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Background: Most reports of Rapid Response Systems (RRS) focus on the efferent, response component of the system, although evidence suggests that improved vital sign monitoring and recognition of a clinical crisis may have outcome benefits. There is no consensus regarding how best to detect patient deterioration or a clear description of what constitutes patient monitoring.Methods: A consensus conference of international experts in safety, RRS, healthcare technology, education, and risk prediction was convened to review current knowledge and opinion on clinical monitoring. Using established consensus procedures, four topic areas were addressed: (1) To what extent do physiologic abnormalities predict risk for patient deterioration? (2) Do workload changes and their potential stresses on the healthcare environment increase patient risk in a predictable manner? (3) What are the characteristics of an "ideal" monitoring system, and to what extent does currently available technology meet this need? and (4) How can monitoring be categorized to facilitate comparing systems?Results and Conclusions: The major findings include: (1) vital sign aberrations predict risk, (2) monitoring patients more effectively may improve outcome, although some risk is random, (3) the workload implications of monitoring on the clinical workforce have not been explored, but are amenable to study and should be investigated, (4) the characteristics of an ideal monitoring system are identifiable, and it is possible to categorize monitoring modalities. It may also be possible to describe monitoring levels, and a system is proposed. [ABSTRACT FROM AUTHOR]

Background: Previous data demonstrated lower survival rates of in-hospital cardiac arrests during nights and weekends compared to weekday daytime. This study aimed to evaluate variations of personnel attending to codes based on day/night/weekend conditions within the US Veterans Affairs (VA) system, as well as variations of personnel responsible for intubations during codes., Methods: Hospital leaders were surveyed regarding code team membership, leadership, and intubations during four time periods (weekday daytime, weekday nighttime, weekend daytime, and weekend nighttime)., Results: Surveys were completed for 93 of 123 eligible VA hospitals (response rate of 75.6%). Code teams were significantly smaller during "off-hours." Membership in code teams during regular vs. off-hours was significantly greater for ICU physicians (44.1% vs. 7.5%-15.0%, p < 0.001), anesthesiologists (34.4% vs. 12.9%, p < 0.001), and pharmacists (46.2% vs. 23.7%-26.9%, p < 0.01). Significant differences were found for codes led by ICU attendings (20.4% vs. 5.4%-7.5%, p < 0.05) and intubations performed by ICU attendings (21.5% vs. 6.5%-10.8%, p < 0.05). ICU-based physicians were team leaders more often in high-complexity hospitals (19.7%-50.0% vs. 0%-14.8%), while hospitalists led the majority in the low-complexity hospitals (28.8%-39.4% vs. 63.0%-70.4%). ICU physicians had significantly less involvement in code intubations in low-complexity hospitals (6.1%-22.7% vs. 3.7%-18.5%), while respiratory therapists took on most of this responsibility in low-complexity hospitals and particularly at night., Conclusion: This study found significant differences in code team composition, leadership, and intubation responsibilities between regular and off-hours. Low-complexity hospitals, which are generally rural, had team compositions and responsibilities that were visibly different from higher-complexity hospitals., (Published by Elsevier Inc.)

Objective: Delayed intensive care unit (ICU) admissions are associated with increased mortality. We present a retrospective study looking at whether indirect admissions to the ICU within 24 hours of hospital admission were associated with increased mortality., Design: Retrospective cohort study SETTING: Mixed medical-surgical ICU at a large tertiary United States Veterans Affairs (VA) Hospital System POPULATION: The patients were a mix of medical and surgical patients. Patients included both those directly admitted from the operating room as well as those escalated to the ICU after initial admission to the ward (indirect admission)., Methods: All admissions to a medical-surgical ICU from 2008 to 2013 were included in the study. The database was queried for time and location where the admission originated. Separate lists were created for patients with severe sepsis, patients who transferred to the ICU within the first 24 hours, and patients who had rapid response or code team activations. Analysis was applied to the whole group and to medical and surgical subpopulations., Results: A total of 3,862 ICU admissions were studied. Univariate analysis indicated an impact of delayed admission on whole group and surgical patients; however, multivariate analysis indicated a significant effect of delayed admission on 1-year surgical mortality. Multivariate analysis also showed a consistent effect of age, ICU length of stay, and cardiac arrest on mortality of both medical and surgical ICU patients., Conclusion: In a large retrospective study, surgical patients had increased 1-year mortality if they required escalation to the ICU within 24 hours of hospital admission. This result was not replicated in medical patients, possibly related to a burden of illness that could not be altered by earlier care., (© 2020 Marshfield Clinic.)

