balance is not captured. Early identification of declining balance would facilitate earlier intervention and improved management of the ageing process. This study sought to determine if (a) a once off inertial sensor measurement and (b) changes in inertial sensor measurements one year apart can identify declining balance for higher functioning older adults. One hundred and nineteen community dwelling older adults (58 males; 72.5±5.8 years) completed a timed up and go (TUG) instrumented with inertial sensors and the Berg balance scale (BBS) at two time points, one year apart. Temporal and spatio-temporal gait parameters as well as angular velocity and turn parameters were derived from the inertial sensor data. A change in balance from baseline to follow-up was determined by sub-components of the BBS. Changes in inertial sensor parameters from baseline to follow-up demonstrated strong association with balance decline in higher functioning older adults (e.g. mean medial-lateral angular velocity odds ratio=0.2; 95% CI: 0.1-0.5). The area under the Receiver operating characteristic curve (AUC) ranged from 0.8 to 0.9, a marked improvement over change in TUG time alone (AUC 0.6-0.7). Baseline inertial sensor parameters had a similar association with declining balance as age and TUG time. For higher functioning older adults, the change in inertial sensor parameters over time may reflect declining balance. These measures may be useful clinically, to monitor the balance status of older adults and facilitate earlier identification of balance deficits.

Cellular calcium mobilization in response to phosphoinositide delivery

Intracellular calcium [Ca(2+)](i) is mobilized in many cell types in response to activation of phosphoinositide (PIP(n)) signaling pathways involving PtdIns(4,5)P(2) or PtdIns(3,4,5)P(3). To further explore the relationship between increases in intracellular PIP(n) concentrations and mobilization of [Ca(2+)](i), each of the seven phosphorylated phosphoinositides (PIP(n)s) were delivered into cells and the metabolism and physiological effects of the exogenously administered PIP(n)s were determined. The efficient cellular delivery of fluorophore-tagged and native PIP(n)s was accomplished using histone protein, neomycin, and dendrimeric polyamines. PtdIns(4,5)P(2) fluorophore-tagged analogs with short- and long-acyl chains were substrates for cellular enzymes in vitro and for phospholipases in stimulated fibroblasts. PtdIns(4)P, PtdIns(3,4)P(2) and PtdIns(4,5)P(2), each induced calcium mobilization rapidly after exogenous addition to fibroblasts. PtdIns(3,4,5)P(3) induced a significant, but smaller increase in intracellular calcium. These observations suggest that PIP(n)s other than PtdIns(4,5)P(2) or PtdIns(3,4,5)P(3) may have direct roles in signaling involving [Ca(2+)](i).

Paclitaxel added to the cisplatin/etoposide regimen in extensive-stage small cell lung cancer -- the use of complete response rate as the primary endpoint in phase II trials

Obtaining a complete response (CR) is the most powerful predictor of survival in extensive-stage small cell lung cancer (SCLC). Improvements in long-term survival in extensive-stage SCLC can be made if the proportion of complete responders to induction therapy can be increased. We performed a phase II trial of the feasibility of adding paclitaxel to standard cisplatin/etoposide (EP regimen) in extensive-stage SCLC. The primary endpoint for this trial is the proportion of patients (pts) obtaining a CR rather than overall response. The null hypothesis for this trial consists of the absence of a CR rate >20%. Paclitaxel was given at doses of 135 (3 pts) or 170 mg/m(2) i.v. over 3 h on day 1. Cisplatin 60 mg/m(2) was given on day 1. On days 1-3 etoposide 80 mg/m(2) per day i.v. was given. G-CSF was used from days 5 to 14 of each cycle. Cycles were repeated q21 days. A two-stage design was used for patient accrual, based on the occurrence of complete responses. Initially, 16 patients were to be accrued. If more than three complete responses were to occur, a further 20 patients would be accrued to the study (Simon's optimal two stage design). Sixteen patients were enrolled. Two patients had a CR (13%) and nine patients had a partial response (56%) for an overall response rate of 69%. The trial was suspended due to the low CR rate. Review of the literature for paclitaxel based front-line treatment combined with EP therapy, in extensive stage SCLC, consistently shows a CR rate <20% but high overall response rate is maintained (thus most responses are partial). As virtually all long-term survivors in extensive-disease SCLC have had a CR to induction therapy and CR remains the strongest predictor of survival for this disease, this may suggest that paclitaxel added to standard EP may improve progression-free survival (and possibly median survival) but is unlikely to significantly improve long-term survival. Initial randomized phase III data confirm the absence of impact on survival for this triple-drug regimen compared to EP therapy alone. Furthermore, other regimens comparing favorably to the EP regimen have all shown consistent CR rates >20% in the phase II setting. In conclusion, consideration should be given to the use of CR rate as a phase II endpoint to determine if a particular regimen should be compared to the standard in a phase III setting for extensive-stage SCLC. A two-stage phase II design based on a minimum required completed responses for further patient accrual is recommended.

Becoming an adolescent father: precursors and parenting

Precursors and outcomes of adolescent pregnancy receive considerable research attention; however, most studies deal with adolescent mothers. This study examined whether risk factors that are precursors to adolescent fatherhood would be consistent with the family coercion model (G. R. Patterson, 1976) of the development of antisocial behavior in childhood. Hypotheses were tested in the Oregon Youth Study (OYS) sample of 206 at-risk boys who were first seen at 9 or 10 years of age. At 18-20 years of age, the profiles for the 35 adolescent fathers included more arrests and substance use than the other OYS participants. At around 2 years of age, 40% of the children had no contact with their fathers. The children, compared with a normative control sample, had somewhat greater health risks. The at-risk parents, compared with a control sample, were observed to show higher levels of negative reactions when their children were working on a puzzle task.

Becoming an adolescent father: precursors and parenting

Precursors and outcomes of adolescent pregnancy receive considerable research attention; however, most studies deal with adolescent mothers. This study examined whether risk factors that are precursors to adolescent fatherhood would be consistent with the family coercion model (G. R. Patterson, 1976) of the development of antisocial behavior in childhood. Hypotheses were tested in the Oregon Youth Study (OYS) sample of 206 at-risk boys who were first seen at 9 or 10 years of age. At 18-20 years of age, the profiles for the 35 adolescent fathers included more arrests and substance use than the other OYS participants. At around 2 years of age, 40% of the children had no contact with their fathers. The children, compared with a normative control sample, had somewhat greater health risks. The at-risk parents, compared with a control sample, were observed to show higher levels of negative reactions when their children were working on a puzzle task.

Predicting the timing of first sexual intercourse for at-risk adolescent males

Event history analysis was used to test a developmental model of the timing of first sexual intercourse in the Oregon Youth Study sample of adolescent males at risk for delinquency. The event history models spanned grades 7-12 with yearly multimethod, multiagent measures. A 3-step mediational model of predictors was tested, including contextual and process factors and boys' characteristics. Predictors included one-time measures of socioeconomic status, parental antisocial behavior, and time-varying measures of parental transitions, parental monitoring, deviant peer association, and the boys' antisocial/delinquent behavior, substance use, physical maturation, academic achievement, and anxiety. As predicted, antisocial/delinquent behavior and substance use along with early physical maturity and parental transitions predicted early onset of sexual intercourse. Anxiety was related to delay of first intercourse. Results and intervention implications are discussed in terms of the developmental findings.

Antisocial boys and their friends in early adolescence: relationship characteristics, quality, and interactional process

This study examines the close friendships of early adolescent boys in relation to antisocial behavior. 186 13-14-year-old boys and their close friends were interviewed, assessed at school, and videotaped in a problem-solving task. Similarity was observed between the demographic characteristics and antisocial behavior of the boys and their close friends. There was a tendency for the close friends of antisocial boys to live within the same neighborhood block and to have met in unstructured, unsupervised activities. Direct observations of interactions with close friends revealed a reliable correlation between antisocial behavior, directives, and negative reciprocity. Positive interactions within the friendship were uncorrelated with antisocial behavior and relationship quality. Implications of these findings for clinical and developmental theory are discussed.

