%0 Journal Article %~ Pubmed %A Hayman, Mark %A Forrest, Paul %A Kam, Peter %T Anesthesia for interventional cardiology. %B Journal of cardiothoracic and vascular anesthesia %D 2012 %V 26 %N 1 %P 134-47 %@ 1532-8422 %X %Z FOR Codes: 110301 110201 110323 %0 Journal Article %~ Pubmed %A Gibbs, N M %A Kam, P C A %T Sugammadex: restricted vs unrestricted or selective vs non-selective? %B Anaesthesia and Intensive Care %D 2012 %V 40 %N 2 %P 213-5 %@ 0310-057X %X %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Huismans, Anna M %A Kroon, Hidde M %A Haydu, Lauren E %A Kam, Peter C A %A Thompson, John F %T Is Melphalan Dose Adjustment According to Ideal Body Weight Useful in Isolated Limb Infusion for Melanoma? %B Annals of Surgical Oncology %D 2012 %V %N %P %@ 1534-4681 %X BACKGROUND: Isolated limb infusion (ILI), introduced in 1992, is a technique used to deliver regional chemotherapy to treat advanced melanoma confined to a limb. Adjusting melphalan dose according to ideal body weight (IBW) has been proposed as a method of decreasing limb toxicity without compromising outcome. The current study analyzed this proposed dose adjustment. METHODS: We reviewed 99 consecutive patients with lower extremity melanomas treated by ILI at our institution between May 1998 and February 2009. Toxicity and outcomes were tested for correlation with differences between administered dose and calculated adjusted dose, both in mg and mg/L, and with differences between actual limb volume and calculated adjusted limb volume. RESULTS: The median actual body weight was 71?kg, whereas the calculated median IBW was 57?kg (p?or=75 years of age (range: 75-93). The patient characteristics in both groups were comparable except that the older group comprised more women (71% vs. 54%; P = 0.02) and had a lower body mass index (median: 24.4 vs. 26.4; P = 0.008). Complete response rates were 34% for those >or=75 years and 41% in the younger group (P = 0.28). There was no difference in limb recurrence free interval after a complete response (median: 24 months for both groups; P = 0.51) or in survival (median: 36 months for <75, 39 months for >or=75; P = 0.36) between both groups. Older patients experienced less limb toxicity after the procedure (Wieberdink grade III/IV toxicity in 36%) compared with younger patients (51%; P = 0.009) while systemic toxicity, complications, and long-term morbidity were similar. CONCLUSIONS: Elderly patients with advanced metastatic melanoma of the limb experience the same or lower toxicity after ILI compared with younger patients while response rates, limb recurrence free interval, survival, and morbidity are similar. ILI is an attractive alternative to the more laborious ILP, especially for older patients. %Z FOR Codes: 1112 %0 Journal Article %~ Pubmed %A Kroon, Hidde M %A Moncrieff, Marc %A Kam, Peter C A %A Thompson, John F %T Factors predictive of acute regional toxicity after isolated limb infusion with melphalan and actinomycin D in melanoma patients. %B Annals of Surgical Oncology %D 2009 %V 16 %N 5 %P 1184-92 %@ 1534-4681 %X INTRODUCTION: Isolated limb infusion (ILI) with cytotoxic drugs is a low-flow isolated limb perfusion (ILP) performed via percutaneous catheters without oxygenation to treat metastatic melanoma confined to a limb. Response rates and duration of response following ILI are similar to those after ILP. Previously we have shown that more significant limb toxicity is not associated with a higher response rate or improved patient outcome. In this study we sought to determine factors predicting toxicity following ILI. METHODS: From our prospective database 185 patients with advanced metastatic melanoma of the limb treated with a single ILI between 1992 and 2007 were identified. In all patients a cytotoxic combination of melphalan and actinomycin D was used. Drug circulation time was 20-30 min under mild hyperthermic conditions (38-39 degrees C). Limb toxicity was assessed using the Wieberdink scale. RESULTS: The average patient age was 74 years (range 29-93 years) and 62% were female. Most patients (134/185) had MD Anderson stage III disease (satellites and in-transit metastases). Toxicity grade I (no reaction) occurred in 3 patients, grade II (slight erythema and edema) in 105 patients, grade III (considerable erythema and edema +/- blistering) in 72 patients, and grade IV (threatened or actual compartment syndrome) in 5 patients. No patient developed grade V toxicity (requiring amputation). On univariate analysis high peak and high final melphalan concentrations were found to be predictive factors for grade III/IV limb toxicity as well as the area under the curve of the melphalan concentration. Surprisingly, a greater rise in the CO(2) level during the procedure was associated with lower toxicity in the univariate analysis. Increased serum creatine phosphokinase (CK) postoperatively was related to higher toxicity score. In the multivariate analysis high final melphalan concentration and shorter tourniquet time were independent predictive risk factors for developing grade III/IV limb toxicity. CONCLUSIONS: ILI is a safe alternative to the more invasive and laborious ILP technique to treat melanoma confined to a limb. Regional acute toxicity following ILI is mild to moderate in most patients. Based on the predictive factors found in this series, altering melphalan dose and tourniquet time may allow further reductions in post-ILI toxicity without compromising effectiveness. %Z FOR Codes: 1112 %0 Journal Article %~ Pubmed %A Woodward, L J %A Kam, P C A %T Ankylosing spondylitis: recent developments and anaesthetic implications. %B Anaesthesia %D 2009 %V 64 %N 5 %P 540-8 %@ 1365-2044 %X Ankylosing spondylitis can present significant challenges to the anaesthetist as a consequence of the potential difficult airway, cardiovascular and respiratory complications, and the medications used to reduce pain and control the disease. There is also an increased risk of neurological complications in the peri-operative period. Awake fibreoptic intubation is the safest option in those patients with a potentially difficult airway as it allows continuous neurological monitoring while achieving a