Background: The Perioperative Surgical Home (PSH) is an anesthesiologist-led, coordinated care model that may improve patient experience and safety. We hypothesized that PSH will decrease activation of the rapid response system for surgical inpatients., Methods: This retrospective study was performed at an academic Veterans Affairs hospital with a PSH. Data from both medical and surgical cohorts admitted to a single ward were analyzed for the Pre-PSH (July 2006 to October 2010) and Post-PSH (November 2011 to May 2015) epochs. The primary outcome was incidence of rapid response team (RRT) activations per 1000 bed-days., Results: Surgical patients had 5.8 RRT activations per 1000 bed-days Pre-PSH versus 3.7/1000 bed-days Post-PSH ( P = .006). There was no difference in RRT activations per 1000 bed-days for medical patients before and after PSH implementation. Pre-PSH was an independent predictor of mortality in the multivariable model (odds ratio = 1.7; P = .010)., Conclusion: PSH is associated with decreased RRT activations among surgical inpatients only.

Background: Frailty is a state of vulnerability to poor resolution of homeostasis after a stressor event and is strongly associated with adverse outcomes. Therefore, the assessment of frailty may be an essential part of evaluation in any healthcare encounter that might result in an escalation of care. The purpose of the study was to assess the frequency and association of frailty with clinical outcomes in patients subject to rapid response team (RRT) review., Methods: In this multi-national prospective observational cohort study, centres with existing RRTs collected data over a 7-day period, with follow up of all patients at 24 h following their RRT call and at hospital discharge or 30 days following the event trigger (whichever came sooner). Investigators also collected data on the triggers and interventions provided and a bedside assessment on the level of patients' frailty using a clinical frailty scale., Results: Amongst 1133 patients, 40% were screened as frail, which was associated with older age (p < 0.001), admission under a medical speciality (p < 0.001), increased severity of illness at the time of the RRT review (p = 0.0047), and substantially higher frequency of limitations of care (p < 0.001). Importantly, 72% of patients screened as frail were either dead or dependent on hospital care by 30 days (p < 0.001). In the multivariable analysis, the significant risk factors for the composite endpoint "poor recovery" (died or were hospital-dependent by 30 days) were age (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.03-1.05; p < 0.001), frailty level (p < 0.001), existing limitation of care (OR, 2.0; 95% CI, 1.3-3.0; p < 0.001), and the quick sequential organ failure assessment (qSOFA) score (p < 0.001)., Conclusions: Higher frailty scores were associated with increased mortality and dependence on health care at 30 days. Our results indicate that frailty has an influence on the clinical trajectory of deteriorating patients and that such assessment should be included in discussion of goals and expectations of care., Trial Registration: Netherlands Trial Registry, NTR5535 . Registered on 23 December 2015.

