A novel view for the scintigraphic assessment of the elbow

Using any imaging modality, the elbow is a complex joint to evaluate. The use of scintigraphy in the evaluation of the effects of acute or chronic trauma has largely been confined to epicondylitis. We developed a skyline view of the elbow that minimized the effect of overlap and assessed its incremental value in the scintigraphic assessment of several pathological conditions. Thirty-four abnormalities were evaluated in 20 patients with a range of pathologies, including epicondylitis, ligamentous avulsion injury, articular injury, fractures and synovitis. The incremental value of addition of the skyline view to the standard views was assessed in addition to the overall accuracy of scintigraphy. Overall, scintigraphy detected 27 of 34 abnormalities, with the standard views of the elbow accurately identifying 15 and the skyline view 23 abnormalities. This gave the skyline view an incremental value of 24% over the standard views. In conclusion, scintigraphy has the potential to identify a greater range of pathologies in the elbow than previously reported, due to the addition of the skyline view to the standard views.     

The use of the iSTAT portable analyzer in patients undergoing cardiopulmonary bypass

Objective. To evaluate the utility of the iSTAT blood analyzer, a bedside device for hematocrit, sodium, potassium, and glucose measurement during cardiopulmonary bypass (CPB).Methods. Forty patients scheduled for elective CPB were evaluated prospectively. In addition to using the iSTAT analyzer, blood samples were analyzed at four time points: following induction of anesthetic, 10 min. after initiation of CPB, 60 min. after initiation of CPB, and following heparin neutralization by protamine. Blood glucose concentration was measured by the hospital laboratory using a Kodak Analyzer and by a glucose meter, electrolytes were evaluated by the Kodak Analyzer and BGE (a device which is commonly used for satellite laboratory determinations of electrolyte and blood gas results), and hematocrit samples were measured by the hospital laboratory using an NE 8,000 and a centrifuge. The means and standard deviations of the differences between the methods were calculated.Results. The hematocrit values determined by the iSTAT machine, when adjusted for the level of total protein (according to manufacturer's directions), differed from the laboratory values by 0.53 = 1.46 percentage points. An alternative to measuring total protein and making the adjustment is simply adding 1 % to the hematocrit in the pre-CPB period and 3% on-CPB or post-CPB, which we found to yield values that differed from the laboratory by 0.52 ± 1.42 percentage points. For all four tests (hematocrit, sodium, potassium, and glucose) the iSTAT had a similar relationship to the laboratory values as did the other commonly used means (centrifuge, BGE, and glucose meter) of clinical evaluation.Conclusion. In summary, we found that in patients undergoing CPB, the iSTAT values agreed sufficiently well with standard laboratory values and that the iSTAT instrument can be relied upon for bedside measurements.Presented in part at the Annual Meeting of the Society of Cardiovascular Anesthesiologists, Philadelphia, PA, May 1995, and at the 70th meeting of the IARS, Washington DC, March 1996. Supported in part by a grant by iSTAT Corporation.     

Laser Induced Autofluorescence Diagnosis of Bladder Cancer

Purpose

We assessed the ability of laser induced autofluorescence to differentiate malignant from nonmalignant bladder lesions.

Materials and Methods

We studied 53 patients with bladder cancer undergoing mucosal biopsies or transurethral resection of a bladder tumor. A quartz optical fiber was advanced through the working channel of a cystoscope and placed in gentle contact with the bladder. Tissue fluorescence was excited by 337 nm. light pulses (nitrogen laser). One fiber was used for transmission of the excitation and emission (fluorescence) light. An optical multichannel analyzer system was used to record fluorescence spectra of the sites of interest.

Results

We analyzed the fluorescence spectra of 114 bladder areas (1 carcinoma in situ as well as 28 malignant, 35 inflammatory, 7 dysplastic, 1 squamous metaplastic and 42 normal areas). These lesions included 44 difficult to diagnose suspicious tumors (11 malignant and 33 nonmalignant). We developed an algorithm that used the I385:I455 nm. fluorescence ratio to distinguish malignant from nonmalignant lesions, including inflammatory areas. By analyzing the data on all 114 lesions, we noted the sensitivity, specificity, and positive and negative predictive values of this method for differentiating malignant from nonmalignant bladder lesions to be 97, 98, 93 and 99 percent, respectively.

Conclusions

Under excitation with 337 nm. light a clear differentiation between malignant and nonmalignant bladder tissues can be made using the I385:I455 nm. autofluorescence ratio.     

Drug Distribution in Obesity and following Bariatric Surgery: A Literature Review

Background: The pharmacokinetic variables of drug clearance and volume of distribution are usually corrected for body weight or surface area. Only recently have the relationships which exist between body size, physiologic function and pharmacokinetic variables been evaluated in the obese population. These effects are not widely known, and data on this and the effects of bariatric surgical procedures are scantily documented in the surgical literature. Methods: Literature review. Results: Drugs with a low or moderate affinity for adipose tissue have a moderate increase in the volume of distribution (Vd), and this correlates with the increase in lean body mass (LBM). Highly lipophilic drugs, with some exceptions, show the expected increase in Vd and prolongation of elimination half-life, indicating a marked distribution into adipose tissue. Drug absorption, in general, is slowed by delayed gastric emptying and is normal when gastric emptying is normal or increased. Most drug absorption occurs in the small intestine where duration of drug/mucosal contact is the most important factor. Conclusions: Drugs whose distribution is restricted to LBM should utilize a loading dose based on ideal body weight (IBW). For those drugs which distribute freely into adipose tissue, the loading dose should be based on total body weight (TBW). Adjustment of the maintenance dose depends on clearance rates. In a few cases dosage adjustment depends on pharmacodynamic data, since drug clearance does not conform to these recommendations, for reasons which remain to be defined. Following bariatric surgery, in the absence of delayed gastric emptying or uncontrolled diarrhea, drug absorption rates are usually comparable to the non-operated patient.     

Receipt of specialty eye care by children.

BACKGROUND: No nationally representative data are available regarding use of eye care services by children. OBJECTIVES: To determine the proportion of children who receive specialty eye care and to evaluate the association of such care with age and other factors associated with health care utilization. METHODS: We used the 2000 National Health Interview Survey to estimate the proportion of nonblind children who received eye care in the preceding 12 months. The association between eye care and the factors of interest among children aged 6-17 years was measured through adjusted bivariate comparisons and logistic regression modeling. RESULTS: Eye care was received in the preceding 12 months by an estimated 7.3% (95% confidence interval [CI] 6.0-8.6) of the 22.8 million children aged 0-5 years and 24.8% (95% CI 23.5-26.2) of the 48.5 million children aged 6-17 years. Among children aged 6-17 years, girls had 29% greater odds than boys to have received eye care (P=.001). Among children <200% of the federal poverty level, those with public health insurance had greater odds of receiving eye care than did uninsured children or those with private health insurance (P<.001). Among children >200% of the federal poverty level, uninsured children had lower odds than did children with public or private health insurance (P<.004) to receive eye care. Well-child care was associated with increased eye care utilization among children aged 12-14 years (P<.001). CONCLUSIONS: Receipt of specialty eye care is common and increases with age. However, there are marked variations among school-aged children. Future studies should address the causes and effects of these findings.     

A Cost-Effective and Rational Surgical Approach to Patients With Snoring,Upper Airway Resistance Syndrome,or Obstructive Sleep Apnea Syndrome

The past decade has seen several innovations in the surgical techniques available for treatment of patients with sleep-disordered breathing. Outpatient techniques such as laser-assisted uvulopalatoplasty (LAUP) and more aggressive procedures designed to address hypopharyngeal and base of tongue obstruction (genioglossus advancement and hyoid myotomy) have been developed and proven successful. We describe the efficacy of LAUP for snoring (72.7%), upper airway resistance syndrome (81.8%), and mild (mean[±SD] respiratory disturbance index [RDI] = 12 ± 8.1) obstructive sleep apnea (41.7%) in 56 patients who underwent 132 LAUP procedures in a 26-month period. Thirty-two patients with more significant obstructive sleep apnea (mean RDI = 41.8 ± 23.1) underwent multilevel pharyngeal surgery consisting of genioglossus advancement and hyoid myotomy combined with uvulopalatopharyngoplasty. The surgical success rate in this group of patients was 85.7% when commonly accepted criteria were applied. We recommend a stratified surgical approach to patients with sleep-disordered breathing. Progressively worse airway obstruction marked by multilevel pharyngeal collapse and more severe sleep-disordered breathing is treated with incrementally more aggressive surgery addressing multiple areas of the upper airway.     

Identification of a novel pulmonary oedema producing toxin from Indian red scorpion (Mesobuthus tamulus) venom.

The experiments were conducted to identify the toxin that produces pulmonary oedema in Mesobuthus tamulus (BT) envenomed animals. Crude BT venom was subjected to Sephadex gel filtration (G-75) and the fractions were screened for optical density (OD), neurotoxicity (prolongation of compound action potential in frog sciatic nerve) and lethality. All these parameters exhibited a peak between 54-94 ml eluates. Fractions of this peak were pooled (SP) and loaded on to carboxymethyl cellulose column. The column was then eluted with increasing buffer concentrations at constant pH and temperature. Eluates were screened for neurotoxicity and OD. Four peaks of neurotoxic activity (T1-T4) were detected. T2 and T3 were lethal whereas T1 and T4 were non-lethal. T2 exhibited mainly neurotoxicity and failed to augment phenyldiguanide (PDG)-induced reflex response or to produce pulmonary oedema. T3 was having minimal neurotoxic actions but augmented PDG-reflex and produced pulmonary oedema. The effects of T3 persisted even after dialysis with 8 kDa cut-off filter but not those of T2. The T3 effects resembled toxic manifestations of BT venom and were blocked by aprotinin pre-treatment. T3 demonstrated a band at approximately 100 kDa in SDS-PAGE. The results demonstrate the presence of a lethal, high molecular weight, pulmonary oedema producing toxin in BT venom.