definitive airway. Neurophysiological monitoring (somatosensory and motor evoked potentials) should be considered in patients undergoing surgery for cervical spine deformity. The medical management of the disease has improved with the use of anti-tumour necrosis factor-alpha agents. There is potential for increased wound infection in patients taking these drugs. This article reviews the anaesthetic issues in patients with ankylosing spondylitis. The challenge to the anaesthetist is in the understanding of these issues so that appropriate management can be planned and undertaken. %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Kroon, Hidde M %A Lin, D-Yin %A Kam, Peter C A %A Thompson, John F %T Isolated limb infusion as palliative treatment for advanced limb disease in patients with AJCC stage IV melanoma. %B Annals of Surgical Oncology %D 2009 %V 16 %N 5 %P 1193-201 %@ 1534-4681 %X INTRODUCTION: In the treatment of patients with advanced limb melanoma a major treatment dilemma can arise when distant metastases are present also. Isolated limb infusion (ILI) has proved to be a useful limb-saving treatment and could potentially be of palliative value in patients with American Joint Committee on Cancer (AJCC) stage IV melanoma. METHODS: We identified 37 patients with advanced symptomatic limb disease as well as documented distant metastases at the time of their ILI. In all patients a drug combination of melphalan and actinomycin D was used. RESULTS: Fifty one percent had visceral distant metastases and 49% had cutaneous distant metastases only. The overall response rate in the treated limb was 76% [complete response (CR) rate 22%, partial response (PR) rate 54%]. Median response duration was 11 months (28 months for patients with CR; p = 0.08). Median survival after CR was 22 months, 17 months after PR, and only 4 months for those with stable or progressive disease (p = 0.002). Patients with visceral distant metastases had a significantly decreased survival compared with those with cutaneous distant metastases only (8 and 21 months, respectively; p = 0.03). Limb salvage was achieved in 86% of the patients. The procedure was well tolerated, with only one patient developing Wieberdink grade IV toxicity (threatened/actual compartment syndrome) and none requiring amputation as a result of the procedure (grade V toxicity). CONCLUSIONS: Minimally invasive ILI can effectively be used as palliative treatment to provide local tumor control and limb salvage in stage IV melanoma patients with advanced, symptomatic limb disease. %Z FOR Codes: 1112 %0 Journal Article %~ Pubmed %A Kroon, Hidde M %A Lin, D-Yin %A Kam, Peter C A %A Thompson, John F %T Major amputation for irresectable extremity melanoma after failure of isolated limb infusion. %B Annals of Surgical Oncology %D 2009 %V 16 %N 6 %P 1543-7 %@ 1534-4681 %X INTRODUCTION: Isolated limb infusion (ILI) is an effective, minimally invasive treatment option that delivers high-dose regional chemotherapy to treat metastatic melanoma confined to a limb. In some patients, however, locoregional disease does not respond to the treatment or extensive recurrence occurs so that an amputation may become inevitable. In this study we analyzed indications for and results of amputation in these cases. METHODS: 14 patients were identified in whom amputation of the affected limb had to be carried out after failure of ILI. RESULTS: Following ILI, three patients had a complete response, seven had a partial response, two had stable disease and two patients had progressive disease. The median duration of response after ILI was 7 months (range 2-30). The median interval between ILI and amputation was 10 months. Amputation was performed in six of 20 patients who had been treated with an upper limb ILI, compared to eight amputations that were performed in 215 patients who had been treated with a lower limb ILI (P = .001). The indications for amputation were severe pain due to progression of tumor (n = 3), uncontrollable and troublesome tumor progression (n = 6) and bleeding from ulcerated lesions (n = 5). Five patients developed stump recurrence after amputation; these were treated by excision or radiation. Six of the eight patients who had a lower limb amputation became ambulant with the aid of prosthesis. Median survival after amputation was 13 months: three patients survived more than 5 years. CONCLUSIONS: Amputation following upper extremity ILI is more common compared to lower extremity ILI. Amputation may provide effective long-term palliation in selected patients when there is extensive inoperable progressive or recurrent disease after ILI. %Z FOR Codes: 1112 %0 Journal Article %~ Pubmed %A Dickinson, M C %A Kam, P C A %T Intravascular iodinated contrast media and the anaesthetist. %B Anaesthesia %D 2008 %V 63 %N 6 %P 626-34 %@ 1365-2044 %X The use of intravascular iodinated contrast media (ICM) in radiological investigations is common. Increasingly, anaesthetists and intensivists are involved in the care of patients undergoing these investigations. Whilst the use of ICM is generally safe there are important adverse effects that need to be recognised and measures instigated to prevent or treat these effects. In patients at risk of developing adverse reactions it is important to consider alternative modes of imaging so that ICM can be avoided. Strategies for the prevention of ICM nephropathy should be considered in all patients receiving ICM. Currently intravascular volume expansion with 0.9% saline has the strongest evidence base. The use of isotonic sodium bicarbonate combined with N-acetylcysteine appears promising in providing further benefits. Although the use of N-acetylcysteine alone has not been shown to significantly reduce the incidence of ICM nephropathy it is cheap, has few adverse effects and it would seem reasonable to continue its use in conjunction with intravascular volume expansion. The routine use of corticosteroid and antihistamine premedication is not always effective in preventing general adverse reactions. %Z FOR Codes: 1115 %0 Journal Article %~ Pubmed %A Thompson, John F %A Kam, Peter C A %T Current status of isolated limb infusion with mild