Biomedical subjects
Publications and source records attributed to C Capuano.
Complex regional pain syndrome is a chronic pain syndrome that is often instigated by postoperative or post-traumatic events. The disease process can progress through three stages, the first of which tends to respond best to treatment. A review of the literature is presented, followed by a report of a patient who developed symptoms of complex regional pain syndrome following a water-skiing accident.
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BACKGROUND: For more than 35 years, cine film has been used as the standard recording medium for coronary angiography. At present, the DICOM and the CD-R format have been established as the standard media for the transport of cardiac angiographic images in place of cine angiographic film. The aim of the study was to compare the media production costs between two cardiac catheterization laboratories, with and without cine film. METHODS: We collected data from two different laboratories in the same geographic area which perform about 1000 procedures/year, using a similar digital x-ray imaging system. In one lab, images are recorded on 35-mm film at 25 frames/sec. In the other one, the image support is based on a CD-R. For each laboratory we considered both direct patient and variable equipment costs. Direct patient costs in the film-lab include: cine film, processing chemicals, processing labor, chemical disposal, maintenance; in the digital lab: CD-R costs and masterization time. Equipment costs in the film-lab include: cine camera, cine film processor and cine projector; in the filmless lab a DICOM formatter and a review workstation. The equipment amortization costs are considered over a three-year period. RESULTS: Total direct patient costs are 90,000 lira for the film and 14,000 lira for the CD-R. Equipment costs are 193,000,000 lira in the film-lab and 150,000,000 lira in the filmless one. Overall cost per patient is 154,300 lira for the cine film and 64,000 lira for the CD-R. CONCLUSIONS: This study shows that the media costs per patient for a digital DICOM CD-R format system are substantially less than for 35-mm film, permitting savings of more than 90,000,000 Italian lira per year in a mid-volume cardiac catheterization laboratory.
BACKGROUND: Brief ischemic periods render the myocardium resistant to infarction from subsequent ischemic insults by a process called ischemic preconditioning. Volatile anesthetics have also been shown to be cardioprotective if administered before ischemia. The effect of preconditioning alone and combined with halothane or isoflurane on hemodynamic recovery and preservation of adenosine triphosphate content in isolated rat hearts was evaluated. METHODS: Seven groups of isolated rat hearts (n = 6 each) were perfused in a retrograde manner at constant temperature and pressure. A latex balloon was placed in the left ventricle to obtain isovolumetric contraction. Heart rhythm, coronary flow, left ventricular pressure and its derivative dP/dt (positive and negative), and developed pressure were monitored. The hearts were paced at 300 beats per minute. Each heart was randomly allocated to (1) a time-control group that received no ischemia, (2) an untreated group that received 25 min of normothermic ischemia only. (3 and 4) an isoflurane group and a halothane group that received 40 min of anesthetic (2.2% and 1.5%, respectively) before ischemia; (5) a preconditioning group that received two 5-min periods of ischemia separated by 10 min of reperfusion before ischemia; or (6 and 7) a isoflurane+preconditioning group and a halothane+preconditioning group that received anesthetic for 10 min at concentrations of 2.2% or 1.5%, respectively, before two 5-min periods of ischemia separated by 10 min of reperfusion. All treated groups received 25 min of normothermic ischemia followed by 30 min of reperfusion. RESULTS: The time-control group remained hemodynamically stable for the entire experiment, and the adenosine triphosphate content was 18.3 +/- 1.7 (SEM) microM/g at the end of 115 min. The untreated group had depressed recovery after 25 min of normothermic ischemia, and the developed pressure was significantly depressed and recovered only 30 +/- 9% (P < 0.001) of its preischemic value. There was also a significant increase in the incidence of ventricular fibrillation (P < 0.001). Adenosine triphosphate content was significantly lower in this group than in all other groups. Five minutes of ischemia in the preconditioning group had little effect on hemodynamics and decreased developed pressure only 6.4%. Halothane depressed developed pressure by 16 +/- 5% (P < 0.001), and isoflurane increased coronary flow by 145 +/- 9% (P < 0.001) but had no significant hemodynamic effect. The treated groups had significantly better recovery of postischemic function than did the untreated group. In the preconditioning group, developed pressure recovered to 85% of control and dP/dt+ to 87% of control. The addition of halothane or isoflurane to preconditioning did not provide additional functional recovery but did increase the level of adenosine triphosphate preservation (13.1 +/- 1.1 and 12.4 +/- 1.1 microM/g, respectively). CONCLUSIONS: The results indicate that preconditioning, halothane, and isoflurane provide significant protection against ischemia. The combination of preconditioning and halothane or isoflurane did not improve hemodynamic recovery but did increase preservation of adenosine triphosphate.
