Clinical results in severe carpal tunnel syndrome and motor nerve conduction studies

The purposes of this study were to assess the value of motor nerve conduction studies as a prognostic indicator for severe carpal tunnel syndrome (CTS) and to investigate residual nerve disorder after surgery. Fifty hands in 46 patients with severe CTS were followed for at least 6 months after surgery for open carpal tunnel release. Compound muscle action potential (CMAP) from the abductor pollicis brevis (APB) muscle and the second lumbrical (SL) muscle were recorded before and after surgery, and distal latency (DL) and amplitude were analyzed. APB-CMAP was not recordable in 43 hands while SL-CMAP was recordable in all 50 hands before surgery. Results were excellent in 28 hands, good in 16 hands, fair in 6 hands, with no poor results after surgery. The ratio of excellent result was 65% in patients in whom DL of preoperative SL-CMAP was less than 10ms, and 20% in patients whose DL was 10ms or more. Delayed DL was seen in postoperative APB-CMAP and SL-CMAP, especially in the patients with good or fair results. We consider that SL-CMAP was valuable as a prognostic indicator for severe CTS, and if DL was 10ms or more, myelinization of fibers would not be sufficient after surgery.     

Predictive Value of the Time–Intensity Curves on Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Lymphatic Spreading in Breast Cancer

Purpose Dynamic contrast-enhanced magnetic resonance imaging (CE-MRI) has emerged as a promising diagnostic modality in various breast cancer treatments. However, little is known about the correlation between the pattern of time to signal intensity curves (TIC) on the CE-MRI and clinicopathologic features. This study was designed to investigate these correlations and evaluate the predictive value of TIC on CE-MRI in order to identify high-risk patients.Methods Between 2001 and 2003, 101 lesions were evaluated to detect malignancy on CE-MRI in 101 women who were suspected of having breast tumors based on either clinical findings or conventional imaging studies. Moreover, the clinicopathologic findings were compared with the pattern of TIC for the 69 surgically treated malignant lesions.Results In detecting malignancy, the sensitivity, specificity, and accuracy were 78.7%, 88.5%, and 81.2%, respectively, in the 101 breast lesions. Especially for the 69 surgically treated malignant lesions, in comparison with breast cancer tumors with the benign pattern of TIC, the breast cancer tumors with a malignant pattern were found more frequently in lymphatic invasion (P < 0.01) and lymph node metastasis (P < 0.005), although no statistical correlation regarding the histological type, tumor size, vascular invasion, extensive intraductal component, hormone receptor status, or pathological stage was noted between the two groups. According to a logistic regression model, lymph node metastasis was found to be a significant independent variable.Conclusion The pattern of TIC could be used to predict lymphatic spreading associated with lymph node metastasis prior to surgery as well as to detect malignancy. Therefore, a more detailed evaluation should be made to identify the presence of lymphatic spreading in patients with a malignant pattern of TIC.This study was presented at the 103rd Annual Congress of the Japan Surgical Society, Sapporo, Hokkaido, June 4–6, 2003     

Opposing effects of isoflurane and sevoflurane on neurogenic pulmonary edema development in an animal model

BACKGROUND: The current study was undertaken to investigate the effects of pretreatment with isoflurane and sevoflurane on the development of neurogenic pulmonary edema in an animal model. METHODS: Rats were exposed to room air (control), 1.5% isoflurane, or 2.5% sevoflurane for 4 h. They were then anesthetized with intraperitoneal injections of pentobarbital sodium, and fibrinogen and thrombin were injected into the cisterna magna to induce neurogenic pulmonary edema. RESULTS: Consecutive injections of fibrinogen and thrombin caused increases in blood pressure, with the peak values obtained in the isoflurane and sevoflurane groups being lower than the control values. The incidence of significant neurogenic pulmonary edema was 58%, 100%, and 8% in the control, isoflurane, and sevoflurane groups, respectively. The lung water ratio, an index of severity of edema, was 4.86 +/- 0.78, 6.15 +/- 0.64, and 4.40 +/- 0.32 in the control, isoflurane, and sevoflurane groups, respectively. Furthermore, immunohistochemical staining for vascular endothelial growth factor demonstrated an increase of expression in the rat lungs exposed to isoflurane. Treatment with an anti-vascular endothelial growth factor antibody during exposure to isoflurane completely inhibited the effect of isoflurane to promote neurogenic pulmonary edema in this model. CONCLUSION: Exposure to 1.5% isoflurane enhances the development of neurogenic pulmonary edema development in this animal model, most likely via release of vascular endothelial growth factor from bronchial epithelial cells, an effect not observed with sevoflurane.     