hyperthermia for melanoma. %B International journal of hyperthermia : the official journal of European Society for Hyperthermic Oncology, North American Hyperthermia Group %D 2008 %V 24 %N 3 %P 219-25 %@ 0265-6736 %X Purpose: Recurrent disease confined to a limb is a frequently encountered clinical problem in patients with melanoma. Regional chemotherapy by isolated limb perfusion (ILP) provides effective treatment but is invasive, complex and costly. Isolated limb infusion (ILI) is a simple yet effective alternative to ILP. Materials and methods: ILI involves drug administration into a limb via percutaneously inserted catheters after vascular isolation of the limb has been achieved with a tourniquet. The infused drug is circulated for 30 minutes via a simple extracorporeal circuit incorporating a heater (to produce mild hyperthermia). Results: Limb tumour remission rates are similar to those achieved by conventional ILP. ILI is well tolerated, and elderly patients and those with major medical co-morbidities and serious peripheral vascular problems can be treated. Conclusions: ILI with mild hyperthermia is an established alternative to hyperthermic ILP for patients with recurrent limb melanoma. It can also be used for patients with soft tissue sarcomas and a variety of serious, chronic dermatological conditions. %Z FOR Codes: 111299 %0 Journal Article %~ Pubmed %A Moncrieff, Marc %A Kroon, Hidde %A Kam, Peter %A Stalley, Paul %A Scolyer, Richard %A Thompson, John %T Isolated limb infusion for advanced soft tissue sarcoma of the extremity. %B Annals of Surgical Oncology %D 2008 %V 15 %N 10 %P 2749-56 %@ 1534-4681 %X Isolated limb infusion (ILI) is a minimally invasive technique for delivering high-dose regional chemotherapy. We report our experience with ILI for the treatment of soft tissue sarcoma (STS). %Z FOR Codes: 110314 %0 Book %A Power, Ian %A Kam, Peter %T Principles of Physiology for the Anaesthetist %B %D 2008 %C United Kingdom %I Hodder Education %V %N %P %@ 9780340887998 %X %Z FOR Codes: 110301 111601 %0 Journal Article %~ Pubmed %A Lim, K-S %A Kam, P C A %T Chlorhexidine--pharmacology and clinical applications. %B Anaesthesia and Intensive Care %D 2008 %V 36 %N 4 %P 502-12 %@ 0310-057X %X Chlorhexidine is a widely used skin antisepsis preparation and is an ingredient in toothpaste and mouthwash. It is an especially effective antiseptic when combined with alcohol. Its antimicrobial effects persist because it is binds strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery and the placement of intravascular access. Catheters impregnated with chlorhexidine and antimicrobial agents can reduce the incidence of catheter-related bloodstream infections. Contact dermatitis related to chlorhexidine is not common in health care workers. The incidence of contact dermatitis to chlorhexidine in atopic patients is approximately 2.5 to 5.4%. Acute hypersensitivity reactions to chlorhexidine are often not recognised and therefore may be underreported. This review discusses the pharmacology, microbiology, clinical applications and adverse effects of chlorhexidine. %Z FOR Codes: 1115 %0 Journal Article %~ Pubmed %A Kroon, Hidde %A Moncrieff, Marc %A Kam, Peter %A Thompson, John %T Outcomes following isolated limb infusion for melanoma. A 14-year experience. %B Annals of Surgical Oncology %D 2008 %V 15 %N 11 %P 3003-13 %@ 1534-4681 %X Isolated limb infusion (ILI) is a minimally invasive technique for delivering regional chemotherapy in patients with advanced and metastatic melanoma confined to a limb. It is essentially a low-flow isolated limb perfusion (ILP) performed via percutaneous catheters without oxygenation. %Z FOR Codes: 111299 %0 Journal Article %~ Pubmed %A Kam, Peter C A %A Thompson, John F %T Pharmacokinetics of regional therapy: isolated limb infusion and other low flow techniques for extremity melanoma. %B Surgical oncology clinics of North America %D 2008 %V 17 %N 4 %P 795-804 %@ 1055-3207 %X Isolated limb infusion (ILI) provides a simple, minimally invasive, and yet effective method of delivering high doses of cytotoxic drugs into tumor tissue with minimal systemic side effects because there is no significant drug leakage into the systemic circulation. The ILI technique is a technically less complex procedure than conventional ILP that can be used in patients who have advanced or persistently recurrent disease in an extremity. It is an attractive palliative option because it preserves limb function and maintains quality of life. Repeat ILI is safe and effective. Because the risk for systemic leakage is extremely low, ILI provides an excellent model in which to test new drugs and drug combinations. %Z FOR Codes: 111204 %0 Journal Article %~ Pubmed %A Kam, Peter Ca %T Anaesthetic management of a patient with thrombocytopenia. %B %D 2008 %V 21 %N 3 %P 369-74 %@ 0952-7907 %X PURPOSE OF REVIEW: New insights into the role of platelets in haemostasis have enabled a better understanding of the pathophysiology of conditions associated with thrombocytopenia. The development of new drugs and the advances in blood transfusion technology have improved the clinical management of patients with thrombocytopenia. The aim of this article is to provide a concise review of major advances in the perioperative management of patients with thrombocytopenia. RECENT FINDINGS: Thrombocytopenia is a symptom, and the underlying cause must be evaluated. Immunotherapy, corticosteroids, immunosuppressive drugs and thrombopoietic growth factors can increase the number of platelets in thrombocytopenic patients. Further, a better understanding of the pathophysiology of heparin-induced thrombocytopenia type II and the development of direct thrombin inhibitors have improved the management of these patients, especially in the perioperative period. SUMMARY: The lack of clinical methods for predicting which type of patients with thrombocytopenia are at risk of bleeding and the effectiveness of various platelet preparations call for research initiatives to provide better guidelines for transfusion practice. Controlled clinical trials are required to evaluate strategies for the prophylactic use of platelets and thrombopoietic