Anaesthesia in the United States. Trainees have much to gain from working in the United States.
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Anesthesiology↗
Biomedical subjects
J Nolan
Publications and source records attributed to J Nolan.
Measurement of parasympathetic activity from 24-hour ambulatory electrocardiograms and its reproducibility and sensitivity in normal subjects, patients with symptomatic myocardial ischemia, and patients with diabetes mellitus.
The parasympathetic nervous system plays a major role in the pathophysiology of many cardiovascular disease, particularly in modulating myocardial electrical stability. Measurements of heart rate variability have been widely used to assess parasympathetic activity. The reproducibility of measurements obtained from 24-hour ambulatory electrocardiograms has not been well documented. We have developed a technique for measuring parasympathetic activity from clinical quality 24-hour ambulatory electrocardiograms by counting beat-to-beat increases in RR interval that are > 50 ms. To determine the reproducibility and sensitivity of our technique, we analyzed repeated 24-hour electrocardiograms of 173 subjects (19 normal subjects, 67 patients with ischemic heart disease, and 87 diabetics) followed up over periods of 2 to 16 weeks. In all subject groups, mean values for repeated measurements were virtually identical. Measurements were stable in all 3 groups throughout the course of the study, as assessed by intraclass correlation coefficients. This technique is sensitive enough to detect relatively small changes in parasympathetic activity in subjects, as demonstrated by the calculated Bland and Altman coefficients of repeatability. Reproducibility and sensitivity of our technique are particularly good in normal subjects and in patients with ischemic heart disease. The results obtained with this technique imply that other related measurements of parasympathetic activity will show similar excellent short- and long-term reproducibility and sensitivity.
Adult↗
Tidal volumes which are perceived to be adequate for resuscitation.
Observers trained in basic life support assessed chest rise in 34 patients who were anaesthetised and paralysed and whose lungs were being mechanically ventilated prior to routine surgery. Making 67 independent assessments, the observers indicated the tidal volume that they considered produced adequate chest rise for resuscitation. The mean tidal volume perceived to be adequate was 384 ml with 95% confidence limits of 362-406 ml. The perceived volumes correlated with the Body Mass Index. Guidelines by various authorities recommend that tidal volumes sufficient to make the chest rise normally should be used during resuscitation. The volumes perceived as adequate by the observers are much lower than the numerical values recommended by the American Heart Association (800-1200 ml). High tidal volumes are associated with an increased risk of gastric regurgitation in patients with an unprotected airway, CO2 delivery to the lungs is likely to be low during cardiac arrest obviating the need for high tidal volumes. In the light of present knowledge and the findings in this study, we would recommend that resuscitation training manikins are recalibrated to indicate satisfactory ventilation at tidal volumes of 400-600 ml. These volumes should reduce the risk of gastric inflation and permit more chest compressions to be carried out in a minute because the ventilation fraction of the CPR sequence is shorter. Adequate CO2 elimination should still be assured.
Adult↗
Entry to care: positive choice or fait accompli? developing a more proactive nursing response to the needs of older people and their carers.
A range of issues surrounding admission to either residential or nursing home care are considered from the perspectives of older people and their family carers. Drawing on the literature and a number of studies conducted by the authors, the processes and perceptions that shape and influence admission to care are identified. On the basis of the interaction of these factors a four-stage typology of admission is suggested: the positive choice, the rationalized alternative, the discredited option, and the fait accompli. The characteristics of each admission type are discussed and the implications for professionals, particularly nurses, working with older people and their carers are addressed.
Aged↗
Zeolite A inhibits osteoclast-mediated bone resorption in vitro.
The effects of Zeolite A on bone resorbing activity of highly purified avian osteoclasts were analyzed. The present study demonstrates that when 100 micrograms/ml of acid-treated Zeolite A is added to the media the number of pits per osteoclast is reduced 3-fold at 24 h after treatment. Secreted cathepsin B enzyme activity was also reduced 3-fold. A similar reduction in pit number per osteoclast was measured following 48 h of treatment with Zeolite A but there appeared to be less reduction of cathepsin B enzyme activity. The effects on pit number and cathepsin B protein activity were Zeolite dose dependent. The structure of the compound seemed to be responsible for the effects measured since compounds used to represent constituents of Zeolite A (silicon dioxide and aluminum chloride) failed to inhibit bone resorption or reduce the level of secreted cathepsin B enzyme activity. Thus the molecular architecture of Zeolite A or a derivative thereof appears to be important. In conclusion, the data indicate that Zeolite A can inhibit bone resorption. Together with previous data on osteoblasts, this might suggest a potential positive activity of intact Zeolite A or a partial substructure of Zeolite A on bone turnover.
