Continuous lumbar epidural infusion of levobupivacaine: effects of small-or large-volume regimen of infusion

Background: The question of whether the dose, concentration or volume of a local anesthetic solution is the relevant determinant of the spread and quality of post-operative epidural analgesia is still open. In this prospective, randomized, double-blind study, we compared the effects of a large volume–low concentration with a small-volume–high-concentration lumbar epidural infusion of levobupivacaine.
Methods: Seventy patients scheduled for total hip replacement were enrolled. After surgery, patients were randomly allocated to receive a continuous epidural infusion of levobupivacaine (10.5 mg/h) using either 0.125% levobupivacaine infused at 8.4 ml/h (low concentration group, n =35) or 0.75% levobupivacaine infused at 1.4 ml/h (high concentration group, n =35). We blindly recorded the degree of pain relief at rest and during movement every 8 h for the first two post-operative days, as well as hip flexion, motor block, rescue analgesic consumption and adverse events.
Results: No difference in pain relief was observed between groups as estimated with the areas under the curve of the verbal Numerical Rating Scale for pain over time, both at rest and during movement. Similarly, there was no difference between groups in hip flexion degree, motor blockade and hemodynamic stability.
Conclusions: Continuous lumbar epidural infusion of 0.75% levobupivacaine was as effective as continuous lumbar epidural infusion of 0.125% levobupivacaine, when administered at the same hourly dose of 10.5 mg, in achieving adequate analgesia both at rest and during movement, without differences in the incidence of hypotension and motor blockade.     

The effect of temperature on systolic blood pressure

OBJECTIVES: To quantify the association between systolic blood pressure and season, indoor and outdoor temperature and short-term trends in outdoor temperature. METHODS: The study used data from the WHO MONICA Project risk factors surveys from 25 populations in 16 countries. Random samples of men and women aged 35-64 years were invited to participate. Systolic blood pressure measurements were available for 115 434 participants. Hierarchical models were used to quantify the association between blood pressure and temperature, and account for differences in the associations between populations. RESULTS: Populations closer to the equator showed larger seasonal changes in blood pressure. A 1 degrees C increase in indoor temperature reduced systolic blood pressure by an average of 0.31 mmHg (95% posterior interval: -0.44, -0.19). A 1 degrees C increase in outdoor temperature reduced blood pressure by the smaller average of 0.19 mmHg (95% posterior interval: -0.26, -0.11). Increased outdoor, but not indoor, temperatures had a stronger effect in women than in men. The effect of outdoor temperature remained after controlling for indoor temperature. Short-term trends in temperature did not have a statistically signicant effect. CONCLUSIONS: Indoor and outdoor temperature have independent effects on systolic blood pressure, and both should be controlled for in studies that measure blood pressure. Improved protection against cold temperatures could lead to a reduction in the winter excess of cardiovascular mortality.     

7α-Methyl-Nortestosterone (MENT): The Optimal Androgen for Male Contraception

Many methods of contraception involve the use of drugs that affect the secretion of hormones essential for reproduction. Oestrogens and progestins have been used for contraception in women as inhibitors of gonadotropin secretion and ovulation. Similarly, androgens must be used in methods of fertility control for men that block gonadotrophin secretion. Androgen supplementation currently involves large, frequent doses of testosterone esters that are associated with wide fluctuations of plasma testosterone levels. Hence, there is a need for an androgen preparation that provides appropriate, continuous replacement doses over long periods. To achieve this goal, 7α-methyl-19-nortestosterone (MENT), a synthetic androgen that is considerably more potent than testosterone, is suitable. As a consequence, it is feasible to administer this androgen as a substitute for testosterone for 1 year by subdermal implants. Another important feature of MENT is that it does not undergo 5α-reduction in prostate as does testosterone. As a consequence, a dose of MENT sufficient to maintain normal muscle mass and gonadotrophin secretion will not hyperstimulate the prostate because its action in this organ is not amplified as is that of testosterone. Thus, MENT can be administered to men with the assurance that it will be less prone to cause diseases of the prostate than testosterone. Conclusions: (i) MENT is the first androgen that has a health benefit compared to testosterone; (ii) MENT will be promoted as one component of a two-implant system for male contraception, the other component being an implant that will release an LHRH analogue; (iii) MENT has potential uses in patients with a variety of disorders, including hypogonadism, prostatic hyperplasia and muscle wasting.     