factors in idiopathic thrombocytopenic purpura and the use of direct thrombin inhibitors in patients with heparin-induced thrombocytopenia. %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Sanki, Amira %A Kam, Peter C A %A Thompson, John F %T Long-term results of hyperthermic, isolated limb perfusion for melanoma: a reflection of tumor biology. %B Annals of Surgery %D 2007 %V 245 %N 4 %P 591-6 %@ 0003-4932 %X PURPOSE: To review the long-term duration of limb tumor complete remission (CR) and patient survival following therapeutic hyperthermic isolated limb perfusion (ILP) with cytotoxic drugs for melanoma. METHODS: A retrospective case series of 124 ILPs performed in 111 patients. RESULTS: There were 120 assessable ILPs. Patient staging (M.D. Anderson system) was stage II 11.7%, stage IIIA 44.2%, stage IIIAB 33.3%, and stage IV 10.8%. CR was initially attained after 83 ILPs (69.2%) and partial remission (PR) after 19 ILPs (15.8%). Limb CR was maintained in 28 (33.7%) of the 83 cases. Disease recurred in the perfused limb after an initial CR in the remaining 55 cases (median time to recurrence, 11 months); in 19 of these cases, the limb was disease-free at last follow-up after further locoregional treatment. A long-term CR was achieved, with or without further treatment, in 47 (56.6%) of the 83 cases in which an initial CR had occurred (mean follow-up, 97 months; median, 65 months). There was no significant difference in long-term local remission for stage IIIA and IIIAB patients. Five-year survival for those who had a partial or no response to ILP was 7%. Ten-year survival for those who had a long-term CR was 49%. CONCLUSIONS: ILP, with or without further locoregional treatment, achieved long-term control of recurrent and metastatic limb disease in 56.6% of cases in which an initial CR was achieved. A complete response to ILP was a positive prognostic indicator for survival, probably reflecting more favorable tumor biology in this subset of patients. %0 Journal Article %~ Pubmed %A Kam, P C A %A Cardone, D %T Propofol infusion syndrome. %B Anaesthesia %D 2007 %V 62 %N 7 %P 690-701 %@ 0003-2409 %X The clinical features of propofol infusion syndrome (PRIS) are acute refractory bradycardia leading to asystole, in the presence of one or more of the following: metabolic acidosis (base deficit > 10 mmol.l(-1)), rhabdomyolysis, hyperlipidaemia, and enlarged or fatty liver. There is an association between PRIS and propofol infusions at doses higher than 4 mg.kg(-1).h(-1) for greater than 48 h duration. Sixty-one patients with PRIS have been recorded in the literature, with deaths in 20 paediatric and 18 adult patients. Seven of these patients (four paediatric and three adult patients) developed PRIS during anaesthesia. It is proposed that the syndrome may be caused by either a direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. An early sign of cardiac instability associated with the syndrome is the development of right bundle branch block with convex-curved ('coved type') ST elevation in the right praecordial leads (V1 to V3) of the electrocardiogram. Predisposing factors include young age, severe critical illness of central nervous system or respiratory origin, exogenous catecholamine or glucocorticoid administration, inadequate carbohydrate intake and subclinical mitochondrial disease. Treatment options are limited. Haemodialysis or haemoperfusion with cardiorespiratory support has been the most successful treatment. %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Hackett, R %A Kam, P C A %T Botulinum toxin: pharmacology and clinical developments: a literature review. %B %D 2007 %V 3 %N 4 %P 333-45 %@ 1573-4064 %X Botulinum toxin is used as first line therapy for some muscular disorders, and is efficacious in treating hypersecretory and some pain syndromes. When used appropriately it has a good safety profile. It has been evaluated in treating a number of conditions that as yet do not have obvious effective or beneficial treatment. With the greater acceptance and use of botulinum toxin therapy for cosmetic purposes, botulinum toxin use will increase. An understanding of the pharmacology, and potential adverse effects is essential for the physician when managing patients having or who would benefit from botulinum toxin therapy. %Z FOR Codes: 110502 110502 %0 Journal Article %~ Pubmed %A Turner, Martin %A Irwig, Les %A Bune, Alexandra %A Kam, Peter %A Baker, A %T Lack of sphygmomanometer calibration causes over- and under-detection of hypertension: a computer simulation study. %B Journal of Hypertension %D 2006 %V 24 %N 10 %P 1931-1938 %@ 0263-6352 %X OBJECTIVE: To estimate the contribution of inadequate sphygmomanometer calibration to over- and under-detection of hypertension. DESIGN: Monte Carlo simulation of the measurement of blood pressure (BP) of a population with calibrated and uncalibrated sphygmomanometers. Simulated BP measurements included systematic sphygmomanometer error and random variability. MAIN OUTCOME MEASURES: The percentage of hypertensive adults (BP > 140/90 mmHg) not detected and the percentage of adults incorrectly classified hypertensive due to sphygmomanometer error. The percentage of the false positives and false negatives attributable to sphygmomanometer error. The number of additional visits patients need to make to obtain the same improvement in hypertension detection as is obtained by sphygmomanometer calibration. RESULTS: After three visits, uncalibrated sphygmomanometer error causes 20 and 28% of all undetected adult systolic and diastolic hypertension, respectively, and 15 and 31% of all falsely detected adult systolic and diastolic hypertension. In some groups, under-detection is worse; for example, sphygmomanometer error causes 27% of all missed systolic hypertension in 35-44-year-old females. In some age groups, over-detection is worse; for example, after three visits, sphygmomanometer error causes 63 and 50% of falsely detected systolic and diastolic hypertension in 18-24-year-old females, respectively. In-service sphygmomanometer calibration achieves the same or greater improvement in hypertension detection as an additional two