Background: Rapid response systems (RRSs) have been universally adopted in much of the developed world; yet, despite broad implementation, their success has often been limited. Even with successful systems, there is a small body of evidence regarding effective organizational elements that are responsible for improved outcomes. New organizational processes were implemented that restructured the existing RRS, and the impact on the number of rapid response team (RRT) alerts, cardiac arrest, and mortality rates was evaluated., Methods: A prospective five-year before-and-after comparison of adult ward patient outcomes was conducted at a community regional medical center. The key intervention was expanded administrative oversight of the system, which led to (1) restructuring the content and depth of ward nurse education regarding early recognition of at-risk patients; (2) system changes empowering prompt mobilization of the RRT; (3) development of RRT treatment protocols; and (4) a more frequent and comprehensive data collection and analysis for system compliance and performance improvement., Results: Some 28,914 patients were observed in the 24-month control period, and 39,802 patients were observed in the 33-month intervention period. RRT activations increased from 10.2 to 48.8/1,000 discharges (p <0.001), ward cardiac arrest decreased from 3.1 to. 2.4/1000 discharges (p = 0.04), hospital mortality decreased from 3.8% to 3.2% (p <0.001), and the observed-to-expected ratio decreased from 1.5 to 1.0 (p <0.001)., Conclusion: Expanded administrative involvement of an existing RRS that focused on early recognition of patient deterioration by the bedside nurse led to improved performance of the system, with a significant increase in number of RRTs and decreases in cardiac arrests and hospital mortality., (Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Aim: The study was developed to characterize short-term outcomes of deteriorating ward patients triggering a Rapid Response Team (RRT), and describe variability between hospitals or groups thereof., Methods: We performed an international prospective study of Rapid Response Team (RRT) activity over a 7-day period in February 2014. Investigators at 51 acute hospitals across Australia, Denmark, the Netherlands, USA and United Kingdom collected data on all patients triggering RRT review concerning the nature, trigger and immediate outcome of RRT review. Further follow-up at 24h following RRT review focused on patient orientated outcomes including need for admission to critical care, change in limitations of therapy and all cause mortality., Results: We studied 1188 RRT activations. Derangement of vital signs as measured by the National Early Warning Score (NEWS) was more common in non-UK hospitals (p=0.03). Twenty four hour mortality after RRT review was 10.1% (120/1188). Urgent transfer to ICU or the operating theatre occurred in 24% (284/1188) and 3% (40/1188) of events, respectively. Patients in the UK were less likely to be admitted to ICU (31% vs. 22%; p=0.017) and their median (IQR) time to ICU admission was longer [4.4 (2.0-11.8) vs. 1.5 (0.8-4.4)h; p<0.001]. RRT involvement lead to new limitations in care in 28% of the patients not transferring to the ICU; in the UK such limitations were instituted in 21% of patients while this occurred in 40% of non-UK patients (p<0.001)., Conclusion: Among patients triggering RRT review, 1 in 10 died within 24h; 1 in 4 required ICU admission, and 1 in 4 had new limitations in therapy implemented. We provide a template for an international comparison of outcomes at RRT level., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Classroom lectures are the mainstay of imparting knowledge in a structured manner and have the additional goals of stimulating critical thinking, lifelong learning, and improvements in patient care. The impact of lectures on patient care is difficult to examine in critical care because of the heterogeneity in patient conditions and personnel as well as confounders such as time pressure, interruptions, fatigue, and nonstandardized observation methods., Methods: The critical care environment was recreated in a simulation laboratory using a high-fidelity mannequin simulator, where a mannequin simulator with a standardized script for septic shock was presented to trainees. The reproducibility of this patient and associated conditions allowed the evaluation of "clinical performance" in the management of septic shock. In a previous study, we developed and validated tools for the quantitative analysis of house staff managing septic shock simulations. In the present analysis, we examined whether measures of clinical performance were improved in those cases where a lecture on the management of shock preceded a simulated exercise on the management of septic shock. The administration of the septic shock simulations allowed for performance measurements to be calculated for both medical interns and for subsequent management by a larger resident-led team., Results: The analysis revealed that receiving a lecture on shock before managing a simulated patient with septic shock did not produce scores higher than for those who did not receive the previous lecture. This result was similar for both interns managing the patient and for subsequent management by a resident-led team., Conclusions: We failed to find an immediate impact on clinical performance in simulations of septic shock after a lecture on the management of this syndrome. Lectures are likely not a reliable sole method for improving clinical performance in the management of complex disease processes.

Background: Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action., Rationale: There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature., Content: This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition., (© 2015 Marshfield Clinic.)

