Pregnant women and car restraints: beliefs and practices

OBJECTIVE: Motor vehicle collisions are a leading cause of death and disability in pregnant women. The purpose of this study was to examine current restraint practices by pregnant women. Additionally, the beliefs and knowledge of pregnant women about restraint laws and effectiveness were studied. METHODS: From May of 1997 to January of 1998, women were surveyed at initial prenatal visit at four obstetrical clinics. Data collected included age, gravida, ethnicity, educational level attained, payor source, restraint use, and knowledge of effectiveness of restraint use. RESULTS: A total of 807 women completed surveys. Most always wore restraints before pregnancy, but increased restraint use during pregnancy (79% vs. 86%, chi2, p = 0.02). Only 52% used restraints properly. Significantly fewer women believed restraints were beneficial to mother and fetus in late pregnancy compared with early pregnancy. Only 21% of women were educated on proper restraint use during pregnancy. Comparison by payor mix showed no difference in use or education received. CONCLUSIONS: Most women use restraints and continue to do so during pregnancy, but they use them improperly. Pregnant women are familiar with mandatory restraint laws but are less informed about restraint use in pregnancy. Few women receive education from health care providers about proper restraint use. This study highlights the need for aggressive educational efforts to improve car restraint use in pregnant women, thereby reduce maternal and fetal injury and death.     

Atropine and hyoscine

The drugs atropine and hyoscine are reviewed in the context of their use by anaesthetists. The results of recent studies are stressed and guidelines given for use of these drugs in modern anaesthetic practice.     

HIV and Bone Loss

The use of antiretroviral therapy has significantly reduced the number of deaths due to HIV/AIDS. However, no current therapy can suppress the virus completely, and as the HIV-infected population continues to live longer new complications are emerging from the persistence of the virus and use of antiretroviral therapy. This review summarizes the clinical evidence linking HIV-associated osteoporosis to direct infection and antiretroviral therapy (ART) use. The purported molecular mechanisms involved in bone loss are also reviewed. Additionally, recommendations regarding the pharmacologic management of HIV/ART-related osteoporosis are given.     

Corticosteroid Injections: Their Use and Abuse

Local injections of corticosteroids are commonly used in orthopaedic practice on the assumption that they will diminish the pain of inflammation and accelerate healing. Less often considered is the possibility that their use may delay the normal repair response. Among the multitude of conditions treated with corticosteroids are acute athletic injuries, overuse syndromes, nerve compression, bone cysts, and osteoarthritis. Unfortunately, there is a paucity of well-controlled studies that provide definitive recommendations for nonrheumatologic use of corticosteroids. Also troubling are the significant potential complications that can occur with their use. The authors believe that use of corticosteroids should be limited to the few conditions that have been proved to be positively influenced by them. Their use must be accompanied by a well-orchestrated treatment plan including close follow-up, physical therapy, and limitation of activities.     

Medical and surgical language

Medical language contains many faults. One of them is the use of cultured and elegant words without knowing its proper significance. A second error is the recourse to using foreign words or phrases (foreignisms), particularly Anglicisms, both in their original spelling (raw foreignisms) and Hispanicised (adapted word); an overlapping mode of foreignism are so-called "calques" or loan translations. Thirdly, there is the use of words that do not exist in Spanish, palabros. Finally, the words are not correctly pronounced. In this article some examples of these errors are demonstrated and it is directed towards the appropriate use of language.     

Use of electronic data processing in the urologic clinic and practice--possibilities and perspectives

The development, present status and future trends in the use of computers in urology in the Federal Republic of Germany are reviewed. The hardware, software required for hospital and private practice and the staff needed are discussed. Proposals are given for the installation and stepwise upgrading of computer systems, from simple text processing units to complex hospital communication systems. Finally new technologies that might considerably change the use of computers in urology are presented.     

Acellular dermal matrices: economic considerations in reconstructive and aesthetic breast surgery

This article is a review of cost considerations and outcomes pertaining to the use of acellular dermal matrices (ADMs) in reconstructive and aesthetic breast surgery. The history of the use of ADMs in breast surgery and all case series describing outcomes and use of ADM in breast reconstructive and aesthetic surgery are reviewed. Weighted averages for clinically relevant outcomes for reconstructive and aesthetic breast surgery are provided. Cost considerations of ADM use in breast surgery are described and as an example, a single institution's experience with implementation of ADM into a preexisting breast surgery program, is used.     

Surgical fires and alcohol-based skin preparations

Alcohol-based skin preparations are known to be flammable. Their use continues despite a significant level of risk. Two cases of fires resulting from ignition of pooled alcohol-based skin preparations are reported. Both cases were associated with use of electrocautery for haemostasis. The literature is reviewed and recommendations are made to reduce the risk of further similar occurrences.     

Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes

The use of sedation has long been integrated into critical care. Because pain, discomfort, anxiety, and agitation are commonly experienced by critically ill patients, the use of medications to alleviate and control these symptoms will continue; however, data showing that prolonged use of sedating medications imparts harm to patients obligate physicians to use agents and methods of sedation that minimize these negative side effects. Numerous observational studies and clinical trials have proven that decisions in sedation management play a crucial role in determining outcomes for mechanically ventilated ICU patients, and recent evidence supports the use of protocols that streamline efforts to discontinue sedation and mechanical ventilation in a safe and parallel fashion. Regardless of choice of sedating agent, and even when patient-targeted sedation protocols are used to minimize oversedation, the use of spontaneous awakening trials dramatically improves patient outcomes for critically ill patients. Intensive care physicians must continue to study the delivery of sedation in efforts to maximize patient comfort while minimizing patient harm.     

Premixed 50% nitrous oxide and oxygen: theoretical recalls and practical modalities

The concept of premixed 50% nitrous oxide and oxygen dated back to 1961 in England, where it is commercialised under the name Entonox. In France, after a so marginal use, premixed 50% nitrous oxide and oxygen now knows such a revival since we first consider the pain provoked by the cure. To use correctly premixed 50% nitrous oxide and oxygen, we need to know the main properties of the nitrous oxide. The four commercial versions, now on the market, are presented (Kalinox, Medimix, Antasol, Oxynox. Except a few contraindications, these indications are large, as well at hospital as outside. In less than 10% of the cases, side effects are possible. Conditions of administration are given in details. The limits of the technic and the particular precautions of use are precised.     

Vasopressin and terlipressin: pharmacology and its clinical relevance

Vasopressin and its analogue, terlipressin, are potent vasopressors that may be useful therapeutic agents in the treatment of cardiac arrest, septic and catecholamine-resistant shock and oesophageal variceal haemorrhage. The aim of this article is to review the physiology and pharmacology of vasopressin and summarise its efficacy and safety in clinical trials and its subsequent therapeutic use. Recent studies indicate that the use of vasopressin during cardiopulmonary resuscitation may improve the survival of patients with asystolic cardiac arrest. Vasopressin deficiency can contribute to refractory shock states associated with sepsis, cardiogenic shock and cardiac arrest. Low doses of vasopressin and terlipressin can restore vasomotor tone in conditions that are resistant to catecholamines, with preservation of renal blood flow and urine output. They are also useful in reducing bleeding and mortality associated with oesophageal variceal haemorrhage. The long-term outcome of the use of these drugs is not known.     

Best practices for assessing and reporting tobacco use in urology oncology practice and research

Tobacco use is the cause of several urologic cancers. Persistent use after diagnosis is associated with worse cancer-specific, quality of life, and overall mortality outcomes. Cigarette smoking remains the most common form of tobacco use despite significant population-level decline over the past few decades. The burden of smoking-related urologic disease is under appreciated by urologists and patients which has resulted in gaps in clinical care and limitations to research progress. We sought to summarize evidence-based practices and guideline recommendations for assessing and reporting tobacco use in the clinical and research settings. With a focus on smoking, our two primary goals are: 1) to promote the adoption of standardized and validated measures of tobacco use and 2) to highlight evidence-based strategies for urologists to use in clinical practice.     

Regional anesthesia and anticoagulation

The perioperative use of neuraxial techniques in the presence of anticoagulation is a controversial issue. There are significant pharmacokinetic differences between anticoagulants that will affect the timing of neuraxial needle insertion or catheter removal. The pharmacologic profiles of commonly used anticoagulants in the perioperative period are reviewed. Studies examining the use of neuraxial techniques in the presence of various anticoagulants are reviewed and evaluated in the context of the American Society of Regional Anesthesia consensus statements.     

Fluidics and pneumatics: principles and applications in anaesthesia.

This article describes the construction and operation of fluidic and pneumatic devices in current use, as well as the principles of their use in medical devices. The designs for an automatic blood pressure cuff inflator, a blood pump and a high performance ventilator are presented.     

Pharmacology and clinical use of plasma expanders

Plasma expanders are colloidal solutions that expand the circulating blood volume more than isotonic crystalloids and are among the most commonly used fluids in critical care and perioperative medicine worldwide. We begin our review of these agents by introducing the modified Starling model, which incorporates the fundamental physiologic role of the endothelial glycocalyx in transcapillary fluid movement. Next, we individually discuss each fluid, starting with their relevant pharmacological properties before delving into the trials on their clinical use. Human trial data on gelatins and dextrans are scarce, making their routine use difficult to justify outside resource-poor settings. Trials on the use of hydroxyethyl starch in critical care imply increased risk of kidney injury, coagulopathy and, possibly, mortality; whether these harms apply to the surgical setting remains an area of debate and ongoing study, but there is no compelling evidence to support the routine use of hydroxyethyl starch in the operating room. Multiple trials suggest that albumin is a safe, albeit more expensive, alternative to crystalloid use in the intensive care unit, with secondary analyses suggesting harm in traumatic brain injury and benefit in septic shock. Finally, more data are required to better define the role of albumin in perioperative medicine.     

Pharmacology and clinical use of plasma expanders

Plasma expanders are colloidal solutions that expand the circulating blood volume more than isotonic crystalloids and are among the most commonly used fluids in critical care and perioperative medicine worldwide. We begin our review of these agents by introducing the modified Starling model, which incorporates the fundamental physiologic role of the endothelial glycocalyx in transcapillary fluid movement. Next, we individually discuss each fluid, starting with their relevant pharmacological properties before delving into the trials on their clinical use. Human trial data on gelatins and dextrans are scarce, making their routine use difficult to justify outside resource-poor settings. Trials on the use of hydroxyethyl starch in critical care imply increased risk of kidney injury, coagulopathy and, possibly, mortality; whether these harms apply to the surgical setting remains an area of debate and ongoing study, but there is no compelling evidence to support the routine use of hydroxyethyl starch in the operating room. Multiple trials suggest that albumin is a safe, albeit more expensive, alternative to crystalloid use in the intensive care unit, with secondary analyses suggesting harm in traumatic brain injury and benefit in septic shock. Finally, more data are required to better define the role of albumin in perioperative medicine.     

Techniques in splintage and support during reconstruction of the tibia

The aim of this article is to help clinicians and allied professionals understand problems that may arise with use of external fixators in limb reconstruction and trauma, and in particular describe how preventative strategies can be implemented. The indications for splinting and orthotic use with external fixators can be broadly subdivided into those that facilitate functional loading and those that maintain joint integrity and function. Specific techniques to accompany use of external fixators in fracture management and limb reconstruction are described. In particular, problems concerning knee, ankle and foot support together with leg length issues are covered and proposals for dealing with joint subluxation, forefoot deformity and toe clawing, regenerate deformity after fixator removal and oedema control are discussed. The solutions described and illustrated are intended to assist those who use external fixators but do not have regular therapist input for support in the after-care of their patients.     

Technology and Clinical Application of Large-Bore and Implantable Catheters

Abstract: The access of choice for patients receiving regular dialysis therapy remains the surgically created arteriovenous fistula. In a number of such patients as well as those requiring treatment for acute renal failure, plasmapheresis or hemoperfusion alternative techniques of access are used. Of the techniques used subclavian and femoral catheterization are preferred for short-term vascular access while in patients requiring long term vascular access the use of a surgically inserted central venous line is favoured. The technology performance and clinical aspects of the use of large bore and implantable catheters are reviewed.     

Hypertonic saline in critical care: a review of the literature and guidelines for use in hypotensive states and raised intracranial pressure*

Hypertonic saline has been in clinical use for many decades. Its osmotic and volume‐expanding properties make it theoretically useful for a number of indications in critical care. This literature review evaluates the use of hypertonic saline in critical care. The putative mechanism of action is presented, followed by a narrative review of its clinical usefulness in critical care. The review was conducted using the Scottish Intercollegiate Guidelines Network method for the review of cohort studies, randomised‐controlled trials and meta‐analyses. The review focuses specifically on blood pressure restoration and outcome benefit in both haemorrhagic and non‐haemorrhagic shock, and the management of raised intracranial pressure. Issues of clinical improvement and outcome benefit are addressed. Hypertonic saline solutions are effective for blood pressure restoration in haemorrhagic, but not other, types of shock. There is no survival benefit with the use of hypertonic saline solutions in shock. Hypertonic saline solutions are effective at reducing intracranial pressure in conditions causing acute intracranial hypertension. There is no survival or outcome benefit with the use of hypertonic saline solutions for raised intracranial pressure. Recommendations for clinical use and future directions of clinical research are presented.     

Intravascular iodinated contrast media and the anaesthetist

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.