visits. CONCLUSIONS: Uncalibrated sphygmomanometers are a preventable cause of clinically significant over- and under-detection of hypertension. Sphygmomanometers should be calibrated regularly by accredited organizations or technicians. Standards and guidelines governing sphygmomanometers in service should be revised. Sphygmomanometer calibration is a cost-effective way of improving hypertension detection. %0 Journal Article %~ Pubmed %A Barrett, N A %A Kam, P C A %T Transfusion-related acute lung injury: a literature review. %B Anaesthesia %D 2006 %V 61 %N 8 %P 777-85 %@ 0003-2409 %X Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of transfusion of blood and blood components. TRALI is under-diagnosed and under-reported because of a lack of awareness. A number of models have been proposed to explain the pathogenesis of TRALI: an antibody mediated model; a two-event biologically active mediator model; and a combined model. TRALI can occur with any type of blood product and can occur with as little as one unit. Its presentation is similar to other forms of acute lung injury and management is predominantly supportive. The main strategy in combating TRALI is prevention both through manipulation of the donor pool and through clinical strategies directed at reducing transfusion of blood products including, but not limited to, evidence-based lower transfusion thresholds. This article presents a review of TRALI and addresses the definition, pathology, pathogenesis, clinical manifestations, treatment and prevention of the syndrome. %0 Journal Article %A Payne, V. %A Kam, Peter %T Mast cell tryptase ? role in the investigation of acute hypersensitivity reactions %B Current Anaesthesia & Critical Care %D 2006 %C United Kingdom %I Churchill Livingstone %V 17 %N %P 29-35 %@ 0953-7112 %X %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Kam, P C A %A Kaur, N %A Thong, C L %T Direct thrombin inhibitors: pharmacology and clinical relevance. %B Anaesthesia %D 2005 %V 60 %N 6 %P 565-74 %@ 0003-2409 %X Although heparin has been a cornerstone of treatment for the prevention of thrombosis, it is limited by its adverse effects and unpredictable bioavailability. Direct thrombin inhibitors are a novel class of drugs that have been developed as an effective alternative mode of anticoagulation in patients who suffer from heparin-induced thrombocytopaenia, and for the management of thromboembolic disorders and acute coronary syndromes. The main disadvantages of the direct thrombin inhibitors are the lack of an antidote or readily available clinical monitoring. The mechanism of action, the properties of direct thrombin inhibitors and their potential to replace currently available anticoagulants are reviewed. %Z FOR Codes: 111501 %0 Journal Article %~ Pubmed %A Cheah, M H %A Kam, P C A %T Obesity: basic science and medical aspects relevant to anaesthetists. %B Anaesthesia %D 2005 %V 60 %N 10 %P 1009-21 %@ 0003-2409 %X Obesity is becoming a major public health problem throughout the world. It is now the second leading cause of death in the United States and is associated with significant, potentially life-threatening co-morbidities. Significant advances in the understanding of the physiology of body weight regulation and the pathogenesis of obesity have been achieved. A better understanding of the physiology of appetite control has enabled advances in the medical and surgical treatment of obesity. Visceral or abdominal obesity is associated with an increased risk of cardiovascular disease and type 2 diabetes. Various drugs are used in the treatment of mild obesity but they are associated with adverse effects. Surgery has become an essential part of the treatment of morbid obesity, notwithstanding the potential adverse events that accompany it. An appreciation of these problems is essential to the anaesthetist and intensivist involved in the management of this group of patients. %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Haghighi, Koroush S %A Steinke, Karin %A Hazratwala, Kiran %A Kam, Peter C A %A Daniel, Steven %A Morris, David L %T Controlled study of in-line ovine spleen transection assisted by radiofrequency ablation. %B The Journal of trauma %D 2005 %V 58 %N 4 %P 841-4 %@ 0022-5282 %X BACKGROUND: Trauma to the spleen or tumors of the spleen often require total splenectomy for control of hemorrhage. Partial splenectomy is the preferred technique because of the short- and long-term sepsis problems in asplenic patients. Multiple techniques for partial splenectomy have been tried in the past with limited success. The authors designed the in-line radiofrequency ablation (ILRFA) probe for liver surgery. It uses radiofrequency energy to make a linear coagulative plane that allows the parenchyma of solid vascular organs to be divided. In this study, for the first time, the efficiency of ILRFA was tested with the ovine spleen. METHODS: Seven sheep were used for this study. With the sheep under general anesthesia, a laparotomy was performed. The first sheep was used for a pilot study. Eight partial splenectomies were made in the remaining six sheep using ILRFA. For a control, a matching partial splenectomy was made in each sheep using diathermy and sutures. Blood loss was measured by determining the difference in the weights of dry sponges and blood-stained sponges after resection. A paired t test was used to compare the bleeding between the control and the ILRFA techniques. RESULTS: The mean blood loss was 33.14 +/- 17 g using ILRFA and 123.43 +/- 72 g in the control group. The bleeding was significantly reduced in the ILRFA group (p = 0.0056). The time required to apply ILRFA was 12 minutes. CONCLUSION: Partial splenectomy was achieved in the ovine spleen using radiofrequency energy with minimal blood loss. %Z FOR Codes: 110305 %0 Journal Article %~ Pubmed %A Haghighi, Koroush S %A Steinke, Karin %A Hazratwala, Kiran %A Kam, Peter C A %A Daniel, Steven %A Morris, David L %T Controlled study of inline radiofrequency ablation (ILRFA) assisted transection of ovine liver. %B The Journal of surgical research %D 2005 %V 123 %N 1 %P 139-43 %@ 0022-4804 %X BACKGROUND: Liver resection is now a standard treatment for