The postoperative course of a patient undergoing cardiac surgery (CS) is dictated by a largely predictable set of interactions between disease-specific and therapeutic factors. ICU personnel need to quickly develop a detailed understanding of the patient's current status and how critical care resources can be used to promote further recovery and eventual independence from external support. The goal of this article is to describe a typical operative and postoperative course, with emphasis on the latter, and the diagnostic and therapeutic options necessary for the proper care of these patients. This paper will focus on coronary artery bypass grafting as a model for understanding the course of CS patients; however, many of the principles discussed are applicable to most cardiac surgery patients., (© The Author(s) 2015.)

We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing. Suggestions to prevent loss of the airway include tips on airway assessment, preparation of airway equipment, and use of exchange catheter techniques. Strategies to avoid and manage both microvascular and large-vessel bleeding are discussed. We also discuss the management of common postprocedure problems including tracheostomy tube obstruction, malposition requiring tube exchange or replacement, and air leak. The practical considerations for successful execution of PDT involve common sense, thorough planning, and structured approaches to prevent adverse effects if the procedure does not go as smoothly as expected. These strategies will aid anesthesiologists and intensivists in improving their comfort level, safety, and competence in performing this beside procedure.

Background: Despite widespread training in basic life support (BLS) and advanced cardiovascular life support (ACLS) among hospital personnel, the likelihood of survival from in-hospital cardiac arrests remains low. In 2006 a university-affiliated tertiary medical center initiated a cardiopulmonary (CPR) resuscitation redesign project. REDESIGNING THE HOSPITAL'S RESUSCITATION SYSTEM: The CPR Committee developed the interventions on the basis of a large-scale view of the process of delivering BLS and ACLS, identification of key decision nodes and actions, and compartmentalization of specific functions. It was proposed that arrest management follow a steady progression in a two-layer scheme from BLS to ACLS. Handouts describing team structure and specific roles were given to all code team providers and house staff at the start of their month-long rotations. To further increase role clarity and team organization, daily morning and evening meetings of the arrest team were instituted. Site-specific BLS training, on-site ACLS refresher training, and defibrillator training were initiated. Project elements also included use of unannounced mock codes to provide system oversight; preparation and distribution of cognitive aids (printed algorithms, dosing guides, and other checklists to ensure compliance with ACLS protocols), identification of patients who may be unstable or a source of concern, event review and analysis of arrests and other critical events, and a CPR website., Conclusion: A mature hospital-based resuscitation system should include definition of arrest trends and resuscitation needs, development of local methods for approaching the arresting patient, an emphasis on prevention, establishment of training programs tailored to meet specific hospital needs, system examination and oversight, and administrative processes that maximize interaction between all components.

This review provides an update on the pharmacology of airway management, emphasizing medications and management strategies widely used in an intensive care unit setting. Induction agents, muscle relaxants, opioids, sedative-hypnotics, and adjunctive agents are reviewed in the context of emergent airway management. Throughout this review, we emphasize the utility of considering a broad set of pharmacologic agents and approaches for airway management of the critically ill patient.

It has been traditionally recommended that candidates for vascular surgery receive noninvasive stress perfusion testing risk stratification to help decide which patients may benefit from coronary artery revascularization. Recent clinical trials have contested the efficacy of revascularization in this population as well as the information yield of noninvasive testing. This article reviews a number of these studies that are likely to change our beliefs regarding testing and subsequent interventions as well as evolving role of medical therapy in patients undergoing vascular surgery.