Integrating Hazard Analysis and Critical Control Point (HACCP) and Sanitation for Verifiable Food Safety

Reliable, verifiable food safety requires the application of technologically correct methods in a systematic way. This requires making a distinction between sanitation and Hazard Analysis and Critical Control Point (HACCP) and integrating these two systems into one food safety system. Although sanitation and HACCP share the same goal of producing safe food products, the focus of sanitation is on the environment surrounding the food to prevent contamination, whereas the focus of HACCP is on controlling hazards intrinsic to food materials. Together they provide the organizational base for applying the correct methods and procedures to ensure and verify that food served is safe for foodservice clients. These approaches also provide records that demonstrate that food safety measures have been planned and completed as planned. One way to demonstrate a responsible approach to food safety is to understand the differences between sanitation and HACCP and to build approaches to food safety that use both of these systems. The resulting integrated system has a better chance of controlling all the hazards than either system by itself. J Am Diet Assoc. 1997; 97: 889–891.     

Anesthesia for major general surgery in neonates with complex cardiac defects

Centers with large cardiac workloads may be presented with neonates who need major general surgery before correction or palliation of a serious cardiac defect. This is still a rare situation with only three short case reports available in the medical literature ( 1–3 ). We have reviewed the anesthetic and analgesic regimens of 18 such neonates who presented to the Birmingham Children's Hospital in the 4-year period 2004–2007. These children require meticulous preoperative evaluation and although it might be anticipated that they would pose a serious challenge to anesthetists, in reality with thorough investigation, preparation, and careful management, they tolerate general anesthesia well. These children may be transferred to centers of specialist pediatric cardiac anesthesia to be benefited from experience obtained there.     

Association of European population levels of thrombotic and inflammatory factors with risk of coronary heart disease: the MONICA Optional Haemostasis Study{dagger}

Aims Classical risk factors do not fully explain internationaldifferences in risk of coronary heart disease (CHD). We thereforemeasured thrombotic and inflammatory markers in a substudy ofthe WHO MONICA project and correlated these with CHD event rates. Methods and results We measured levels of fibrinogen (clottableand nephelometric), von Willebrand factor (vWf), tissue plasminogenactivator antigen, plasminogen activator inhibitor activity,fibrin D-dimer, plasma viscosity, C-reactive protein, and totalcholesterol in 12 MONICA populations (listed at the end of thispaper), all but one European. Men and women aged 45–64years were studied from 10 countries. All samples were collectedusing a carefully standardized protocol, and analysed centrally.Results were available for 3996 subjects (nephelometric fibrinogenand viscosity), 2378 subjects (other thrombotic assays), and1757 subjects (C-reactive protein and total cholesterol). Significantdifferences in levels of thrombotic and inflammatory factorsexist in MONICA populations mainly from European countries.These differences persist after adjustment for age, smokinghabit, and body mass index. Cross-sectional correlations betweencoronary event rates and these thrombotic/inflammatory markerswere significant for vWF antigen in both sexes, nephelometricfibrinogen in men, and D-dimer in women. Conclusion In particular, vWF, nephelometric fibrinogen, andD-dimer should be examined in further research as potentialrisk factors which may help explain differences in coronaryrisk between European populations.     

Motility Studies in Fifty Patients with Achalasia of the Esophagus

Esophageal motility tests with constantly perfused polyethylene catheters were done in 50 patients with achalasia of the esophagus using 30 asymptomatic adults as control. The mean gastroesophageal sphincter pressure was 19.0 ± 1.3 mm. Hg. (mean ± SE) which was significantly higher than the control group (P < 0.001). The intraesophageal resting pressure was significantly higher than the mean fundic pressure and no correlation among resting gastroesophageal sphincter pressure and resting intraesophageal pressure was found. An incomplete relaxation of the sphincter after swallowing was found in 45 patients with achalasia as opposed to complete sphincter relaxation in normals.