primary and secondary hepatic tumors around the world. Intra-operative blood loss during liver resection is a major factor associated with morbidity and mortality. We have developed a new instrument using radiofrequency energy (ILRFA), which is intended to achieve coagulative ablation in a plane. This plane can then be cut through with a scalpel, ultrasonic dissector, or diathermy with minimal blood loss. MATERIALS AND METHODS: Five sheep were used in this non-recovery experiment. In these sheep we performed five liver resections with the ILRFA and five similar resections using diathermy and suturing as control. Blood loss was measured by determining the difference in the weights of dry sponges and blood stained sponges after resection. RESULTS: ILRFA was successful in achieving coagulative ablation in all cases to a width of 1 cm. The mean blood loss in ILRFA was 43.2 g (SD36) and 221.8 g (SD147) in the control group. The bleeding was significantly reduced in ILRFA group with a P value of 0.005. CONCLUSIONS: Bleeding remains an important complication of liver resection. To reduce bleeding during liver surgery, different techniques have been used. In this study, we have demonstrated that by using ILRFA we can perform liver resections in sheep with minimal blood loss. %Z FOR Codes: 110305 %0 Journal Article %~ Pubmed %A McElduff, Aidan %A Mather, Laurence E %A Kam, Peter C %A Clauson, Per %T Influence of acute upper respiratory tract infection on the absorption of inhaled insulin using the AERx insulin Diabetes Management System. %B British Journal of Clinical Pharmacology %D 2005 %V 59 %N 5 %P 546-51 %@ 0306-5251 %X AIMS: To assess the effects due to an uncomplicated acute upper respiratory tract infection (URTI) on the pharmacokinetics and glucose response of insulin when delivered by oral pulmonary absorption. METHODS: Normally healthy adult men (n = 11) and women (n = 9) received a single dose of inhaled human insulin, equivalent to approximately 6 IU subcutaneous, using the AERx insulin Diabetes Management System (iDMS), during and following recovery from an URTI. The first dose was administered with ongoing symptoms of < 3 days' duration, the second dose following recovery, and within 3 weeks of the first. Blood sampling for determination of insulin pharmacokinetics (serum AUC(0-6 h), AUC(0-8), C(max),t(max), t(1/2), MRT) and glucose response (plasma AOC(0-6 h)) was performed from 15 min predose to 6 h postdose. RESULTS: Insulin pharmacokinetics were not different for subjects during and following recovery from URTI [e.g. URTI: no URTI ratio in serum AUC(0-6 h) = 0.92 (95% confidence interval 0.81, 1.05)]; this was reflected by a similar glucose response. Inhaled insulin delivered by AERx iDMS was well tolerated by all subjects; no significant changes were observed in pulmonary function tests. No safety concerns arising from the mode of insulin administration were raised by either dose. CONCLUSIONS: The results suggest that insulin can be administered via AERx iDMS to nondiabetic subjects experiencing a URTI without any statistically significant changes in insulin pharmacokinetics or pharmacodynamics, and that the necessity for dose adjustments will not differ from subjects with an acute URTI who are receiving subcutaneous insulin. %Z FOR Codes: 110306 %0 Journal Article %~ Pubmed %A Ladd, L A %A Kam, P C %A Williams, D B %A Wright, A W E %A Smith, M T %A Mather, L E %T Ventilatory responses of healthy subjects to intravenous combinations of morphine and oxycodone under imposed hypercapnic and hypoxaemic conditions. %B British Journal of Clinical Pharmacology %D 2005 %V 59 %N 5 %P 524-35 %@ 0306-5251 %X AIMS: Previous isobolographic analysis revealed that coadministration of morphine and oxycodone produces synergistic antinociception in laboratory rodents. As both opioids can produce ventilatory depression, this study was designed to determine whether their ventilatory effects were synergistic when coadministered to healthy human subjects. METHODS: A placebo-controlled, randomized, crossover study was performed in 12 male volunteers. Ventilatory responses to hypoxaemia and hypercapnia were determined from 1-h intravenous infusions of saline ('placebo'), 15 mg morphine sulphate (M), 15 mg oxycodone hydrochloride (O), and their combination in the dose ratios of 1:2, 1:1, 2:1. Drug and metabolite concentrations in serial peripheral venous blood samples were measured by high-performance liquid chromatography-MS/MS. RESULTS: 'Placebo' treatment was without significant ventilatory effects. There were no systematic differences between active drug treatments on either the slopes or intercepts of the hypoxaemic and hypercapnia ventilation responses. During drug treatment, the mean minute ventilation at PetCO(2) = 55 mmHg (V(E55)) decreased to 74% of the subjects' before treatment values (95% confidence interval 62, 87), 68% (57, 80), 69% (59, 79), 68% (63, 73), and 61% (52, 69) for M15, M10/O5, M7.5/O7.5, M5/O10 and O15, respectively. Recovery was more prolonged with increasing oxycodone doses, corresponding to its greater potency and lower clearance compared with morphine. CONCLUSIONS: Although adverse ventilatory effects of these drugs were found as expected, no unexpected or disproportionate effects of any of the morphine and oxycodone treatments were found that might impede their use in combination for pain management. %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Kam, P C A %A Yarrow, M %T Anabolic steroid abuse: physiological and anaesthetic considerations. %B Anaesthesia %D 2005 %V 60 %N 7 %P 685-92 %@ 0003-2409 %X This review summarises the physiological and pharmacological effects of the anabolic steroids used to enhance performance in sports. The anabolic steroids promote muscle growth and protein synthesis. Side-effects of anabolic steroids include cardiomyopathy, atherosclerosis, hypercoagulopathy, hepatic dysfunction, and psychiatric and behavioural disturbances. It is therefore appropriate that the anaesthetist be familiar with the abuse of anabolic steroids, their potential adverse effects, and the peri-operative risk associated with the use of these