Comparison of radical retropubic prostatectomy under combined lumbar spinal and epidural anesthesia with that under combined general and epidural anesthesia

PURPOSE: To evaluate the efficacy of combined lumbar spinal and epidural (CLSE) anesthesia in retropubic radical prostatectomy. MATERIALS AND METHODS: Twenty consecutive patients who underwent radical retropubic prostatectomy by a single surgeon (H.K.) under CLSE anesthesia from July of 2003 to February of 2004 were selected as subjects. They were compared with 20 consecutive patients who underwent radical retropubic prostatectomy performed by the same surgeon under combined general and epidural (CGE) anesthesia from April to December of 2002. Both periods were carefully selected to exclude radical prostatectomies with intraoperative complications to evaluate genuine effects of anesthesia. For lumbar spinal anesthesia, 0.5% hyperbaric bupivacaine hydrochloride or 0.5% hyperbaric tetracaine hydrochloride (dissolved in a 10% glucose solution) was used. An epidural tube was inserted for both lumbar spinal anesthesia and general anesthesia mainly for the purpose of controlling a pain after operation. RESULTS: Intraoperative blood loss was significantly less in the CLSE anesthesia group compared with CGE anesthesia group (p = 0.024). Postoperative water drinking was started at 0.4 days (average) for CLSE anesthesia and at 1.1 days (average) for CGE anesthesia (p < 0.0001). Postoperative diet was begun at 0.7 days (average) for CLSE anesthesia and at 1.5 days (average) for CGE anesthesia (p < 0.0001). Compared with the CLSE anesthesia group, the mean of the highest intraoperative mean blood pressure was significantly higher in the CGE anesthesia group (p = 0.002). CONCLUSION: Intraoperative blood loss was less, intraoperative change in blood pressure was less and recovery of postoperative intestinal peristalsis was earlier in patients who underwent prostatectomy under CLSE anesthesia than in patients who underwent prostatectomy under CGE anesthesia. We believe that prostatectomy under CLSE anesthesia is more advantageous than prostatectomy under CGE anesthesia.     

Long-term clinical course of laser in situ keratomileusis--two year follow-up

PURPOSE: To evaluate the cases that were treated with laser in situ keratomileusis (LASIK) and who were follwed up for a full 2-year period without fail. MATERIALS AND METHODS: LASIK was performed in 62 eyes of 35 patients between June 1997 and March 1999. Mean age was 29.1 years and the preoperative mean spherical equivalent refraction was -6.90 +/- 2.49 (mean +/- standard deviation) diopter (D). Five aspects were studied as follows. RESULTS: 1. Safety: 26 eyes (41.9%) gained 1 line or more in best corrected visual acuity. Twenty eyes (32.3%) were unchanged. Sixteen eyes(25.8%) lost 1 line. No eye lost 2 lines or more. The safety index was 1.04. 2. Efficacy: The efficacy index was 0.85. 3. Predictability: Forty-eight eyes (77.4%) were predictable within +/- 0.5 D, and 55 eyes (88.7%) were within +/- 1.0 D. 4. Stability: Manifest refraction was relatively stable after 3 months. 5. Complication: No complications were experienced. CONCLUSIONS: Our 2-year follow-up showed that postoperatively LASIK was safe and effective.     

Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial

Context  Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions, but few studies have reported their outcomes. Objective  To investigate whether ethics consultations in the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, as well as the reactions to the consultations of physicians, nurses, and patients/surrogates. Design  Prospective, multicenter, randomized controlled trial from November 2000 to December 2002. Setting  Adult intensive care units (ICUs) of 7 US hospitals representing a spectrum of institutional characteristics. Patients  Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment. Interventions  Patients were randomly assigned either to an intervention (ethics consultation offered) (n = 278) or to usual care (n = 273). Main Outcome Measures  The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge. We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups. We also interviewed physicians and nurses and patients/surrogates about their views of the ethics consultation. Results  The intervention and usual-care groups showed no difference in mortality. However, ethics consultations were associated with reductions in hospital (-2.95 days, P = .01) and ICU (-1.44 days, P = .03) days and life-sustaining treatments (-1.7 days with ventilation, P = .03) in those patients who ultimately did not survive to discharge. The majority (87%) of physicians, nurses, and patients/surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts. Conclusion  Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU.