Effect of bepridil in patients with chronic stable angina: results of a multicenter trial

The effects of bepridil, a calcium antagonist with a half-life of approximately 42 hr, were assessed in a double-blind, randomized, placebo-controlled crossover trial. Forty-four patients (39 men, five women) with exercise-induced angina pectoris and ST segment depression with exercise testing (modified Bruce protocol) were studied. Compared with placebo bepridil (400 mg daily) increased total exercise time, time to onset of angina, time to 1 mm of ST segment depression, time to 2 mm of ST segment depression, and total work achieved (all p less than or equal to .001). Both frequency of angina and nitroglycerin consumption decreased during the bepridil compared with the placebo period (p = .02 and .03, respectively). Minor side effects were noted during both the bepridil and placebo phases. Four patients experienced side effects that limited therapy (dizziness in three and abnormal results of liver function tests in one) and one patient died during the bepridil phase. This study suggests that bepridil, 400 mg daily, is effective for the treatment of exercise-induced myocardial ischemia and angina pectoris.     

Cobalamin binding proteins (haptocorrin and transcobalamin) in human cerebrospinal fluid

The unsaturated cobalamin binding capacity of transcobalamin and haptocorrin was studied in cerebrospinal fluid (CSF) and plasma (P) from 37 reference individuals. These comprised 27 males and 10 females who underwent minor surgery in spinal anaesthesia. The 5th and 95th percentiles were as follows: P-Transcobalamin 300-870 pmol/l (median 550 pmol/l); CSF-Transcobalamin 90-540 pmol/l (median 194 pmol/l); P-Haptocorrin 75-290 pmol/l (median 159 pmol/l); CSF-Haptocorrin 10-41 pmol/l (median 21 pmol/l). No sex difference was found between the levels of haptocorrin or transcobalamin in plasma or cerebrospinal fluid. A positive correlation between P-Transcobalamin and CSF-Transcobalamin was found, whereas no correlation between P-Haptocorrin and CSF-Haptocorrin values was found. The plasma/CSF ratios of transcobalamin, haptocorrin, albumin and IgG indicated that the binders may be synthetized into the cerebrospinal fluid or are actively being transported into the cerebrospinal fluid.     

Can autologous bone culture predict spinal fusion capacity?

The capacity of the individual patient to initiate osteoblast proliferation as a predictor for successful lumbar spinal fusion has not yet been reported. The objectives of this study were, first, to analyze the relationship between in vitro osteoblast proliferation and clinical bony fusion in the individual patient in order to predict the fusion outcome and, second, to measure the effect of preoperative tobacco smoking on osteoblast proliferation. Sixty-one patients (mean age 46 years) underwent posterolateral lumbar fusion in the period 1994–1995. Thirty-eight patients received CD pedicle screw implants and 23 received posterolateral fusions alone. During surgery, autogenous iliac bone was harvested and 1 g of trabecular bone without blood or bone marrow was then isolated for cell culturing. The cultures were classified as excellent (confluence within 4 weeks), good (confluence between 4 and 6 weeks) and poor (no or poor growth). Spine fusion was evaluated by two independent observers from plain anterior-posterior, lateral, and flexion/extension radiographs taken 1 year postoperatively, and the functional outcome was measured by the Dallas Pain Questionnaire (DPQ). Twenty-three patients had excellent, 19 good, and 19 poor in vitro osteoblast proliferation. Bony fusion was obtained in 77% of patients: 83% in the CD instrumentation group and 70% in the non-instrumentation group (NS). There was no significant correlation between osteoblast proliferation and spinal fusion or functional outcomes when analyzing the CD instrumentation and non-instrumentation groups together or separately. Elderly patients had a significantly poorer osteoblast proliferation than younger patients (P < 0.008). Preoperative tobacco consumption had no discernible effect on osteoblast proliferation, and no correlation between smoking and fusion was found. Further refinement of autologous osteoblast culturing may provide a biological tool for selection of patients who require biological enhancement of their bone fusion capacity. The poorer osteoblast proliferation related to advanced age supports the important negative biological influence of age on bony fusion. However, with more sensitive testing and better discrimination, other results are possible – or can in any event not be excluded. Received: 17 April 1998 Revised: 10 September 1998 Accepted: 12 October 1998     

Randomized clinical trial of laparoscopic versus open inguinal hernia repair

BACKGROUND: Several studies have suggested that better results are obtained after laparoscopic repair of inguinal hernia than after conventional operation. This is most obvious for bilateral and recurrent hernias but less accepted for primary unilateral hernias. METHODS: This was a randomized clinical trial comparing transabdominal preperitoneal laparoscopic repair with the Shouldice technique in patients with primary unilateral hernia. Some 138 patients were randomized to laparoscopic hernia repair and 130 to open surgical repair. RESULTS: The complication rates in the two groups were similar. In the laparoscopic group the patients returned to work more rapidly with a median time of 13 versus 18 days (P < 0.005) and had a shorter period of analgesia intake with a median time of 2.1 versus 2.7 days (P < 0.02). The follow-up was 97.8 per cent complete. At a median of 12 months, four recurrences (2.9 per cent) were detected in the laparoscopic group and three (2.3 per cent) in the open group. CONCLUSION: This study shows that in patients with a primary unilateral hernia laparoscopic repair results in less postoperative pain and a quicker recovery than open repair.     

Lack of postoperative pain relief after hysterectomy using preperitoneally administered bupivacaine

BACKGROUND AND OBJECTIVES: It is well known that wound infiltration with local anesthetic can reduce postoperative pain in various degrees and with very few side effects. A previous study showed better analgesic effect when local anesthetic was applied in the subfascial, rather than the subcutaneous, layer. The present study investigated the effect of frequent bolus injections of bupivacaine (15 mL 2.5 mg/mL) preperitoneally through catheters placed intraoperatively in women who had undergone hysterectomy. METHODS: Postoperative pain and analgesic requirements were studied in a double-blind randomized trial including 41 patients. During surgery, the patients were randomized to one of two groups, and the investigators were blinded. Prior to closure of the peritoneum, the surgeon placed a catheter between the muscle layer and the peritoneum on each side of the wound. One group (n = 22) received bupivacaine (15 mL 2.5 mg/mL) every 4 hours for 48 hours via each catheter starting in the operating room. The placebo group (n = 19) received saline in a like manner. Postoperative pain was evaluated using a visual analog scale (VAS) and verbal rating scale (VRS) twice a day for 2 days at rest and on movement. Requirements of supplementary analgesics were monitored, as was wound infection after discharge. RESULTS: Bupivacaine administered preperitoneally did not improve analgesia at rest, during coughing, or during mobilization compared with saline. No difference between the groups was found regarding analgesic requirements. No complications of postoperative wound healing or toxic side effects were seen. CONCLUSION: Bolus injections of bupivacaine through intraoperative placed catheters did not improve analgesia postoperatively compared with saline injections.     

Clinical impact of diagnostic SPET investigations with a dopamine re-uptake ligand

The diagnosis of Parkinson's disease is based on clinical features with pathological verification. However, autopsy has been found to confirm a specialist diagnosis in only about 75% of cases. Especially early in the course of the disease, the clinical diagnosis can be difficult. Imaging of presynaptic dopamine transporters (DAT receptors) has provided a possible diagnostic probe in the evaluation of Parkinson's disease. The cocaine analogue [(123)I]-2-beta-carboxymethoxy-3-beta(4-iodophenyl)tropane ([(123)I]-beta-CIT) is one of several radioligands that have been developed for single-photon emission tomography (SPET). The purpose of this study was to evaluate the impact of [(123)I]-beta-CIT SPET on the diagnosis and clinical management of patients with a primary, tentative diagnosis of parkinsonism. We undertook a retrospective evaluation of the clinical records of 90 consecutive patients referred to [(123)I]-beta-CIT SPET from the neurological department, Bispebjerg Hospital. In 58 subjects the scans revealed altered tracer uptake consistent with Parkinson's disease, progressive supranuclear palsy and multiple system atrophy. A significant change in the management or treatment because of the scan was found in 25 patients (28%). The sensitivity of the examination was 97% and the specificity 83%. In conclusion, a significant clinical impact of DAT receptor SPET imaging was found. DAT receptor imaging is a useful diagnostic probe in patients with a possible diagnosis of parkinsonism.     

Reliable assessment of general surgeons' non-technical skills based on video-recordings of patient simulated scenarios

Background

Nontechnical skills are essential for safe and efficient surgery. The aim of this study was to evaluate the reliability of an assessment tool for surgeons' nontechnical skills, Non-Technical Skills for Surgeons dk (NOTSSdk), and the effect of rater training.

Methods

A 1-day course was conducted for 15 general surgeons in which they rated surgeons' nontechnical skills in 9 video recordings of scenarios simulating real intraoperative situations. Data were gathered from 2 sessions separated by a 4-hour training session.

Results

Interrater reliability was high for both pretraining ratings (Cronbach's α = .97) and posttraining ratings (Cronbach's α = .98). There was no statistically significant development in assessment skills. The D study showed that 2 untrained raters or 1 trained rater was needed to obtain generalizability coefficients >.80.

Conclusions

The high pretraining interrater reliability indicates that videos were easy to rate and Non-Technical Skills for Surgeons dk easy to use. This implies that Non-Technical Skills for Surgeons dk (NOTSSdk) could be an important tool in surgical training, potentially improving safety and quality for surgical patients.     

Intraoperative Subareolar Injection of <Superscript>99m</Superscript>Tc-Labeled Sulfur Colloid Results in Consistent Sentinel Lymph Node Identification

Background Preoperative parenchymal or peritumoral (PT) injection of ^99mTc-labeled sulfur colloid (TcSC) is the standard method for sentinel lymph node (SLN) identification in patients with breast cancer. Limitations of this method include variable identification rates, slow transit times, and painful injections. We hypothesize that TcSC will travel to the SLN within minutes after injection into the subareolar (SA) lymphatics, thus making an intraoperative injection technique feasible.Methods One hundred twenty-two women with invasive breast cancer were enrolled onto this prospective study. Immediately after the induction of general anesthesia, patients were injected with 1 to 2 mCi of filtered TcSC in the SA location. Then, 5 mL of 1% isosulfan blue dye was injected into the PT location. The SLN or SLNs were identified as radioactive, blue, or both and removed for pathologic evaluation.Results The mean patient age was 56 years. The mean tumor size was 1.5 cm. In 86.1% of patients, a transcutaneous axillary hot spot was identified by handheld gamma probe. The mean time from TcSC injection to axillary incision was 17.6 minutes. At least one SLN was identified in 99.2% of patients. The mean number of SLNs identified per patient was 1.83. The mean count of radioactive SLNs was 2715 cps. In 97.2% of patients, blue SLNs were also radioactive.Conclusions TcSC injected into the SA lymphatics rapidly drains to the SLN. The radioactive SLN is easily and quickly identified after an intraoperative SA TcSC injection. The simplicity of this method eliminates the inherent problems associated with standard PT injection.