Faculty Bibliography

We report the occurrence of accidental hyperthermia in a young child undergoing anesthesia for cardiac magnetic resonance imaging. Although the tendency during anesthesia is to develop hypothermia, the absorbed radiofrequency energy from magnetic resonance scanning is added to metabolic energy and must be balanced by appropriate heat loss to maintain normothermia. In addition to stressing the clinical importance of temperature monitoring, this report suggests that the recommended specific absorption rates to prevent excessive patient heating may need to be revised for infants and young children

Treatment of child victims of a bioterrorism attack is complicated because they may be more vulnerable to the agents used and may suffer more complications from the treatment strategies. Isolation and other infection control measures can be psychologically harmful to young children and may require that they undergo sedation. Most of the recommended antibiotics and antiviral treatments for bioterror agents have not been approved for use in children, and children undergoing smallpox vaccination have a higher incidence of complications than adults. Pediatric anesthesiologists should expect to be part of the pediatric care team and must be careful to observe infection control procedures to limit the spread of disease caused by bioterror attack

Pneumocystis carinii is unable to synthesise S-adenosylmethionine and thus scavenges this intermediate. We aimed to test whether measurement of concentrations of this metabolic intermediate in plasma could provide a new method for rapid diagnosis of Pneumocystis carinii pneumonia (PCP). We measured S-adenosylmethionine plasma concentrations in 12 healthy controls, 16 patients with confirmed or suspected PCP, and 36 patients with other infections. Median concentration in healthy controls was 106 nmol/L (range 86-128), but the protein was undetectable in eight patients with histologically proven and seven with suspected PCP, and was 8 nmol/L in another confirmed case (p<0.0001). In 36 patients with other infections, S-adenosylmethionine concentrations were much the same as in controls: 18 had bacterial pneumonia, two tuberculosis, five cryptococcal meningitis, three had other infections, and eight had asymptomatic HIV-1 infection. After treatment for PCP, S-adenosylmethionine concentrations rose rapidly in all but one patient who died of the disease. Measurement of plasma S-adenosylmethionine concentrations could prove useful for diagnosis of PCP and assessment of patients' response to treatment

Anesthesiologists sometimes have difficulty discussing uncertainties with patients. The widespread and deeply visceral uncertainty about sleep, dreams, and death--the daily terrain of the anesthesiologist--has its roots in the classical representations of these states as siblings, the children of the goddess Night. The symbolism of mythology can guide the practitioner by recognizing, through allegory, the range of our own and our patients' fears

Horner's syndrome is a rare side effect of epidural analgesia. In association with ipsilateral brachial plexus block, it has only been reported once before, in French. Unilateral blockade has also been reported, although its etiology is unclear and may be multifactorial. The patient described here experienced an asymmetrical epidural blockade with a unilateral Horner's syndrome and ipsilateral brachial plexus block

Since it was first introduced in the late 1800s, the tuberculin test has undergone continual refinement in its formulation, standardization, and dosage, as well as its interpretation and indications for use. New guidelines have replaced universal screening with targeted testing and rigid definitions of positivity with individualized criteria formulated from a Bayesian approach. This review summarizes the evolution of the test and provides information to help gauge its predictive value

SETTING: Several social service agencies in New York City, and the Chest Clinic of Bellevue Hospital, a large public hospital. OBJECTIVE: To determine the utility of screening as a preventive and control measure among persons at risk for tuberculosis. DESIGN: Persons seeking social services at several private agencies in New York City were screened, and those with a positive skin test or symptoms suggestive of active tuberculosis were referred to the Chest Clinic for evaluation. RESULTS: Of 3828 persons evaluated, 20 had active tuberculosis, and 33% of the screened cohort were tuberculin skin test positive. Of 466 persons with tuberculosis infection who were evaluated, only 55 persons were given isoniazid (INH), and only 20 completed preventive therapy. Most patients who were not given INH had taken it previously, were older than 35 years, or had continuing alcohol use which made physicians reluctant to prescribe isoniazid. CONCLUSION: Screening for tuberculosis may detect a significant number of cases of active disease when the background prevalence of the disease is very high. However, screening for infection as a means to prevent future cases is unlikely to be effective unless rates of administration and completion of isoniazid preventive therapy are increased

Lymphocyte-proliferative responses (LPRs) to HIV antigens are absent or of low magnitude in the majority of HIV-infected individuals, even early in the disease. However, lymphocytes from 2% to 3% of individuals proliferate very strongly to HIV Env or Gag antigens, and these individuals remain well clinically, without antiretroviral therapy. In established HIV infection, suppression of HIV-replication with potent antiretroviral therapy does not result in the development of strong LPRs to HIV antigens. Large LPRs to HIV antigens can be induced by HIV vaccines in patients with established infection, even though they were not formed in response to infection. Studies must be designed to determine whether large LPRs induced by vaccines administered in conjunction with potent antiretroviral therapy are associated with long-term control of HIV infection