Background: We sought to determine the impact of a rapid response system on cardiac arrest rates and mortality in a United States veteran population., Methods: We describe a prospective analysis of cardiac arrests in 9 months before and 27 months after institution of a rapid response system, and retrospective analysis of mortality 3.5 years before the intervention and 27 months after the intervention. The study included all inpatients from a university-affiliated United States Veterans Affairs Medical Center, before and after implementation of a rapid response system, including an educational program, patient calling criteria, and a physician-led medical emergency team. Primary end points were hospital-wide cardiac arrests and mortality rates normalized to hospital discharges. Comparisons of event rates between various time points during the implementation process were made by analysis of variance., Results: Three hundred seventy-eight calls were made to the medical emergency team in the time period studied. Compared with preintervention time points, cardiac arrests were reduced by 57%, amounting to a reduction of 5.6 cardiac arrests per 1000 hospital discharges (P < 0.01). Mortality was reduced during the intervention, but this was attributable to a natural decrease occurring over all phases of the study., Conclusions: A significant reduction in the rate of cardiac arrests was realized with this intervention, as well as a trend toward lower mortality. We estimate that 51 arrests were prevented in the timeframe studied. Our results suggest that further reductions in morbidity can be realized by expansion of rapid response systems throughout the Veterans Affairs network.

Background: There is widespread recognition that the conduct of cardiac resuscitation is problematic. In situ simulation has been used to train and evaluate cardiac arrest teams' performance in the hospital setting, but in work at a university-affiliated, tertiary care facility, the simulated cardiac arrests were used to understand how well health care providers and their environment function during arrests, with the goal of a rapid intervention to correct problem areas. Latent conditions--innate, mostly hidden, workplace factors--can have a large detrimental impact on resuscitation efforts., Methods: Observations from a series of unannounced simulated cardiac arrests undertaken at diverse locations within a university-affiliated, tertiary care hospital were a component of an ongoing initiative to improve performance of emergency cardiovascular care., Results: Fourteen cardiac arrest simulations revealed 24 hazardous findings, approximately two thirds of which had a high likelihood of compromising patient survival if they had occurred during an actual cardiac arrest. Categories of problems included active errors by teams and individuals and systemic or latent errors of the environment. Because the simulations were designed with the goal of discovering and documenting errors, most errors led to further actions, policies, and procedures that were rapidly adopted by the medical center to prevent their recurrence., Conclusions: In situ simulation of cardiac arrests elicits lifelike behaviors and allows engagement of all personnel and resources applicable to real arrests. This method allowed for remedial plans to be developed before further harm could occur. Accordingly, in situ simulation of high-risk events may be a useful, efficient technique that complements existing quality assurance processes in hospitals.

Introduction: Moderate capability simulators such as Laerdal's SimMan allow for the operator to control the vital signs presented on the monitor. However, the presence of the mannequin simulator may not always be needed to achieve specific teaching goals. In this report, we describe the use of the SimMan software to generate, control, and project vital signs on a projector screen, with an appearance identical to that of its normal companion monitor., Methods: We connected a laptop computer running Laerdal's SimMan software to a video projection system through a VGA or S-video connection and were able to create a controllable monitor that could be used for tabletop simulation sessions., Results: We were able to create an interactive and dynamic patient monitor that could be projected to a large group to facilitate tabletop simulation utilizing the Laerdal SimMan software and an external projection screen setup., Conclusions: Laerdal SimMan software can be used to create a dynamic and interactive presentation tool for classroom learning.

Aim: Establish the frequency of abnormal vital signs in medical and surgical ward patients; study their association with "critical events," which for the purposes of this study, were mortality, cardiac arrests and unplanned ICU transfers., Design and Methods: Four-month prospective, observational cohort study; University-affiliated US Veteran's hospital. Vital signs from all regular ward medical and surgical inpatients were recorded over the study period and compared with records of cardiac arrests, mortality and ICU admissions., Results: Using the Hospital's Medical Emergency Team criteria to define normal/abnormal thresholds for vital signs, abnormal vital signs (VS(MET)) were found in 16% of patients; of these; 35% experienced a critical event vs. 2.5% in the patients with normal vital signs (OR 21, 95% CI 12-35, p<0.001). The sensitivity of VS(MET) to predict a critical event was 0.72 and the positive predictive value was 0.35; sensitivity decreased to 0.28 and positive predictive value increased to 0.78 for patients that had two different VS(MET). Survival was significantly lower in both medical and surgical patients with VS(MET) at both 30 days and at 1 year following discharge (p<0.02). Both medical and surgical patients with VS(MET) had twice the length of stay of patients with normal vitals (3 vs. 7 days; p<0.001)., Conclusions: Even single recordings of VS(MET) signaled increased risk for critical events in hospital ward patients. Use of vital signs as criteria for additional patient assessment and possible ICU admission appears justified. Development of abnormal vitals during hospitalization may signify impaired physiologic reserve that places a patient at higher risk for mortality after discharge.

