Biomedical subjects
Publications and source records attributed to R G Hahn.
We report 2 patients who absorbed large amounts of irrigating fluid during transurethral resection of bladder tumours (TURB). Ethanol indication facilitated diagnosis of this complication and showed that absorption had occurred by the extravascular route. Symptoms occurred in one case but they resolved when hypertonic saline and furosemide were given.
We studied urine excretion and plasma electrolytes in 38 rabbits during and after a 60-min intravenous infusion of 150 ml/kg of irrigating fluid containing either 3.3-6% of mannitol, 5% sorbitol, or 2.7% sorbitol and 0.54% mannitol (Cytal). The Osmolality of the solutions ranged between 165 and 350 mosmol/kg. The excreted urine volume, peak flow rate, duration of 80% of peak urine flow and the ratio of urine excreted per volume of infused irrigating fluid varied greatly but in direct proportion to the osmolality of each solution. There were no differences between the irrigating fluids with respect to dilution changes in plasma sodium and chloride concentrations. We conclude that the urine flow after infusion of irrigating fluids is governed primarily by the osmolality of the solution. Mannitol has no superior effect over sorbitol as a diuretic.
We used 25 rabbits to study blood chemistry, urinary flow and solute excretion for 2 h during and after intravenous infusion of 50, 75 and 100 ml/kg of 4 solutions that have recently been introduced in Sweden for irrigation during transurethral operations. Infusion of mannitol 3% + ethanol 1% and sorbitol 2% + mannitol 1% were followed by a higher urinary flow and excretion of sodium and other solutes than after glycine 1.5% + ethanol 1%, glycine 1.0% + ethanol 1%, and normal saline (control). The volume of urine and the total solute excretion, but not the sodium and potassium excretion, increased with the infused volume. The urea and creatinine clearances increased in proportion to the urinary flow. Using a mathematical model, we found a volume-dependent increase in the ratio of extracellular to intracellular accumulation of water, although the average ratio was the highest for glycine 1.5% + ethanol 1% (mean 0.78) and the lowest for mannitol 3% + ethanol 1% (mean 0.60). We conclude that there are marked differences between recently introduced irrigating fluids with respect to diuretic effects and the distribution in the body.
Ethanol monitoring is a fairly new method for assessing fluid absorption during transurethral resection of the prostate. The volume of irrigant absorbed is usually estimated from a nomogram every 10 min during the operation. We report a case in which a patient developed a transurethral resection syndrome and circulatory shock despite ethanol monitoring and adequate volume replacement. The further course of the operation showed that absorption had occurred by the extravascular route. In these cases, ethanol monitoring can be misleading as the maximum breath ethanol level occurs after a delay of 20 min and the fluid absorption is three times larger than indicated by the nomogram.
We evaluated signs and symptoms of the transurethral resection syndrome recorded during and after 273 transurethral prostatic resections performed at 2 hospitals between 1984 and 1993. Glycine solution was used as the irrigant and ethanol served as a tracer for fluid absorption. The incidence and severity of symptoms that could possibly be related to the syndrome increased progressively as more glycine solution was absorbed. Patients who absorbed 0 to 300 ml. of glycine solution had an average of 1.3 such symptoms. This number increased to 2.3 when 1,001 to 2,000 ml. were absorbed, 3.1 when 2,001 to 3,000 ml. were absorbed and 5.8 for volumes greater than 3,000 ml. Nausea and vomiting occurred significantly more often when 1,001 to 2,000 ml. were absorbed compared to no absorption. Confusion and arterial hypotension were other prominent signs of fluid absorption, whereas hypertension was not. The severity of symptoms was markedly aggravated when more than 3,000 ml. were absorbed. Extravasation resulted in higher risks of bradycardia, hypotension and failed spontaneous diuresis postoperatively than absorption by the intravascular route.
BACKGROUND: Uterine fundal height has long been used to assess fetal growth. The common prediction rule states that the distance in centimeters between the pubic symphysis and the top of the fundus equals the gestational age in weeks. The correlation holds best between weeks 18 and 32. This study compares manual and ultrasound measurements of fundal height. METHODS: We compared palpated and ultrasound symphysis-fundal height. We then compared both measurements with gestational age as determined by usual ultrasound measurements. Patients were statistically separated by weight into two groups: normal and obese. We hypothesized that manual measurements of fundal height would be affected by obesity and race. RESULTS: Ultrasound fundal height and manual fundal height were equivalent (P < or = .01, R2 = .92). Regression analysis in normal weight and obese patients showed that both methods have the same predictive power in determining fetal age. CONCLUSION: Manual measurements are still a reliable and inexpensive means of evaluating the course of pregnancy. Ultrasound is needed when there is a size-vs-date discrepancy. Ultrasound is also useful for teaching the measurement of fundal height.
