Elective Caesarean section is associated with a reduction in developmental dysplasia of the hip in term breech infants

We wished to establish whether delivery by Caesarean section influenced the incidence of developmental dysplasia of the hip in term breech infants compared with those delivered vaginally. We used maternal charts, singleton term breech presentation, mode of delivery and incidence of developmental dysplasia of the hip for births between January 1997 and October 2002. During the study period 46 089 infants were born. We analysed a total of 941 breech infants of whom 756 were delivered by Caesarean section (515 pre-labour, 241 intrapartum) and 185 vaginally. The incidence of developmental dysplasia of the hip according to the mode of delivery was 19 of 515 (3.69%) following pre-labour Caesarean section, 16 of 241 (6.64%) for intrapartum Caesarean section and 15 of 185 (8.11%) after vaginal delivery. There was a lower incidence of developmental dysplasia of the hip among those infants delivered by elective Caesarean section compared with those delivered vaginally (p < 0.02). These results demonstrate a significantly lower incidence of developmental dysplasia of the hip in term singleton breech births delivered by elective, pre-labour Caesarean section and suggest that labour and delivery influence hip stability in predisposed infants.     

Endovascular management of a patient after SAH

Treatment of acute aneurysmal subarachnoid hemorrhages consists of occluding the aneurysm to prevent rebleed, attempting to prevent vasospasm, and maintaining blood flow to the brain through vessels in vasospasm. Endovascular treatment has been shown to be as safe as, or safer, than surgical clipping for patients with SAH. Engineering solutions to our clinical problems continue to improve endovascular outcomes. This article reviews the current state of endovascular therapy.     

The comparison and validity of troponin I assay systems in diagnosing myocardial ischemic injury after surgical coronary revascularization

OBJECTIVE: A prospective observational study was conducted to test the agreement between 2 commercially available automated cardiac troponin-I immunoassay systems (Opus Plus, Behring Diagnostics UK Ltd, Hounslow, UK; AxSYM, Abbott Laboratories, Abbott Park, IL) and to determine a normal reference range and threshold value indicative of perioperative myocardial infarction (PMI) after elective coronary artery bypass graft (CABG) surgery for the Opus Plus system. DESIGN: Prospective, observational study. Setting : Single institution, cardiothoracic specialty hospital. PARTICIPANTS: Seventy patients undergoing elective CABG surgery. INTERVENTIONS: After institutional review board approval, patients received standardized anesthetic, surgical, and myocardial preservation techniques. Serial electrocardiographs, creatine kinase-MB, troponin-I, and perioperative outcome data were collected. Correlation between the immunoassay systems was tested using 124 duplicate samples from the first 18 patients. The normal reference range and threshold value indicative of PMI were tested for the Opus Plus system using duplicate samples from all 70 patients. MEASUREMENTS AND MAIN RESULTS: Peak troponin-I concentrations (median [interquartile range]) differed significantly when measured by the Opus Plus and AxSYM immunoassay systems (5.61 [3.20-22.35] microg/L v 46.50 [14.55-70.95] microg/L, respectively; p < 0.001). There was clear proportional bias that was corrected with log transformation of the raw data. By using confidence interval and receiver operating characteristic curve analysis, the authors showed that a value > or =15 mug/L was indicative of PMI (Opus Plus system) and accordingly report a 35.7% (2.9% Q-wave) overall incidence of PMI in this study population (n = 70). CONCLUSIONS: These data highlight differences between commercially available troponin-I assay systems. The authors recommend that each institution establish a local reference range and threshold indicative of perioperative myocardial infarction for its specific patient population and assay system and provide sample methodology.     

A description of the spread of injectate after psoas compartment block using magnetic resonance imaging

BACKGROUND AND OBJECTIVES: Magnetic resonance imaging (MRI) provides for excellent visualization of spread of solution after peripheral nerve block. The aim of this observational study was to utilize MRI to describe the distribution of injectate (gadopentetate dimeglumine) administered for continuous psoas compartment block (PCB) performed by use of two approaches (Capdevila and modified Winnie) and to describe the spread of injectate to the lumbar plexus. METHODS: Four volunteers were enrolled in a prospective crossover study. Each volunteer underwent PCB with catheter placement performed by use of Capdevila's approach followed 1 week later by PCB, with catheter placement performed by use of a modified Winnie approach. MRI of injectate distribution was performed after each PCB. RESULTS: The catheter was unable to be inserted in 1 volunteer undergoing Winnie's approach; therefore, 7 sets of MR images were analyzed. In 6 of 7 cases (4 Capdevila and 2 Winnie) spread was primarily within the psoas muscle. Contrast surrounded the L2-3 lumbar branch of the femoral nerve at L4 and cleaved the fascial plane within the psoas muscle and spread cephalad to reach the lumbar nerve roots. In 1 case (Winnie approach) contrast spread between the psoas and quadratus lumborum muscles. Contrast surrounded the femoral and obturator nerves where they lie outside the psoas muscle at L5. CONCLUSION: The most common pattern of injectate spread seen on MRI with both approaches to PCB was spread within the body of the psoas muscle around the lumbar branches (L2-4), with cephalad spread to the lumbar nerve roots. One catheter resulted in injectate between the psoas and quadratus lumborum muscles.     

Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic

PURPOSE: To compare a template-driven medical documentation system to undirected handwritten documentation and determine whether the template (1) decreases physician evaluation time, (2) increases gross billing, and (3) increases physician satisfaction with the documentation process. METHODS: A prospective randomized trial of documentation with a template system (T-System for Primary Care, Dallas, TX) versus undirected handwritten documentation was conducted in 2 separate teams of a single family medicine residency program. After training, one team used the template system and the other team used undirected written documentation. Clinic visit duration was recorded. Medical records were evaluated by a blinded professional coder to assign an evaluation/management code. Clinic visit duration and coding level differences were evaluated using an independent t test. At the conclusion of the study, residents completed a questionnaire to determine physician satisfaction with the documentation tool. Survey responses were on a -2 to + 2 Likert scale. Means and standard deviations are reported. RESULTS: A total of 1339 patients were included in the analysis of patient visits. There was no significant difference in clinic time between the template system and the written documentation visits. The mean visit time was 1.75 hours for both teams. For the analysis of gross billing, 1237 charts were included. The mean billing amount for written documentation was USD $150 and for the template system it was USD $163--a statistically significant difference. The physicians' surveys favored continuing to use the template documentation method. CONCLUSIONS: The template medical documentation system compared with undirected written documentation produced a significantly higher bill for the visit, yielding no differences in evaluation time, and was overall positively received by the residents and faculty.     

Highly efficient and reliable chemically assisted enucleation method for handmade cloning in cattle

The purpose of the present study was to find an efficient and reliable chemically assisted procedure for enucleation related to the handmade cloning (HMC) technique. After in vitro maturation oocytes were incubated in 0.5 microg mL(-1) demecolcine for 2 h. Subsequently, zonae pellucidae were digested with pronase, and one-third of the cytoplasm connected to an extrusion cone was removed by hand using a microblade. The remaining two-thirds were used as recipients for HMC, and reconstructed and activated embryos were cultured for 7 days. The time-dependent manner of the development of extrusion cones, the efficiency (oriented bisection per oocyte; 94%), reliability (success per attempted enucleation; 98%), and the blastocyst per reconstructed embryo rates (48%) were measured. Ultrastructural analyses demonstrated that demecolcine treatment resulted in disoriented and haphazardly orientated microtubules. The general ultrastructure of the oocyte organelles, however, appeared to be unaltered by the treatments. Considering that no oocyte selection based on polar body presence was performed, this system seems to be more efficient and reliable than any other enucleation method. Moreover, expensive equipment (inverted fluorescence microscope) and a potentially harmful step (staining and ultraviolet illumination) can be eliminated from the HMC procedure without compromising the high in vitro efficiency.     

Implications of an animal model of sugar addiction, withdrawal and relapse for human health

The effect of intermittent glucose administration on the circadian rhythm of body temperature was studied in rats to provide evidence of sugar addiction, withdrawal and relapse. Metabolic and behavioral phenomena were also observed. Biotelemetry transmitters recorded body temperature for the duration of the 4-week experiment. Rats were divided into an experimental and a control group, which were maintained on the same habituation conditions for the duration of the experiment, with the exception of weeks 2 and 4, when the experimental group was presented with a 25% glucose solution. Experimental animals displayed a precipitous drop in body temperature and behavioral changes associated with withdrawal during week 3, when sugar was removed. There was an increase in kilocalories (kcal) consumed during weeks 2 and 4 by experimental animals and, by the end of the experiment, these animals showed a greater percent increase in body weight. Elevated blood glucose levels were found in experimental animals. The study demonstrates that the effects of sugar addiction, withdrawal and relapse are similar to those of drugs of abuse. Implications of the rewarding and addicting effects of sugar are related to weight gain, obesity and Type II diabetes. Furthermore, pitfalls related to dieting are elucidated.     

Plasma levobupivacaine concentrations following scalp block in patients undergoing awake craniotomy

Background. Levobupivacaine is an effective local anaestheticagent for nerve blockade with less systemic toxicity than racemicbupivacaine. The safety and efficacy of levobupivacaine forscalp blockade during awake craniotomy have not been addressedpreviously. Methods. Serial arterial plasma levobupivacaine concentrationsfollowing scalp blockade were measured to 2 h in 10 patientsbooked for awake craniotomy for epilepsy or tumour surgery.Bilateral scalp blockade providing surgical anaesthesia wasachieved with a mean dose of 177 mg (2.5 mg kg^–1, range1.6–3.2 mg kg^–1) of levobupivacaine (0.5%, 5 mgml^–1) with epinephrine (5 µg ml^–1) added immediatelybefore the block insertion. Results. The maximum measured plasma levobupivacaine concentrationwas 1.58 (0.44) µg ml^–1 [mean (SD)] with a meantime to peak plasma concentration of 12 (4) min. There wereno episodes in any of the 10 patients of symptoms or signs suggestiveof either CNS or CVS toxicity. Conclusions. This study demonstrated a relatively rapid riseof plasma levobupivacaine concentration without evidence ofcardiovascular or central nervous system sequelae in a samplepopulation of patients who may be particularly prone to perioperativeseizures.     

Is the pulmonary artery catheter useful?

In the United States more than 1.5 million pulmonary artery catheters (PACs) are inserted each year. Of these, approximately 55% are placed in high-risk surgical and trauma patients. Most clinicians believe that PAC use is beneficial in guiding therapy and may improve outcome. Despite these beliefs and hundreds of published articles related to PACs, appropriate use and impact on outcome remain unclear. A review of the current literature reveals conflicting data and significant flaws in most study designs. Inadequate sample size, lack of randomization, lack of standardization of therapies to PAC data, and deficiencies in user knowledge all significantly limit interpretation of clinical trials. Despite these deficiencies and the need for better-designed investigations, it is the opinion of the authors that access to hemodynamic data provided by the PAC, coupled with accurate interpretation of the data, may lead to reduced perioperative morbidity and mortality.