Intensive care units are complex and dynamic clinical environments in which the delivery of appropriate and timely care to critically ill patients depends on the integrated and efficient actions of providers with specialized training. The use of realistic clinical simulator systems can help to facilitate and standardize the training of critical-care physicians, nurses, respiratory therapists, and pharmacists without having the training process jeopardize the well-being of patients. In this article, we review the current state of the art of patient simulator systems and their applications to critical-care medicine, and we offer some examples and recommendations on how to integrate simulator systems into critical-care training.

Objective: Opioid-induced hyperalgesia (OIH) is a state of paradoxically increased nociceptive sensitivity seen in both humans and rodents following the resolution of the acute opioid antinociceptive effects or during periods of chronic opioid administration. Using the power of genetic analysis, we hoped to discover novel mechanisms modulating this trait., Basic Methods: The degree of opioid-induced hyperalgesia displayed in response to a thermal stimulus applied to the hind paw was measured in 16 strains of inbred mice after 4 days of morphine administration. The degree of thermal sensitization was then used in a recently developed in silico haplotypic mapping algorithm along with a haplotypic map constructed from a database containing 209,000 single nucleotide polymorphisms., Main Results: Analysis of the data resulted in the identification of several haplotype blocks strongly associated with the thermal opioid-induced hyperalgesia trait. The most strongly associated block was located within the Abcb1b P-glycoprotein drug transporter gene. Experiments using the P-glycoprotein inhibitor cyclosporine A and P-glycoprotein null mutant mice supported the hypothesis that a functional association exists between P-glycoprotein transporters and opioid-induced hyperalgesia. The observation of a correlation between morphine brain concentrations and the development of opioid-induced hyperalgesia was consistent with this hypothesis as well. In addition, P-glycoprotein gene deletion and pharmacological inhibition altered morphine ED50, tolerance and physical dependence., Conclusions: We conclude that the use of haplotypic mapping to identify novel mechanisms controlling complex traits is a viable approach. Variants of the Abcb1b gene may explain some portion of the interstrain differences in OIH and perhaps other consequences of chronic opioid administration.

Background: In locations where oxygen and anesthesia gas supplies are limited, and where circle systems are not practical, means to reduce fresh gas flow during maintenance of inhalational anesthesia are of potential value. We investigated whether a common transport breathing apparatus could be modified to allow interchange between Mapleson D (Map-D) and Mapleson A (Map A) configurations., Methods: A common Map-D transport system was converted to a Map-A system by switching positions of the exhaust valve and the elbow connector where fresh gas is delivered; these two breathing systems were compared in this study. The key question was whether rebreathing of CO2 could be eliminated at a lower fresh gas flow rate (FGF) with the Map-A design. A structured protocol was followed., Results: A mean decrease in FGF of 2.8 l/min was seen with the Map-A apparatus when compared with the Map-D (P=0.003). With no significant differences in physiologic or anesthetic variables, FGF/V(E) was significantly lower with the Mapleson A configuration than with the Mapleson D system design (1.1 vs. 1.8; P=0.007). The extent to which FGF could be lowered when switching between Mapleson D and A systems correlated strongly with the patients' respiratory rate while under anesthesia (r=0.45, P<0.01)., Conclusions: Cost and resource savings can be realized through the use of a breathing system modification that achieves appropriate ventilation at lower fresh gas flows.

Intravenous fluid administration is critical to the care of hospitalized patients. Despite the lack of a clear consensus on fluid administration, one may use the principles in this article to develop an organized framework for patient care.