drugs. %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Thong, C L %A Lambros, M %A Stewart, M G %A Kam, P C A %T An unexpected cause of an acute hypersensitivity reaction during recovery from anaesthesia. %B Anaesthesia and Intensive Care %D 2005 %V 33 %N 4 %P 521-4 %@ 0310-057X %X Acute hypersensitivity reactions to chlorhexidine in the operating room are probably more likely to occur during the early phases of anaesthesia because chlorhexidine is often used for cleaning the surgical field or during placement of indwelling catheters. We report a case of an acute hypersensitivity reaction that occurred in the post anaesthetic care unit. Subsequent skin testing suggested sensitivity to chlorhexidine, which had been applied over the vaginal mucosa at the end of surgery. Relevant issues in the investigation of acute hypersensitivity reactions in the post anaesthetic period are discussed. %Z FOR Codes: 110301 %0 Journal Article %~ Pubmed %A Turner, Martin J %A Baker, A Barry %A Kam, Peter C %T Effects of systematic errors in blood pressure measurements on the diagnosis of hypertension. %B Blood pressure monitoring %D 2004 %V 9 %N 5 %P 249-53 %@ 1359-5237 %X OBJECTIVE: To estimate the effects of systematic errors in measurements of blood pressure on the diagnosis of hypertension. METHODS: We fitted regression curves to distributions of diastolic and systolic BP from recent Canadian and UK surveys and calculated the effect of systematic measurement errors on changes in the numbers of patients who would be classified hypertensive at thresholds of 85, 90 and 95 mmHg diastolic and 140 and 160 mmHg systolic pressure respectively. RESULTS: Overestimation of diastolic BP by 5 mmHg increases the number of patients whose diastolic BP exceeds 85, 90 and 95 mmHg by 102, 132 and 166% respectively. Equivalent underestimation causes 57, 62 and 67% respectively of hypertensive patients to be missed. If systematic error in diastolic pressure is limited to +/-1 mmHg the diagnosis errors are between -15 and +23%. Overestimation of systolic BP by 3 and 5 mmHg increases the number classified as hypertensive by 24 and 43% respectively. Equivalent underestimation causes 19 and 30% of patients with systolic hypertension to be missed. CONCLUSIONS: Small systematic errors in BP measurements may cause large variations in the proportion of patients diagnosed as hypertensive. To limit over- or under-diagnosis of diastolic hypertension to approximately 20%, systematic errors in diastolic BP measurements should be limited to 1 mmHg. An uncertainty of 3 mmHg may be adequate for detecting systolic hypertension. %0 Journal Article %~ Pubmed %A Lindn?r, P %A Thompson, J F %A De Wilt, J H W %A Colman, M %A Kam, P C A %T Double isolated limb infusion with cytotoxic agents for recurrent and metastatic limb melanoma. %B European Journal of Surgical Oncology %D 2004 %V 30 %N 4 %P 433-9 %@ 0748-7983 %X Metastatic melanoma confined to a limb can be treated effectively by isolated limb infusion (ILI) with cytotoxic drugs. The present study was undertaken to determine whether electively performing a second ILI procedure after 4 weeks increases the frequency and/or duration of response, and also to assess the value of a second ILI when disease recurrence or progression in a limb occurs after a first ILI. In 47 patients, a planned double ILI protocol achieved an overall response (OR) rate of 88% (complete response (CR) 41%, partial response (PR) 47%, median duration of response 18 months). Response rates after double ILI were similar to those in 81 patients treated with a single ILI over the same time period (CR 41%, PR 41%), without significant differences in response duration. After double ILI more patients experienced Wieberdink Grade III or IV limb toxicity. Following a second ILI for progression after an initial ILI (n=14), the OR rate was 71%, with a 5 month median duration of response. Since elective double ILI increases toxicity without increasing efficacy, performance of a single ILI is the preferred treatment option for melanoma confined to a limb. However, a second ILI can be of value if limb disease recurs or progresses following a previous ILI. %0 Journal Article %~ Pubmed %A Bonenkamp, J J %A Thompson, J F %A de Wilt, J H %A Doubrovsky, A %A de Faria Lima, R %A Kam, P C A %T Isolated limb infusion with fotemustine after dacarbazine chemosensitisation for inoperable loco-regional melanoma recurrence. %B European Journal of Surgical Oncology %D 2004 %V 30 %N 10 %P 1107-12 %@ 0748-7983 %X BACKGROUND: Isolated limb infusion (ILI) is a simple yet effective alternative to conventional isolated limb perfusion for the treatment of advanced melanoma of the extremities. PATIENTS AND METHODS: The study group comprised 13 patients with very advanced limb disease who had failed to achieve a satisfactory response to one or more ILIs with melphalan, and in whom amputation was the only other realistic treatment option. The aim of this study was to evaluate the efficacy and toxicity of ILI with fotemustine after systemic chemosensitisation with dacarbazine (DTIC). RESULTS: Complete remission was achieved in four patients and partial remission in eight patients, with a median response duration of 3 months. Limb salvage was achieved in five of 12 assessable patients (42%). Limb toxicity peaked 9 days after ILI; two patients experienced Wieberdink grade IV (severe) toxicity and four patients had grade V toxicity (requiring early amputation). CONCLUSIONS: ILI with fotemustine after DTIC chemosensitisation can be successful when gross limb disease has not been controlled by one or more ILIs with melphalan. However, it cannot be recommended as a routine method of treatment for advanced melanoma of the extremities because of the high incidence of severe limb toxicity. %0 Journal Article %~ Pubmed %A Thompson, John F %A Kam, Peter C A %T Isolated limb infusion for melanoma: a simple but effective alternative to isolated limb perfusion. %B Journal of surgical oncology %D 2004 %V 88 %N 1 %P 1-3 %@ 0022-4790 %X %0 Book Section %A Thompson, John %A Kam, Peter %A de Wilt, JHW %A Lindner, Per %T Isolated limb infusion for melanoma %B Textbook of Melanoma %D 2004 %C London %I