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Twenty patients undergoing abdominal surgery under general anaesthesia were studied to determine whether beta 2-adrenergic receptor sensitivity and adrenaline-induced hypokalaemia are related to preceding adrenergic stress. Half of the patients were given epidural analgesia with bupivacaine-adrenaline before starting surgery and then a booster dose after 60 min of surgery. The others were given only the epidural dose of bupivacaine-adrenaline at 60 min. Despite marked increases in the plasma adrenaline concentration after the intra-operative epidural dose, there was no decrease in the serum potassium concentration in either group. In the patients who received only the 60 min dose, the plasma adrenaline concentrations increased more, but the plasma level of cyclic AMP (a marker for beta 2-stimulation) increased similarly, which suggests that beta 2-adrenoceptor responsiveness was somewhat reduced. After the intraoperative bupivacaine-adrenaline, the T wave amplitude decreased, but neither U waves nor tachycardia developed. In conclusion, adrenergic stimulation during surgery does not decrease the serum potassium concentration, regardless of whether the surgical stress response has been modified by epidural analgesia. This lack of a hypokalaemic effect might be partly due to reduced responsiveness of beta 2-adrenoceptors to adrenaline.
OBJECTIVE: We compared fluid absorption, blood loss, and immediate postoperative complications in transurethral resection of the prostate (TURP) performed with the continuous flow and the intermittent flow irrigation techniques. We also studied pressure conditions under which fluid absorption occurs when continuous flow irrigation is used. METHODS: One experienced urologic surgeon performed TURP in 40 patients using suprapubic drainage of the bladder and in 40 other patients using the intermittent-filling technique. Fluid absorption was measured by the ethanol method every ten minutes. The intravesical pressure was recorded continuously in 23 of the patients with suprapubic drainage. RESULTS: Fluid absorption was more common when suprapubic drainage was used (P < 0.004). There were no differences in operating time, blood loss, postoperative complications, or in the period of hospitalization. Low-degree absorption occurred during minor elevations of the intravesical pressure, and massive fluid absorption was associated with pressures between 1.0 and 2.5 kPa (10 and 25 cm H2O). CONCLUSIONS: Continuous flow irrigation promoted fluid absorption, which occurred at lower pressures than commonly believed. With respect to other parameters, we found no superiority of one irrigating technique over the other.
The electrocardiogram (ECG) was recorded and the serum levels of creatine kinase (CK), aspartate transaminase (ASAT) and prostatic acid phosphatase (PAP) was measured in 22 patients undergoing transurethral resection of the prostate (TURP) under spinal or epidural anaesthesia. The irrigating fluid consisted of 1.5% glycine and 1% ethanol, and absorption of the fluid was monitored by detection of alcohol in the expired breath. The results show that nine of the 11 patients (82%) who absorbed more than 1,000 ml of irrigating fluid had developed ECG changes 24 h after the operations. The most common alteration was depression of the T wave. This sign was only seen in one (9%) of the patients who absorbed none or very small amounts of irrigating fluid (P < 0.001). The serum activity of CK and ASAT increased in five patients who also developed ECG changes, and the highest values were recorded 24 h after TURP. The CK-MB isoenzyme was detected in 85% of the samples with elevated total CK, but the criteria for myocardial infarction were never fulfilled. In contrast, PAP increased in all patients and the highest level occurred at the end of TURP. The activity-time profiles suggest that CK and ASAT entered the circulation by a mechanism different from that of PAP. We conclude that absorption of glycine solution during TURP is frequently followed by nonspecific ECG signs of altered cardiac function and also that the serum activities of CK and ASAT increase in some of these patients.
One metabolic pathway for glycine leads to glyoxylate which is the precursor of oxalate. To investigate whether absorption of glycine solution in transurethral operations may promote precipitation of calcium oxalate stones, we collected urine for 24 h before and after an intravenous infusion of 22 g of glycine in 10 male volunteers. There were no significant changes in the urinary excretion of oxalate, calcium, or citrate. Urine volume and amino acid excretion increased, while the urine contained less potassium. These results provide no biochemical evidence of an increased risk of renal lithiasis due to glycine irrigation during transurethral operations.
Thirty-nine patients with locally advanced transitional cell carcinoma of the bladder received presurgical combination chemotherapy in an effort to improve survival, reduce local tumor recurrence and distant failure, and enhance surgical resectability and potentially salvage the bladder. One to six cycles (median 2.8) of M-VAC (methotrexate, vinblastine, doxorubicin, cisplatin), CMV (cisplatin, methotrexate, vinblastine), or VP16 CDDP (etoposide, cisplatin) were administered after initial diagnosis and clinical staging of the bladder cancer and transurethral resection of the tumor. Clinical staging was repeated before each cycle of chemotherapy. Transurethral resection and systemic neoadjuvant chemotherapy clinically downstaged 31 of 39 patients (79%). Subsequently, 26 patients underwent radical cystectomy and 13 patients received bladder salvage (6 received a partial surgical resection and 7 observation). At 41 months' median follow-up, 4-year overall survival was 63 +/- 17%, cancer-specific survival was 71 +/- 19%, local recurrence-free survival was 66 +/- 22%, and metastasis-free survival was 73 +/- 16%. Patients with a complete clinical and pathologic response had far better survival than those without a complete response; for pathologic stage, survival was 100% vs. 45% for those with residual tumor (p = 0.003). Local recurrence (Ta or TiS) occurred in 46% of those with their bladder salvaged and still in situ. These data suggest that with neoadjuvant chemotherapy bladder salvage seems feasible in selected patients, although they appear to be at higher risk for tumor recurrence. Accurate selection of the group of patients most likely to benefit is difficult and may not be possible in a predictable manner with currently available selection methods.