Aluminum Chloride↗
Exercise-induced left ventricular dysfunction in alcoholic and non-alcoholic cirrhosis.
BACKGROUND/AIMS: Autonomic and cardiac dysfunction have been reported in patients with cirrhosis. We studied left ventricular and autonomic function in 20 patients with both alcoholic and non-alcoholic cirrhosis. METHODS: Autonomic function was assessed by a standard battery of cardiovascular reflex tests. Supine exercise radionuclide ventriculography was used to assess the cardiac response to exercise. RESULTS: Exercise capacity was reduced in all patients in association with marked chronotropic incompetence (peak heart rates 120.5 +/- 6 bpm). Unlike normal subjects there was no increase in left ventricular ejection fraction on exercise. Stroke volume increased by 23 +/- 6%, mediated by an increase in end-diastolic.volume of > 20%. Cardiac output was subnormal at maximal exercise, increasing by only 96 +/- 14% and 97 +/- 11% in alcoholic and non-alcoholic groups respectively. The majority (83%) of our patients had autonomic reflex abnormalities. CONCLUSIONS: Patients with cirrhosis of alcohol and non-alcohol related aetiologies have significantly impaired cardiovascular responses to exercise, which are similar to those of a denervated heart. This may have important clinical implications for the ability of these patients to withstand cardiovascular stress.
Autonomic Nervous System↗
Busy doing nothing: activity and interaction levels amongst differing populations of elderly patients.
This paper considers the activity and interaction levels amongst three differing populations of elderly patients (long-stay, short-stay and respite). It begins with a consideration of the literature on staff-patient interactions in care environments for elderly patients, highlighting the virtual absence of preplanned, purposeful activity. Data are then presented which suggest that, despite the emphasis nurses place on communicating with their patients, many patients continue to spend most of their time inactive. It is suggested that if the quality of care elderly patients receive is to improve, nursing staff must see the provision of activity as an integral part of their role and function.
Activities of Daily Living↗
Continuing professional education: identifying the characteristics of an effective system.
The need for a functioning system of continuing professional education (CPE) in nursing, midwifery and health visiting has received increased attention in recent years. However, whilst the literature describes a number of benefits, detailed empirical studies have been limited. There is, in particular, a dearth of information on nurses' perceptions of the important components of a CPE programme. Using the results of a recent evaluation of the Welsh National Board's Framework for Continuing Education, this paper highlights a number of key issues identified by practitioners, educators and managers throughout Wales. Using a structure-process-outcome model, attention is focused on the outcomes of CPE and the structure and process variables which facilitate or inhibit success. The results indicate a strong commitment to the principles of CPE and identify a complex range of perceived benefits. Potential barriers inhibiting both the uptake of CPE and the achievement of subsequent change are discussed and the need to create an equitable, well-resourced system is stressed.
Education, Nursing, Continuing↗
Changes in atrial natriuretic peptide and plasma renin activity following changes in right atrial pressure in patients with chronic renal failure.
Since it was first discovered in the early 1980s, the role of atrial natriuretic peptide (ANP) in the control of fluid and electrolyte balance and blood pressure has been extensively studied in both health and disease. We report here a study of ANP and its relationship to corresponding changes in right atrial pressure (RAP) in patients with chronic renal failure (CRF) on haemodialysis compared to healthy controls. Although there was a positive correlation between RAP and ANP in both groups, the changes in ANP following changes in RAP between the two groups were not statistically significant. A unique observation was the response of RAP to changes in posture, with RAP falling significantly as expected in healthy controls in contrast to the exceptional absence of a significant fall in patients with CRF. Healthy controls demonstrated appropriate postural changes in plasma renin activity (PRA) despite marked suppression of PRA levels due to salt loading, in complete contrast to patients with CRF who, despite chronic fluid overload and elevated levels of ANP, continued to have grossly elevated PRA levels that failed to change significantly in response to changes in posture.
Atrial Function, Right↗
Radiolytic and photochemical reduction of the hypoxic cytotoxin 1,2-dihydro-8-(4-methylpiperazinyl)-4-phenylimidazo [1,2-a] pyrido [3,2-e] pyrazine 5-oxide (RB90740) and a potential mechanism for hypoxia-selective toxicity.
PURPOSE: To study the reduction of RB90740 (1), a fused pyrazine mono-N-oxide that has an oxic:hypoxic cytotoxicity ratio of > 10 in a range of murine and human tumor cells in vitro. METHODS AND MATERIALS: Reduction of 1 has been initiated radiolytically and photochemically in aqueous solution and the products isolated and characterized by high performance liquid chromatography (HPLC). RESULTS: Radiolytic reduction of 1 leads to the formation of the 2-electron reduced product, 2. The stoichiometry of the reduction is pH dependent, increasing from 1 to 2 with increasing pH, but independent of the presence of formate or 2-methyl 2-propanol in the reduction mixture. A dimerization product, 3, is also found, which is produced in greater yields at lower pH (< 6). Photochemical reduction of 1 to 2 was also found to be facile. Photolysis of 1 also leads to a deoxyribonucleic acid cleavage reaction. CONCLUSION: Since 2 is not cytotoxic towards hypoxic cells at concentrations at which 1 is toxic, a probable candidate as the cytotoxic species under hypoxic conditions is the 1-electron reduced intermediate species.
Animals↗
Comparison of the separation of proteins by sodium dodecyl sulfate-slab gel electrophoresis and capillary sodium dodecyl sulfate-gel electrophoresis.
Capillary sodium dodecyl sulfate-gel electrophoresis, a one-dimensional version of the well-established planar analytical method of SDS-polyacrylamide gel electrophoresis, has proven a powerful new microanalytical method for the separation of protein molecules according to their size. In this paper the planar SDS-PAGE and the capillary SDS-gel electrophoresis of different proteins are compared with respect to performance, precision, and efficiency. Molecular weight versus migration distance and migration time curves for 65 proteins, running from 14,200 to 205,000 Da, are given for both methods.
Capillary Action↗
Information technology factors in transferability of knowledge based systems in medicine.
The history of knowledge based systems in medicine has been that they are generally very localised, serving a special need in a single setting. Very few have proven to be capable of transfer to a distant environment. With the advent of tele-medical services and the associated transfer of data and knowledge in such services, the ability of medical KBS to transfer will be crucial to the success of tele-medical services. Differences in knowledge acquisition methods, knowledge representation techniques and in the epidemiological composition of training databases may influence viable transfer of knowledge based systems. Through experiments we demonstrate how rule-based systems may impose inflexible demands on data, how different knowledge acquisition techniques acquire different aspects of knowledge, though trained on a common training database, and how different knowledge acquisition techniques show varying degrees of robustness to slight changes in training databases.
Algorithms↗
Cardiac parasympathetic activity in severe uncomplicated coronary artery disease.
BACKGROUND: Previous studies have suggested that coronary artery disease is independently associated with reduced cardiac parasympathetic activity, and that this is important in its pathophysiology. These studies included many patients with complications that might be responsible for the reported autonomic abnormalities. OBJECTIVE: To measure cardiac parasympathetic activity in patients with uncomplicated coronary artery disease. PATIENTS AND METHODS: 44 patients of mean (SD) age 56 (8) with severe uncomplicated coronary artery disease (symptoms uncontrolled on maximal medical treatment; > 70% coronary stenosis at angiography; normal ejection fraction; no evidence of previous infarction, diabetes, or hypertension). Heart rate variability was measured from 24 hour ambulatory electrocardiograms by counting the number of times successive RR intervals exceeded the preceding RR interval by > 50 ms, a previously validated sensitive and specific index of cardiac parasympathetic activity. RESULTS: Mean (range) of counts were: waking 112 (range 6-501)/h, sleeping 198 (0-812)/h, and total 3912 (151-14 454)/24 h. These mean results were unremarkable, and < 10% of patients fell below the lower 95% confidence interval for waking, sleeping, or total 24 hour counts in normal people. There was no relation between the severity of coronary artery disease or the use of concurrent antianginal drug treatment and cardiac parasympathetic activity. CONCLUSION: In contrast with previous reports no evidence of a specific independent association between coronary artery disease and reduced cardiac parasympathetic activity was found. The results of previous studies may reflect the inclusion of patients with complications and not the direct effect of coronary artery disease itself.
Adrenergic beta-Antagonists↗
Delayed onset of insulin activation of the insulin receptor kinase in vivo in human skeletal muscle.
During the infusion of insulin in vivo, the rate of activation of glucose disposal lags significantly behind the rate of increase in serum insulin levels. To determine whether this delay was related to transcapillary transport of insulin, we determined increments in serum insulin levels, glucose disposal rates (GDR), and insulin receptor (IR) kinase activity measured during continuous infusions of insulin (40 and 120 mU.m-2.min-1) administered to 8 nondiabetic males; similar studies were done at 1,200.m-2.min-1 in 2 of the subjects. Half-maximal insulin levels were achieved at a mean of 4.9 and 7.2 min during the 40 and 120 mU.m-2.min-1 clamps, respectively, with corresponding half-maximal GDR stimulation at a mean of 59 and 47 min. Unlike the rise in insulin levels, IR kinase activation was much slower with half-maximal activity occurring at approximately 40-60 min in the 2 clamps. Thus, the rise in serum insulin levels in each clamp was much faster than the increment in either kinase activity or glucose disposal. Insulin infusion increased both IR kinase and GDR maximally approximately 10-fold, with half-maximal stimulation at approximately 3,600 and approximately 700 pM, indicating spare kinase for glucose disposal. These results demonstrate that the delay in stimulation of glucose disposal by insulin is related to a rate-limiting step between the intravascular space and the cell-surface of skeletal muscle. This may involve delayed transendothelial transport of insulin.
Adult↗
Why we need government regulation. Interview by Diana Madden.
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Health Services Needs and Demand↗
General anesthesia and bone marrow harvesting procedure have no effect on the concentration of CD34 stem cells in peripheral venous blood.
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Alfentanil↗
Cardiac effects of sodium stibogluconate: myocardial, electrophysiological and biochemical studies.
The pentavalent antimonial sodium stibogluconate is the mainstay of anti-leishmanial therapy. Sodium stibogluconate is less cardiotoxic than antimony and the trivalent derivatives, but has been associated with dose-related electrocardiographic changes. The effect of the currently-used regimen of sodium stibogluconate (20 mg/kg/day for 20 days) on cardiac function is uncertain. We studied 12 soldiers, mean age 24 years, with proven cutaneous leishmaniasis treated with this regimen. There were no significant changes in echocardiographic indices of left ventricular systolic or diastolic function during treatment. Indices of myocardial electrical stability (heart-rate variability and episodes of overt supraventricular and ventricular arrhythmias) were unchanged, but there was a reversible decrease in T-wave amplitude during treatment. Systolic and diastolic blood pressure fell and the heart rate increased during treatment. This regimen of sodium stibogluconate does not measurably impair left ventricular systolic or diastolic function. Minor T-wave changes occur during treatment, but there is no increase in arrhythmia frequency or change in heart-rate variability. In most young fit patients, this regimen has no cardiac side-effects. However, idiosyncratic reactions cannot be excluded, and patients with malnutrition, impaired renal function or pre-existing heart disease may be more sensitive to any cardiotoxic properties of sodium stibogluconate.
Adult↗
Autonomic function in cirrhosis assessed by cardiovascular reflex tests and 24-hour heart rate variability.
OBJECTIVES: To assess the prevalence of autonomic dysfunction in cirrhosis and to observe the effect of disease severity on autonomic dysfunction. METHODS: Seventy patients with cirrhosis (Child's class A, 42; Child's class B, 10; and Child's class C, 15) (45 alcoholic, 15 primary biliary cirrhosis, five chronic active hepatitis, and eight idiopathic) underwent standard cardiovascular reflex tests. In addition, in 40 patients, 24-h ECG RR variability tests were performed to detect autonomic dysfunction. RESULTS: Forty-two of 70 (60%) patients had abnormalities of cardiovascular reflex function of varying severity, whereas 24 of 34 (70%) had 24-h RR counts with the 95% age-related tolerance. The prevalence of abnormality increased with increasing severity of liver disease but not with different etiologies. CONCLUSION: Irrespective of etiology, there is a high prevalence of autonomic dysfunction in cirrhosis, and it is related to disease severity: the mechanism is unknown.
Autonomic Nervous System Diseases↗