Objective: Inherited differences in renal function underlie the effect of high salt diets on blood pressure in Dahl rats. We probed the kidneys of inbred Dahl SS/Jr and SR/Jr for anonymous and candidate genes whose expression was regulated by dietary sodium., Methods: mRNA quantitation of both candidate genes implicated in sodium excretion and anonymous gene products found by differential hybridization in the kidneys of salt-resistant (SR) and salt sensitive (SS) inbred Dahl rats on high and low salt diets for 21 days., Results: Differential screening revealed a cDNA clone (H1) that showed increased dietary salt-dependent expression only in SS rats. Sequencing of the H1 cDNA showed it was the Dahl rat homologue to a perchloric acid soluble protein expressed in liver and kidney. Among candidate genes, transcript levels of arginosuccinate synthetase (AS) and arginosuccinate lyase (AL) were higher in SS on low salt diets, and AS mRNA increased in response to a high salt diet in SR. Renal mRNA for the ANP-A and the vasopressin type II receptors did not differ by strain or dietary conditions., Conclusions: Three new salt-sensitive genes were detected in the kidneys of inbred Dahl rats. Two genes encode enzymes in the biosynthesis of L-arginine. The upregulation of these genes by dietary salt indicates increased demand and biosynthesis of L-arginine in Dahl SS rats. A third gene encodes a small acid-soluble protein thought to influence the transcription/translation of numerous genes. Further studies will be needed to determine the nature of the association of these genes with salt-sensitivity and blood pressure.

A patient with the genetic condition neurofibromatosis type I and no known coagulopathy undergoing cesarean delivery, had diffuse uterine and surgical site bleeding that was not correctable by oxytocin, methylergonovine and PGF2 alpha. Despite good uterine tone, hemorrhage continued from the uterus and the surrounding tissues, persisting even after surgical ligation of the uterine arteries. With no change in her condition, which was behaving clinically as a coagulopathy, an infusion of desmopressin acetate (DDAVP) was begun. The patient's bleeding promptly resolved shortly after infusion of this agent. A review of relevant literature suggests that platelet reactivity of patients with neurofibromatosis type 1 is attenuated in some in vitro conditions. Thus, there may be some theoretical basis for using DDAVP in patients with neurofibromatosis type 1 who have bleeding problems with no other known source, such as in the case presented here.

Study Objective: To determine the onset and clinical duration of cisatracurium and rocuronium in equipotent doses in balanced opioid/isoflurane anesthesia., Design: Randomized, controlled study., Setting: University hospital., Patients: 40 healthy patients scheduled for elective surgery., Interventions: Patients underwent anesthesia induction with thiopental or propofol with a cisatracurium intubating dose of either 0.15 or 0.2 mg/kg or a rocuronium dose of either 0.9 or 1.2 mg/kg. These doses correspond to three and four times the ED95 dose., Measurements and Main Results: The onset time and time to 25% recovery of baseline first twitch in a train-of-four were determined using an accelerometric sensor. Rocuronium had a faster onset time that cisatracurium at equipotent doses (3 x ED95: 134 vs. 220 sec respectively, and at 4 x ED95: 95 vs. 162 sec). Recovery tended to be faster, but not statistically different for cisatracurium compared to rocuronium., Conclusions: With equipotent intubating doses of rocuronium and cisatracurium, rocuronium produces a more rapid onset of muscle relaxation. The data suggest a tendency toward more rapid clinical recovery of cisatracurium compared to equipotent doses of rocuronium, although these differences were not statistically significant.

Chromosome size polymorphisms occur in Leishmania such that each strain of a given species has a distinctive molecular karyotype. Despite this variability, the chromosomal similarities among closely related strains of Leishmania are sufficiently characteristic to permit classification of unidentified clinical isolates. Mechanisms generating chromosome size polymorphisms are related to chromosomal evolution. In this review, Geoffrey Lighthall and Suzanne Giannini explain that the chromosomal profiles of members of different species may be diverging from a conserved 'consensus' karyotype at different rates, and present a current understanding of the genomic organization of Leishmania with emphasis on chromosomal elements.