Iron supplementation for acute blood loss anemia after coronary artery bypass surgery: a randomized, placebo-controlled study

OBJECTIVE

To evaluate the use of oral iron replacement therapy as an effective treatment for acute surgically induced anemia.

DESIGN

Double-blind, placebo-controlled, randomized clinical trial.

SETTING

Perioperative acute care hospital and a surgery clinic for a single cardiothoracic physician group.

PATIENTS

One hundred twenty-eight men and postmenopausal women, 50 years of age or older, admitted for elective coronary artery bypass surgery over a consecutive 8-month period.

OUTCOME MEASURES

Before surgery: serum iron, serum ferritin, hemoglobin and hematocrit. Six days after surgery: hemoglobin and hematocrit. Mean of 59 days after surgery: serum iron, serum ferritin, hemoglobin and hematocrit.

INTERVENTION

Patients were randomized to one of four groups: control group; placebo group; low-dose group, 50 mg elemental iron + 60 mg ascorbic acid in a multi-vitamin daily; and usual-dose group, 200 mg elemental iron daily.

RESULTS

One hundred twenty-one subjects completed the study: 100 men (82.6%) mean age 64.5 years and 21 women (17.4%), mean age 65.7 years. There were no statistically significant age or gender differences among groups. Statistical analysis revealed, except for side effects, no differences between or among groups for any variable measured during the last two time intervals. The mean hemoglobin and hematocrit of the entire sample at 6 days was 9.5 +/- 1.2 gm/dl and 28% +/- 2.3%, respectively. At a mean of 59 days later these values increased equally for all groups to a mean for the cohort of 13.6 +/- 1 gm/dl for hemoglobin and 40.6% +/- 3 for hematocrit. Serum iron and ferritin were within the normal range. The 200 mg group experienced significantly more side effects (p < 0.01).

CONCLUSION

Thus the use of oral iron supplements for the treatment of acute blood loss anemia after uncomplicated coronary artery bypass surgery did not assist in restoring red blood cell mass or help maintain total body iron stores.

Subcutaneous emphysema, pneumomediastinum, and potentially life-threatening tension pneumothorax. Pulmonary complications from arthroscopic shoulder decompression

Subcutaneous emphysema, pneumomediastinum, and tension pneumothorax are previously unreported complications of shoulder arthroscopy with subacromial decompression. Three patients developed extensive subcutaneous emphysema, pneumomediastinum, and bilateral tension pneumothorax during or immediately after shoulder arthroscopy with subacromial decompression. The procedure was terminated and appropriate treatment was given. All three patients recovered completely with no residual damage. The complications are thought to be associated with the extravasation of air that may be drawn in from the lateral portal when the arthroscopic infusion pump and power shaver with suction are turned on. Early diagnosis, followed by immediate termination of the infusion pump and suction shaver along with appropriate treatment can be life-saving.

Respiratory tract responses to dust: relationships between dust burden, lung injury, alveolar macrophage fibronectin release, and the development of pulmonary fibrosis