Martin Dunitz %V %N %P 429-437 %@ 1 90186 565 7 %E Thompson, John %E Morton, Donald %E Kroon, Bin %X %0 Journal Article %~ Pubmed %A Jorm, Christine %A Kam, Peter %T Does medical culture limit doctors' adoption of quality improvement? Lessons from Camelot. %B Journal of health services research & policy %D 2004 %V 9 %N 4 %P 248-51 %@ 1355-8196 %X This paper analyses aspects of medical culture, explains why this culture is antagonistic to quality improvement, and provides solutions to help medical colleges meet the challenge of clinical governance. Like the knights of Camelot, doctors have their own all-pervading culture, occupationally centred, exclusive to the initiated and tending to the traditional, either overtly or through assumed values. The Camelot metaphor is supported by analysis of empirical evidence, especially the documents produced by medical colleges. Suggested initiatives to overcome these organisational barriers include improvements in continuing medical education, accreditation, guideline production and responsibility for the performance of doctors. Central to these improvements should be the involvement of every doctor, via the Delphi process, and substantial contributions to college processes from other health care professions and patients. %Z FOR Codes: 111799 %0 Book Section %A Thompson, JF %A Kam, PCA %A Lindner, P %A de Wilt, JHW %T Isolated limb infusion %B Cutaneous Melanoma %D 2003 %C Missouri %I Quality Medical Publishing %V 1 %N %P 495-506 %@ 1-57626-159-X %X %0 Journal Article %~ Pubmed %A Kam, P C A %A Nethery, C M %T The thienopyridine derivatives (platelet adenosine diphosphate receptor antagonists), pharmacology and clinical developments. %B Anaesthesia %D 2003 %V 58 %N 1 %P 28-35 %@ 0003-2409 %X The thienopyridines, ticlopidine and clopidogrel, are antiplatelet drugs. They are prodrugs and are metabolised in the liver to active metabolites that are non-competitive antagonists of the platelet adenosine diphosphate receptor, P2Y12. Inhibition of platelet aggregation by these drugs is delayed until 24-48 h after administration, with maximal inhibition achieved after 3-5 days. Recovery of platelet function after drug withdrawal is slow (7-14 days). Ticlopidine and clopidogrel are effective in preventing atherothrombotic events in cardiovascular, cerebrovascular and peripheral vascular disease. Gastrointestinal side effects and skin rashes are common. However, neutropenia and thrombotic thrombocytopenic purpura are significant and sometimes fatal adverse effects of ticlopidine. Clopidogrel appears to offer several advantages over ticlopidine: a more rapid onset of action and a lower incidence of neutropenia and thrombotic thrombocytopenic purpura.A combination of clopidogrel and aspirin has become standard for antithrombotic therapy in cardiovascular disease. The anaesthetic considerations of patients taking the thienopyridine compounds are discussed. %Z FOR Codes: 110301 111501 %0 Journal Article %~ Pubmed %A Kam, P C A %A Liew, S %T Traditional Chinese herbal medicine and anaesthesia. %B Anaesthesia %D 2002 %V 57 %N 11 %P 1083-9 %@ 0003-2409 %X An increasing number of people in the western world are using traditional Chinese herbal medicines. There are concerns that these Chinese medicines may contain potentially toxic ingredients and contaminants such as heavy metals. Undeclared conventional western drugs such as the non-steroidal anti-inflammatory and antihistamine drugs, steroids and oral hypoglycaemic agents are frequently added to Chinese herbal medicines. The constituents of the herbal products can cause adverse effects. The anaesthetist should be aware of the potential adverse effects of the herbal products, their contaminants and also of undeclared additives. The potential for drug interactions, coagulopathy and organ dysfunction caused by traditional Chinese herbal medicines has important anaesthetic implications. %0 Journal Article %A Kam, PC %A Egan, M %T Platelet Glycoprotein IIb/IIIa Antagonists %B Anesthesiology %D 2002 %C 530 Walnut St, Philadelphia, Pa, 19106-3621 %I Lippincott Williams & Wilkins %V 96 %N %P 1237-1249 %@ 0003-3022 %X %0 Journal Article %A Lindner, P %A Doubrovsky, A %A Kam, PC %A Thompson, JF %T Prognostic Factors After Isolated Limb Infusion With Cytotoxic Agents for Melanoma %B Annals Of Surgical Oncology %D 2002 %C 530 Walnut St, Philadelphia, Pa, 19106-3621 %I Lippincott Williams & Wilkins %V 9(2) %N %P 127-136 %@ 1068-9265 %X %0 Journal Article %A Kam, PC %A Fisher, MM %A Ford, SA %A Baldo, B A %T Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery %B Journal of Cardiothoracic and Vascular Anesthesia %D 2001 %C 1114 First Ave, 4Th Fl, New York, Ny, 10021 %I Rockefeller Univ Press %V 193 %N %P 661-670 %@ 0022-1007 %X %0 Journal Article %~ Pubmed %A Kavanagh, R J %A Kam, P C %T Lazaroids: efficacy and mechanism of action of the 21-aminosteroids in neuroprotection. %B British Journal of Anaesthesia %D 2001 %V 86 %N 1 %P 110-9 %@ 0007-0912 %X %0 Journal Article %A Kam, PC %A Kavanaugh, R %A Young, FFY %T The arterial tourniquet: pathphysiological consequences and anaesthetic implications %B Anaesthesia %D 2001 %C 515 N State St, Chicago, Il, 60610 %I Amer Medical Assoc %V 119 %N %P 1186-1190 %@ 0003-9950 %X %0 Journal Article %A Kam, PC-A %A Power, I %T New selective COX-2 inhibitors %B Pain reviews %D 2000 %C %I Arnold %V 7 %N %P 3-13 %@ 0968-1302 %X %0 Journal Article %A Kam, PC-A %A Ferch, NI %T Apoptosis: mechanisms and clinical implications %B Anaesthesia %D 2000 %C %I Blackwell Science Ltd %V 55 %N %P 1081-1093 %@ 0003-2409 %X %0 Journal Article %A Kam, PC-A %A See, AU-L %T Cyclo-oxygenase isoenzymes: physiological and pharmacological role %B Anaesthesia %D 2000 %C %I Blackwell Science Ltd %V 55 %N %P 442-449 %@ 0003-2409 %X %0 Journal Article %A Kam, PC-A %T Recent advances in anaesthesia %B Current Therapeutics %D 2000 %C %I ADIS Press Australasia Pty Ltd %V March %N %P 76-80 %@ 0311-905X %X %0 Book Section %A Kam, P %A Thompson, JF %A Uren, RF %T Microanatomy and Physiology of the Lymphatic System %B Lymphatic Mapping and Probe Applications in Oncology %D 2000 %C %I Marcel Decker Inc %V %N %P 1-22 %@ 0-8247-0267-0 %X