We examined cognitive functions by means of a standardized mini-mental status (MMS) test before and 2 and 24 h after surgery in 100 patients undergoing transurethral resection of the prostate (TURP). There was a strong correlation between the results of this test on all three occasions, but a transient deterioration in the MMS score occurred 2 h after TURP in two thirds of the patients. Fluid absorption was the factor most strongly associated with the change in MMS status during TURP, while the preoperative health status and the choice of anesthesia (general or spinal) had no influence.
We examined for a possible correlation between coagulopathy and fluid absorption, serum level of prostatic acid phosphatase (S-PAP) and blood loss in 25 patients undergoing transurethral resections of the prostate (TURP). Blood coagulation parameters were measured before and at the end of TURP and 10 and 24 hours later. Fluid absorption was measured by the ethanol method. There was a close correlation between the changes in haemostatic parameters and blood haemoglobin concentration. No relationship was found between the coagulation status and fluid absorption, S-PAP or blood loss during the operation. Fibrinolysis was evidenced by increasing titres of fibrin degradation products in most patients. However, no increase occurred in the two patients who required reoperation because of severe postoperative bleeding, which implies that fewer blood clots were formed in these cases. We conclude that the coagulation parameters during and after TURP varies primarily with the dilution of the blood.
We studied the effect of eating a meal on the rate of ethanol elimination (clearance) from the blood after giving 0.4 g/kg by intravenous infusion to six female and six male volunteers. Half of the subjects had eaten breakfast whereas the other half had fasted overnight. After the first infusion of alcohol, those who had fasted ate lunch, and all the volunteers received a second infusion with the same dose of ethanol. The blood ethanol concentration was measured repeatedly for up to 180-240 min after the start of each experiment. Intake of food (lunch or breakfast) increased the clearance of ethanol by about 60% (P < 0.001). Alcohol intoxication was less pronounced at the end of the ethanol infusions preceded by eating a meal (P < 0.01). Gender had no significant effect on the rate of ethanol elimination. We conclude that eating a meal increases the rate of ethanol elimination even when alcohol is given by intravenous infusion.
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BACKGROUND: Gallbladder disease is four times as common in women as in men, and pregnancy appears to contribute to the development of gallstones. During pregnancy, most women receive ultrasound scans, which are highly sensitive to the detection of gallstones. The purpose of this study was to examine the additional time and effort required to scan the gallbladder during obstetric ultrasound scanning. METHODS: The maternal gallbladder was examined in 228 consecutive obstetric ultrasound scans performed for medical indications at any time during pregnancy. Scanning was conducted by family physician faculty located in two university settings and one rural private practice. Patients were not required to fast prior to the scan. RESULTS: Gallstones were found in 5.3% of the patients, and an additional 3.1% had undergone prior cholecystectomy, for an overall incidence of current or previous gallbladder disease among 8.4% of the patients. The gallbladder was visualized in 97.4% of patients without a previous cholecystectomy. In 95.7% of cases, obtaining this additional information required less than 2 minutes. CONCLUSIONS: This study suggests that an evaluation of the maternal gallbladder at the time of obstetric ultrasound scans can be performed rapidly without special patient preparation. The study further suggests that obstetric ultrasound skills may allow family physicians to expand their diagnostic use of ultrasound to include gallbladder evaluation. Scanning techniques and the clinical significance of having this information in the patient's medical record are discussed.
BACKGROUND: The epidophyllotoxin VM 26 has been shown to have single-agent activity in patients with diffuse aggressive lymphoma. In an attempt to determine its activity in combination with other agents known to be effective in lymphoma, a Phase II trial of a novel chemotherapy regimen was conducted. METHODS: Forty-two patients with Stages II, III, and IV diffuse aggressive lymphoma were treated with teniposide, doxorubicin, prednisone, cyclophosphamide, vincristine, and bleomycin (PA Ten-CPOB) as part of a Phase II trial of the Eastern Cooperative Oncology Group. Fifty-five percent of patients had Stage IV disease, 21% Stage III, and 24% Stage II. RESULTS: The overall complete response rate was 64%. Of the 27 patients who had complete response, 19 (70% [45% of the entire group]) are still alive without disease (median follow-up, 5.7 years). No patient had a follow-up time of less than 5 years. On examination of factors that were predictive of survival and relapse, it was found that age younger than 60 years was predictive of long-term survival, as 76% of patients younger than 60 years of age were alive without disease. Forty patients were evaluable for toxicity. There were four (10%) early deaths, and six patients (15%) had Grade 4 hematologic toxicity. CONCLUSIONS: This alternating combination chemotherapy regimen (PA Ten-CPOB) results in a complete response rate comparable to what has been reported previously in the literature, but 45% of patients in this series demonstrated long-term disease-free survival. When patients younger than 60 years of age with follow-up times of at least 5 years were considered, disease-free survival was 76%.