A multidisciplinary approach was used to investigate the responses of the respiratory tract to silica (SiO2) or titanium dioxide (TiO2). Rats were intratracheally instilled with 5-100 mg/kg of dust and bronchoalveolar lavage fluid (BALF) lactate dehydrogenase (LDH) and total protein (TP) and ex vivo alveolar macrophage (AM) fibronectin release assessed on Days 7, 14, and 28 after exposure. Lung dust burdens were determined on Days 1, 7, and 28 after instillation. Both dusts elicited dose-related increases in BALF LDH and TP, a response which was more pronounced and progressive with SiO2. All doses of SiO2 elicited persistent increases in AM fibronectin release. TiO2 stimulated persistent increases in AM fibronectin release at greater than or equal to 50 mg/kg, with transient or no effect at less than or equal to 10 mg/kg. Increased SiO2 retention was observed for all doses and TiO2 retention was increased only at doses greater than or equal to 50 mg/kg. In vitro exposure of naive AM to SiO2 or TiO2 did not stimulate AM fibronectin release. Histopathology demonstrated fibrosis at all SiO2 doses; only TiO2 doses greater than or equal to 50 mg/kg resulted in fibrosis. These results reveal an association between increased dust retention, lung injury, activation of AM fibronectin release, and the development of fibrosis. The magnitude and temporal pattern of responses clearly differentiated SiO2 from TiO2. The correlation of BALF markers of lung injury and increased AM fibronectin release with the development of fibrosis supports the use of these parameters as predictive biomarkers of dust-induced interstitial lung disease.

Clinical neurologic assessment tool: development and testing of an instrument to index neurologic status

The clinical neurologic assessment tool (CNA) is a 21-item instrument assessing response to verbal and tactile stimulation, ability to follow commands, muscle tone, body position, movement, chewing, and yawning in the patient with head trauma. The CNA was developed to detect subtle changes in the patients' neurologic status that may indicate transitions in the comatose state. The CNA has been extensively pilot tested. Reliability determined by using Cronbach's alpha revealed an internal consistency of 0.96. Concurrent validity testing with the Glasgow Coma Scale indicated a strong positive correlation, r = 0.94. Construct validity was assessed with factor analysis using 0.50 for a loading criterion. Three factors were demonstrated: general level of consciousness, muscle tone and resistance, and chewing or yawning. Discriminant function analysis revealed that the CNA scores correctly classified 95.1% of the patient observations into their respective Glasgow Coma Scale categories. The CNA is reliable, valid, convenient, and easily scored and captures the subtle changes in the patient with head trauma.

Morphologic and immunohistochemical evidence of human papillomavirus capsid antigen in smokeless tobacco keratoses from juveniles and adults

Seventy-seven tissue samples from patients with either degree I, II, or III smokeless tobacco keratoses were examined. The tissues were evaluated for the presence of human papillomavirus (HPV) antigen by immunocytochemical staining. Capsid antigen could be identified in sixteen cases (20.78%). This investigation further supports the concept that smokeless tobacco-associated leukoplakias can be correlated with HPV infection.

Whole body leucine, phenylalanine, and tyrosine kinetics in end-stage liver disease before and after hepatic transplantation

The kinetics of leucine, phenylalanine, and tyrosine metabolism following orthotopic human liver transplantation in end-stage liver disease in hospitalized patients were evaluated and compared to controls. The investigation was carried out by protein turnover studies using 13C leucine, D5-phenylalanine, and [U-14C] tyrosine by continuous infusion and employing a stochastic model in 32 patients with end-stage liver disease, 17 of whom went on to receive an hepatic allograft, and 7 controls without significant liver disease who underwent elective abdominal surgery. Mean tyrosine flux in the liver disease group was 3,242 +/- 811 (n = 32) v 2,899 +/- 688 mumol/h in controls (n = 7) (P less than .001), while the tyrosine oxidation was 328 +/- 179 v 422 +/- 185 mumol/h (P less than .001). Tyrosine clearance in pretransplant patients was 719 +/- 345 (n = 17) v 1,193 +/- 568 mL/min (P less than .005) in posttransplant patients (n = 17) with virtually no overlap. There was a significant correlation between serum albumin levels and the tyrosine clearance (r = .60, P less than .05), but correlations with other conventional liver function tests were of a low order. Leucine and phenylalanine kinetics in liver disease patients did not show any significant differences from controls. Leucine and tyrosine fluxes in controls did exhibit a significant correlation (r = .70, P less than .05), but no correlation was observed in patients with liver disease. These findings indicate that the kinetics of the amino acid tyrosine are substantially altered by end-stage liver disease, with the most profound effect on tyrosine clearance.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of intraoperative glucose on protein catabolism and plasma glucose levels in patients with supratentorial tumors

Animal studies suggest that hyperglycemia (glucose concentrations greater than 225 mg/dl) occurring prior to periods of brain ischemia exacerbates neurologic damage. Neurosurgical patients, a group at risk for intraoperative brain ischemia, often receive glucose. Therefore, the effects of intraoperative glucose administration (IGA) on these patients were studied. Sixteen patients undergoing supratentorial craniotomy were randomly assigned to receive either 5% glucose in 0.9% sodium chloride solution (G) or 0.9% sodium chloride solution (S) infusion (both at a rate of 3-4 ml X kg-1 X h-1) during the first 4 h of surgery. All patients received glucose infusions postoperatively. Plasma glucose, insulin, free fatty acids, alanine, ketones, base excess, pH, triglycerides, and lactate were measured during the infusion period and 24 h postoperatively. Urinary nitrogen was measured, commencing with the infusion and continuing for 24 h. Neurologic testing included preoperative and postoperative neurologic and psychomotor exams, time to extubation (min), and degree of alertness at the completion of anesthesia. The G group had significantly greater intraoperative plasma glucose concentrations at all time periods studied during the infusion (P less than 0.05). Glucose levels ranged from 200-242 mg/dl compared with 120-160 mg/dl in G and S groups, respectively. G group hyperglycemia was within the range associated with exacerbation of ischemic brain damage in animal studies. Free fatty acids and ketones were significantly greater (P less than 0.05) intraoperatively in the S group. Lactate and insulin were significantly greater in the G group at 4 h.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of reduced left ventricular mass on chamber architecture, load, and function: a study of anorexia nervosa

We investigated the effects of reduction in left ventricular mass on cavity geometry, afterload, pump function, and exercise performance in 17 patients with anorexia nervosa and in 10 age-and sex-matched normal subjects. Left ventricular mass index determined by two-dimensional echo-cardiography was significantly lower than that in normal subjects (53 +/- 15 vs 79 +/- 18 g/m2; p less than .005). Left ventricular end-diastolic and end-systolic volume indexes were also reduced in patients with anorexia nervosa compared with normal subjects (49 +/- 11 vs 65 +/- 17 ml/m2, p less than .005; 14 +/- 5 vs 19 +/- 4 ml/m2, p less than .025). In spite of the reductions in left ventricular mass and volume indexes, left ventricular chamber architecture described as h/R ratio, mass to volume ratio, and short/long left ventricular axis ratio were normal. Left ventricular afterload assessed as end-systolic meridional and circumferential wall stress was normal (59 +/- 18 vs 79 +/- 19 dyne/cm2 X 10(3) and 170 +/- 26 vs 167 +/- 23 dyne/cm2 X 10(3)). Ejection fraction, percent fractional shortening, and the relationship between end-systolic wall stress and ejection fraction were all within normal limits. In seven patients restudied after a 15% to 20% weight gain, left ventricular mass and volume indexes increased significantly but end-systolic wall stress and ejection fraction did not change. Ten patients with anorexia nervosa and resting heart rates and systolic blood pressures significantly lower than control values underwent treadmill testing. Exercise duration, peak heart rate, peak systolic blood pressure, and peak oxygen consumption in these patients were all significantly lower than normal. The hypotensive effect of fasting resulted in an initial decrease in afterload, which was the stimulus for reduction in left ventricular mass. The left ventricular remodeling associated with the mass reduction occurred in such a way that (1) orthogonal, meridional, and circumferential wall stresses were normalized, (2) normal chamber shape and architecture were maintained, and (3) chamber function and stress-shortening relationships were preserved. Thus down-regulation of left ventricular mass per se, like up-regulation of left ventricular mass, is not associated with abnormal left ventricular function.