There are many reasons for a specific management plan for adolescents with insulin-dependent diabetes mellitus (IDDM). Although most new patients can be managed initially on an outpatient basis, as they reach their teenage years, blood glucose control deteriorates and insulin requirements increase. Eating disorders, missing insulin injections, excess of alcohol all contribute to poor glycaemic control. Teenagers who have had diabetes for a number of years may have developed microvascular complications and disturbances of growth can occur, more often in girls than in boys. The transition to adult care continues to be a significant problem both for paediatricians and patients. Diabetes management during adolescence requires a team effort involving nurse educator, dietitian, paediatric diabetologist and, possibly, a social worker, with referral to specialists if necessary. Organizing this type of care requires a Regional Paediatric Diabetes Centre.
A study was undertaken to investigate factors important to senior medical students, particularly prospective anesthesiology residents, in selecting a residency program. A previously published questionnaire was used to determine whether previous findings could be replicated. One hundred ninety-seven senior medical students rated the importance of 22 items in their selection of a residency program. Factors were ranked nearly identically as in the previous study. Factors rated as most important were "diversity of training experience" as well as "house officer satisfaction," whereas items about treating patients with the acquired immunodeficiency syndrome were rated as least important. There were gender differences that showed women assigned more importance to having a manageable case load, call schedules, and geographic location. Prospective anesthesiology residents perceived "prestige" of the program, and the department as significantly more important than did prospective nonanesthesiology residents. The replication of results with regard to the overall ranking of factors demonstrates the reliability of the results. Resident selection committees need to focus on the issue of quality of training, the impression made by the interviewers, and include satisfied residents as part of the interview process.
The effects of induced hypotension with isoflurane and labetalol on cerebral edema formation were compared following a cryogenic brain injury in dogs. Thirteen dogs received a maintenance anesthetic of 70% N2O, 0.5% isoflurane in O2 and a fentanyl infusion (3 micrograms.kg-1 x hr-1). All dogs were normoventilated (PaCO2 of 35-40 mmHg) and monitored for temperature, arterial blood pressure, central venous pressure (maintained between 7-10 mmHg), end-tidal CO2, end-tidal anesthetic level, and urine output. Following a right parietal craniectomy, a standard sized cryogenic brain lesion was made. The animals were randomly allocated in two groups. Group I (n = 6) received maintenance anesthesia, but within a 30 minute period, mean arterial pressure (MAP) was reduced to 60 mmHg with isoflurane varying in inspired concentration from 2 to 4%. Thereafter, the MAP was maintained at this level for 60 minutes. The inspired concentration of isoflurane was decreased, then discontinued to allow the MAP to return to baseline during the next 30 minutes. Group II (n = 7) received maintenance anesthesia, and MAP was reduced to 60 mmHg during a 30 minute period with intravenous labetalol (20 mg.kg-1). This MAP was maintained for one hour with a continuous labetalol infusion. The infusion was discontinued and the MAP returned to baseline during the next 30 minutes. The wounds were surgically closed. Anesthesia was discontinued, paralysis was reversed, and the animals were extubated and transported to a recovery room. Forty-eight hours postoperatively, all animals were reanesthetized, injected with Evans' blue dye and sacrificed. The brain was removed, fixed in formalin, and sent "blindly" coded for neuropathologic evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)
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The effect of vecuronium on intracranial pressure (ICP) was investigated in six cats with normal and increased ICP. Cats were anaesthetized with pentobarbitone 33 mg kg-1 i.p. and acepromazine 0.6 mg kg-1 i.p., the trachea was intubated, and the lungs ventilated with nitrous oxide in oxygen. Mean arterial pressure (MAP), heart rate (HR), twitch response and ICP were recorded continuously. After the effect of vecuronium had been ascertained under the condition of normal ICP, and after full recovery of twitch response, pH-adjusted Ringer's lactate solution was infused to the cisterna magna until an ICP baseline of 26 +/- 2 mm Hg was established, and had stabilized. Vecuronium was administered again to determine its effect under the condition of increased ICP. Complete ablation of twitch response was obtained in 68 +/- 15 s with vecuronium 80 micrograms kg-1, and there was no significant change in ICP, MAP, HR or cerebral perfusion pressure (CPP) under either ICP condition.
