Biomedical subjects
F Cunningham
Publications and source records attributed to F Cunningham.
Can we do better with postoperative pain management?
BACKGROUND: In the last decade, there has been heightened awareness that pain management needs to be a priority for all health care settings and clinicians. The article will overview practice guidelines and new technology, and assess their impact on pain relief in inpatient and outpatient surgeries from a patient's perspective. METHODS: Literature was retrieved by searches from 1996 to 2000 Medline and CINAHL (nursing database), using keywords "postoperative pain," "postsurgical pain," "patient outcomes," "pain outcomes," "survey," "questionnaire," and "practice guidelines." RESULTS: Overall, current practice standards have had minimal impact on decreasing patients' reports of pain. The incidence of moderate to severe pain with cardiac, abdominal, and orthopedic inpatient procedures has been reported as high as 25% to 50%, and incidence of moderate pain after ambulatory procedures is 25% or higher. CONCLUSIONS: Despite the advances, the incidence of pain remains high. Yet the future is promising, with new standards from the Joint Commission on Accreditation of Health care Organizations paving the way for reduction of institutional barriers and improved implementation of guidelines.
Changes in the phamacologic treatment of hypertension in the Department of Veterans Affairs 1997-1999: decreased use of calcium antagonists and increased use of beta-blockers and thiazide diuretics.
Older studies of antihypertensive treatment have shown that prescribing patterns are not consistent with recommendations from expert national panels. We determined whether prescribing patterns for antihypertensive drugs changed recently in the largest integrated health care system in the United States. Specifically, we determine 1) patterns of antihypertensive medication use at all Department of Veterans Affairs (VA) medical facilities for fiscal years 1997 to 1999, 2) the cost of this care, and 3) savings associated with changes in treatment patterns. Data were aggregated by individual medication as well as by antihypertensive drug class. Estimates of VA national antihypertensive drug costs are based on the median cost and the number of units for each dosage form of each medication dispensed at all facilities. At VA medical facilities, calcium antagonist use went from 33% to 29.3% of antihypertensive treatment days between 1997 and 1999, angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) use from 36.4% to 36.8%, beta-blockers from 19.1% to 21.1%, and thiazide diuretic use from at 11.5% to 12.8%. If treatment patterns had remained the same between 1997 and 1999 in terms of the proportion of medications from each drug class, an additional six million dollars would have been spent on antihypertensive medications in 1999. Although calcium antagonists and ACE inhibitors/ARB remained the most commonly dispensed antihypertensives at VA facilities from 1997 to 1999, there was a proportional decrease in calcium antagonist use and an increase in the use of thiazide diuretics and beta-blockers. These changes were consistent with improved compliance with VA national guidelines. The cost implications of these changes in practice patterns were considerable.
Actions and interactions of ADP, 5- HT, histamine and PAF on equine platelets.
Platelets are thought to play a role in equine diseases such as acute laminitis and verminous arteritis and may be involved in allergic disease. Mediators implicated in the pathophysiology of these conditions activate platelets and responses may be enhanced by interactions between mediators. The present study compared platelet aggregation, thromboxane production and release of radiolabelled [(3)H]5- HT in response to 5- HT, histamine, ADP and PAF alone and in combination in vitro.PAF caused concentration-related aggregation, [(3)H]5- HT release and thromboxane production. In contrast, ADP caused aggregation and 5- HT induced the release of [(3)H]5- HT with little effect on other platelet functions. Histamine had little or no effect on equine platelets. Addition of 5- HT (10 microM) prior to ADP significantly displaced the aggregation response curve to the left. The profile of responses to PAF, ADP and 5- HT suggests differential activation of intracellular signalling pathways regulating these events. The enhanced response to ADP in the presence of 5- HT may have implications in thromboembolic disease in the horse.
Pediatric advanced life support training of pediatricians in New Jersey: cause for concern?
OBJECTIVE: The Pediatric Advanced Life Support (PALS) course teaches the fundamental basics for pediatric emergency care, and it is recommended that all physicians, nurses, and paramedics who care for children complete training and refresher courses on a regular basis. The purpose of this study was to determine how many pediatricians in general practice participated in PALS courses in the first 3 years since its introduction in New Jersey. METHODS: A questionnaire was sent to all PALS training centers in New Jersey that administered the course from 1990 through 1993. The questionnaire was designed to determine the number of physicians trained; their specialty, and their practice setting. The questionnaire and follow-up telephone interviews focused on the perceptions of course coordinators as to why primary care pediatricians did or did not take PALS courses, and their recommendations for improving pediatrician participation. RESULTS: Two PALS training centers provided courses for only 1 year and did not maintain records of their students. A total of 3652 individuals completed training in the remaining 11 centers. Only 649 of these students were physicians. The largest groups of physicians who completed training were Emergency Medicine physicians (248) and Pediatric residents (175). Forty-two students were pediatricians in general office-based practice, which represents a crude rate of only 0.81% of New Jersey American Academy of Pediatrics (AAP) members. Training center coordinators offered several opinions for these findings. CONCLUSIONS: The majority of those students who participated in PALS training were not physicians. Pediatricians in general office practice accounted for a small percentage of those who could have participated. Further research should be conducted to determine attitudes toward PALS training and the barriers that exist to the office-based pediatrician participating in PALS training.
Heart rate variability and plasma catecholamines in patients during opioid detoxification.
It has been shown that rapid opioid detoxification is associated with increased sympathetic activity (SYMP) and plasma catecholamines. Heart rate (HR) variability may provide a noninvasive method of evaluating withdrawal and sympathetic activation caused by the reversal of opioid binding in patients who are opioid dependent. The purpose of this study was to evaluate the relationship between HR variability and plasma catecholamines during opioid detoxification. Patients were anesthetized with propofol, intubated, paralyzed with rocuronium infusion, and ventilated. The bispectral index (BIS) of the electroencephalogram was recorded with the patient awake as well as during propofol anesthesia. SYMP was determined by power spectral analysis of HR variability. Plasma epinephrine and norepinephrine were measured at baseline propofol anesthesia and during naltrexone treatment in eight opioid-dependent patients. Nonopioid-dependent controls (n = 7) were monitored during surgery without naltrexone treatment or measurement of plasma catecholamines. Compared with an awake status, propofol anesthesia significantly decreased the BIS and SYMP in both groups of patients. Controls showed no change from baseline anesthetized levels during surgery. Plasma norepinephrine and epinephrine as well as SYMP increased 300 to 400% (P < .05) during naltrexone treatment in opioid-dependent patients, and the time to peak increase in plasma norepinephrine correlated with the increase in SYMP (r = 0.89, P < .01). These results confirm that opioid detoxification increases plasma catecholamines and SYMP in a similar manner. HR rate variability may provide a low-cost real-time noninvasive method of evaluating the reversal of opioid binding in opioid-dependent patients.
The in vivo unidirectional conversion of nitro-D-arginine to nitro-L-arginine.
We recently reported that nitric oxide synthase in the brain can be inhibited not only by nitro-L-arginine (L-NA) but also by its D-enantiomer nitro-D-arginine (D-NA). In the present study, we found that D-NA, when tested in vitro, was 400 times less potent than L-NA. However, when D-NA was injected in vivo, its L-enantiomer, L-NA, was found to rapidly appear in plasma samples (approximately 1 min), rose to a maximum concentration at 30 min (approximately 40% conversion), and remained at this plateau for about 5 h. This was consistent with the changes in blood pressure. There was no conversion of L- to D-NA. The results suggested that D-NA has very weak biological actions by itself, but when administered in vivo, D-NA can be converted to L-NA.
Comparative pharmacokinetics and pharmacodynamics of remifentanil, its principle metabolite (GR90291) and alfentanil in dogs.
Remifentanil is an esterase-metabolized opioid developed for use in anesthesia. The principal metabolite of remifentanil, GR90291, is considered to be less potent. This study determined the relative potency of GR90291 and alfentanil, compared with remifentanil, in anesthetized dogs. Male dogs received thiamylal sodium, and anesthesia was maintained using isoflurane and N2O in oxygen. Each dog received a 5-min infusion of 0.5 microg/kg/min remifentanil, 500 microg/kg/min GR90291 and 1.6 mg/kg/min alfentanil in random order, separated by 1 week. Serial blood samples were collected during and after the infusion. The electroencephalogram was evaluated using aperiodic analysis. The pharmacokinetics and pharmacodynamics of remifentanil, GR90291 and alfentanil were determined using nonlinear least-squares regression analysis. Remifentanil was rapidly eliminated, with a terminal half-life of 6 min, compared with 19 min for GR90291 and alfentanil. Using the estimated concentration that elicits 50% of the maximum response (EC50) for delta EEG activity and spectral edge95, remifentanil was 4213 to 4637 times more potent than GR90291 and 7.7 to 8.5 times more potent than alfentanil. The blood-brain equilibration half-life was 2.3 to 5.2 min for remifentanil, 0.39 to 0.41 min for GR90291 and 3.1 to 3.7 min for alfentanil.
Changes in cerebral blood flow velocity in children during sevoflurane and halothane anesthesia.
The purpose of this study was to evaluate arterial blood pressure and middle cerebral artery blood flow velocity in children during induction of anesthesia with sevoflurane. These measures were compared to findings in a control group anesthetized with halothane. Each child received mask induction of sevoflurane (n = 9) or halothane (n = 9) with 70% nitrous oxide in oxygen. Blood pressure was measured noninvasively by an oscillometric technique using a Dinamap. Blood flow velocity was measured using a transcranial Doppler with a 2-MHz probe. End-tidal CO2, nitrous oxide, and anesthetic concentrations were measured by a Datex Ultima Capnomac. Both sevoflurane (2.4%) and halothane (1.3%) combined with 70% nitrous oxide decreased blood pressure and increased cerebral blood flow velocity. Intubation increased blood pressure and further increased cerebral blood flow velocity with both anesthetic treatments. These results indicate that sevoflurane and halothane combined with nitrous oxide decrease blood pressure and increase cerebral blood flow velocity and suggest that sevoflurane produces cerebrovascular effects similar to those of halothane during anesthetic induction.
Exemplars from an acute care geriatric psychiatry unit.
The exemplars in this article reflect caring contexts and creative nursing solutions to dementia, depression, and addiction, common mental health problems afflicting elderly patients and for which inpatient evaluation and treatment are necessitated. Optimal functioning and quality of life for elderly individuals depend substantially upon both physical and mental capacity. The coexistence of mental and physical illness leads to rapid impairment of functioning and interrupts the individual's zest for living. Although in most cases dementia is irreversible, other treatable comorbid conditions like delirium can exacerbate suffering and decline. Conversely, mental disorders, like depression and addiction, can amplify the negative effects associated with other health conditions, causing excess disability and mortality, and are associated with older individuals having the highest suicide rate of any age group in the United States. Nurses are well positioned to identify mental health problems and humanely treat primary and secondary symptoms associated with these disorders in their elderly patients. A document to guide medical professionals' assessment of mental disorders is now available (Spitzer et al., 1994). Remaining attentive to early identification of high-risk individuals and mobilizing resources in their behalf will substantially contribute to their well-being. There is ample research evidence on the benefits and efficacy of mental health interventions (Lebowitz, 1994). Much of the challenge and hard work for nurses lies in getting to know the patient, grasping what is happening for the individual and determining which treatment interventions will be most effective given the present circumstances surrounding the illness episode (Benner, 1984).
Giant squamous cell carcinoma of the hand: epithelioma cuniculatum--a case report.
We report a case of a giant squamous cell carcinoma of the hand. It demonstrates the natural history of a neglected well differentiated squamous cell tumour in this site. It resembles the epithelioma cuniculatum variant of squamous cell carcinoma, previously described as being peculiar to the foot.
Effects of remifentanil, a new short-acting opioid, on cerebral blood flow, brain electrical activity, and intracranial pressure in dogs anesthetized with isoflurane and nitrous oxide.
BACKGROUND: A new short-acting opioid, remifentanil, is metabolized by esterase activity in blood and tissue. It is important to know whether remifentanil may decrease the time to recovery of opioid-induced cardiovascular and cerebral effects compared to that of other short-acting agents such as alfentanil. METHODS: Baseline measures were made during 1% end-tidal isoflurane and 50% N2O in oxygen in dogs. Approximately equipotent low- and high-dose remifentanil (0.5 and 1.0 micrograms.kg-1.min-1) or alfentanil (1.6 and 3.2 micrograms.kg-1.min-1) were infused for 30 min each (total infusion time 60 min) followed by a 30-min recovery period. Blood pressure, heart rate, and intracranial pressure were recorded continuously. Electroencephalogram measurements were made using aperiodic analysis, and regional cerebral blood flow using radioactive microspheres. RESULTS: Both remifentanil and alfentanil decreased blood pressure and heart rate 25-30%. Cortex, hippocampus, and caudate blood flow decreased 40-50% during opioid infusion, but flow changes in lower brain regions were modest or absent. The electroencephalogram showed a shift from low-amplitude, high-frequency activity during baseline to high-amplitude, low-frequency activity during opioid infusion. During a 30-min recovery period, heart rate, electroencephalogram, and regional cerebral blood flow recovered to baseline levels in remifentanil--but not in alfentanil--treated dogs. Blood pressure and intracranial pressure decreased during opioid infusion and increased above baseline levels during the recovery period in remifentanil-treated dogs. CONCLUSIONS: These results show that the cardiovascular and cerebral effects of remifentanil and alfentanil are similar but that recovery of these parameters occurs sooner following remifentanil.
Effects of alprazolam on platelet activating factor-induced wealing.
Explore the source record for details and available documents.
A prospective study of BCG given to young children in Agra, India--a region of high contact with environmental mycobacteria.
A multiple skin test survey of school children (aged 5-15 years) living in Agra, India showed very high levels of sensitisation to numerous species of mycobacteria and little difference in tuberculin positivity between those with and without BCG scars. A total of 136 children aged 3 months to 8 years, living in Agra, were skin tested with Tuberculin and Leprosin A and examined for scars of previous BCG vaccination. Of those who had not previously received BCG and who had responses to Tuberculin of zero or less than 5 mm induration, 109 were offered BCG vaccination: 107 accepted and as many of them as possible were followed up with repeat skin testing 1 and 2 years later. The results are discussed in relation to the background of environmental sensitisation. A comparison is made with the data obtained from other places, particularly the Lebanon, where there is little sensitisation from the environment. Although the high level of Tuberculin conversion achieved after BCG suggested that the vaccine might have an important protective effect, the large size of Tuberculin responses in comparison with those obtained in the UK was worrying. Evidence was obtained suggesting that sensitisation to mycobacteria may occur in very young children which is not detected by the Tuberculin test, but which influences responses to BCG vaccination.
The value of intraoperative wound cultures in predicting the bacteriology of wound infection after elective abdominal surgery.
Explore the source record for details and available documents.
Factors influencing progress towards viability of federally funded HMOs. A national study.
Explore the source record for details and available documents.
The steady-state pharmacokinetics of piroxicam: effect of food and iron.
Explore the source record for details and available documents.
Sural nerve entrapment--case report.
Explore the source record for details and available documents.