Nitrous oxide is often used as anesthesia during ophthalmic surgery that requires intraocular injection of sulfur hexafluoride gas or air. Ventilation with N2O is known to increase intraocular pressure in the presence of intraocular bubbles, but little is known about the effect of N2O on intraocular bubble volume. Accordingly, we have compared the effect of N2O:O2 ventilation (66% N2O, balance O2) with that of air ventilation and oxygen ventilation on intraocular bubbles of SF6 or air. Aspiration of anterior chamber gas after 180 minutes of N2O:O2 ventilation in cats showed an increase in bubble volume of more than threefold when the original intraocular bubble was SF6 and an increase of more than twofold when the original intraocular bubble was air. In contrast, during air ventilation, intraocular SF6 bubble volume increased by 50%, and intraocular air bubble volume increased by only 7.5%. During O2 ventilation, intraocular SF6 bubble volume increased by 35%, and intraocular air bubble volume decreased by 13%. Our results indicate that N2O is contraindicated when gas is injected into the closed eye.
The effect of atracurium on intracranial pressure (ICP) was investigated in six cats with normal and increased ICP. The cats were anaesthetized with intraperitoneal pentobarbitone (33 mg . kg-1), acepromazine (0.6 mg . kg-1) and incremental fentanyl (p.r.n. approximately equal to 20 micrograms . kg-1), intubated, and ventilated with nitrous oxide in oxygen. Mean arterial pressure (MAP), heart rate (HR), twitch response and ICP were continuously recorded. After the effect of atracurium had been ascertained under the condition of normal ICP, and after full recovery of twitch response, pH-adjusted Ringer's lactate solution was infused into the cisterna magna until an ICP baseline of 26 +/- 2 mmHg was established and stabilized. Atracurium was then administered again to determine its effect under the condition of elevated ICP. Complete ablation of twitch response was obtained in 68 +/- 15 sec with 0.4 mg . kg-1 atracurium, and there was no significant change in ICP, MAP, HR or cerebral perfusion pressure (CPP) whether initial ICP was normal or elevated.
The effect of diltiazem-induced hypotension on intracranial pressure (ICP) was studied in dogs with normal and elevated ICP. Eight dogs were anesthetized with intravenous pentobarbital, intubated, and ventilated with N2O:O2. Mean arterial pressure (MAP), heart rate (HR), pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), and cardiac out-put (CO) were recorded. A ventriculostomy was performed for measurement of ICP. Baselines were established, and diltiazem was infused to reduce MAP 40 +/- 1% for 10 min. After recording the effects of diltiazem-induced hypotension during normal ICP, ICP was elevated by infusion through a ventriculostomy cannula of pH-adjusted Ringer's lactate, baselines were reestablished, and MAP was again reduced by 40 +/- 1% with diltiazem. When baseline ICP was normal, diltiazem-induced hypotension produced a statistically significant increase in ICP (4.8 +/- 0.6 mm Hg) and a decrease in cerebral perfusion pressure (CPP). When baseline ICP was elevated, a smaller increase in ICP occurred (1.3 +/- 0.5 mm Hg). Although these increases in ICP were not clinically significant, the dose of diltiazem required to lower MAP 40% caused significant alterations in HR, systemic vascular resistance, CO, and PCWP. Serious cardiac rhythm disturbances occurred in five of eight dogs when baseline ICP was normal and in six of eight dogs when baseline ICP was elevated. The relatively long duration of diltiazem's hemodynamic effect and the high incidence of cardiac rhythm disturbances make it an unsuitable drug for inducing deliberate hypotension.
In anesthetized cats ventilated with oxygen, 0.5 ml of the inert gas sulfur hexafluoride (SF6) was substituted for vitreous. When the ventilating gas was changed to nitrous oxide (N2O) 66%, balance oxygen, intraocular pressure increased from 14.4 to 30.3 mmHg in 19.5 min. When the ventilating gas was changed back to oxygen, intraocular pressure decreased from 29.1 to 12.0 mmHg in 18.1 min. This intraocular pressure change secondary to gas volume alteration may adversely affect therapeutic outcome of ophthalmic surgery. Accordingly, N2O should be avoided in patients during and following intravitreal injection of SF6 for up to 10 days.
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A survey on glycemic control in 201 diabetic children and adolescents, aged 0-18 years, was performed in two Italian Centers for Childhood Diabetes (Chieti and Parma). Mean HbA1c was 7.8+/-1.4 (range 4.8-13.3%; median 7.6%). With progression of diabetes duration, deterioration of glycemic control was observed (r=0.20; p< 0.002), more evident in girls than in boys, with peaks at 14 (8.9+/-2.0 vs 6.9+/-1.7%; p<0.05) and 16 years (9.5+/-1.4% vs 8.1+/-1.1; p<0.02). No differences were found in BMI values in boys or girls, or for insulin doses which were increased significantly in both sexes according to age (r= 0.33, p<0.04). The number of insulin injections did not influence glycemic control. Only one severe hypoglycemic episode was reported during the period of observation. This study demonstrates that modern management, continuous education and patient and family empowerment are effective in attaining excellent glycemic control without increasing the risk of hypoglycemia.
The concomitant occurrence of diabetic ketoacidosis and hyperosmolarity is reported in two children, as early symptoms of misdiagnosed type 1 diabetes mellitus. The precipitating factor for both severe metabolic abnormalities was the ingestion of a large amount of high-carbohydrate-containing fluids, a few days before admission. A similar situation has never been reported before in the literature. A successful therapeutic scheme is described.
In this study the effectiveness of a quantitative test of beta-hydroxybutyrate (beta-HBA) against a commercial test for urine ketone bodies (UKB) in monitoring diabetic ketoacidosis (DKA) was evaluated to verify whether this ketone-testing method was able to reduce the monitoring costs and professional burden of nurses and physicians. Thirty-three children with severe (arterial pH < or = 7.2) or moderate (7.2 < pH < or = 7.3) DKA were studied. Sixteen patients were randomly monitored with blood beta-HBA (group 1) and 17 by UKB (group 2). Contrary to UKB, beta-HBA levels appeared correlated with: HbA1c values on admission (r = 0.99; p = 0.0001); latent period before diagnosis of diabetes (r = 0.95; p = 0.0001); changes in arterial pH (r = -0.82; p = 0.0001) and blood bicarbonate values (r = -0.63; p = 0.001) during the treatment for DKA. Required time to achieve the resolution of ketosis in group 1 patients was related to the values of beta-HBA on admission (r = 0.84; p < 0.001). Determination of beta-HBA showed that ketosis in group 1 patients cleared 4 to 9.5 hours earlier than in group 2. Due to this early normalization, the patients of group 1 left the Intensive Care Unit 6.5 +/- 1.5 hr earlier than those of group 2. This led to 22 hr saved for clinical assessment and 375 laboratory investigations for a total saving of 2940 euros including costs for laboratory tests (29.8%) and clinical assessment (70.2%). Quantitative determination of beta-HBA levels seems to offer useful information for monitoring DKA in newly-diagnosed diabetic children and for reducing time and costs in an Intensive Care Unit.