Hyperacute spinal subdural haematoma as a complication of lumbar spinal anaesthesia: MRI

We report two cases of hyperacute spinal subdural haematoma secondary to lumbar spinal anaesthesia, identified with MRI. Prompt diagnosis of this infrequent, potentially serious complication of spinal anaesthesia is essential, as early surgical evacuation may be needed. Suggestive MRI findings in this early phase include diffuse occupation filling of the spinal canal with poor delineation of the spinal cord on T1-weighted images, and a poorly-defined high-signal lesion with a low-signal rim on T2-weighted images. Received: 10 November 1998 Accepted: 6 April 1999     

Changes in oxygen saturation in the jugular bulb during cardiac surgery

OBJECTIVE: Heart surgery with cardiopulmonary bypass (CPB) leads to changes in supply and consumption of cerebral oxygen (DO2 and VO2C). Monitoring jugular bulb oxygen saturation (SjO2) detects changes in the DO2C/VO2C ratio that occur in patients undergoing heart surgery. The objective of this study was to determine the evolution of SjO2, of the arteriovenous difference of cerebral oxygen and of cerebral oxygen extraction, as well as the possible relation between those variables and changes in mean arterial pressure, hemoglobin counts and temperature in patients undergoing heart surgery with CPB. PATIENTS AND METHOD: A prospective study carried out in 31 patients who underwent coronary valve surgery. To monitor SjO2, each patient's internal jugular vein was cannulated with an oximetric catheter in a retrograde direction to monitor SjO2. RESULTS: Baseline SjO2 (68 +/- 7.4%), obtained after anesthetic induction, was similar to SjO2 before (65 +/- 6%) and after (67 +/- 8.2%) CPB. However, SjO2 upon starting CPB (60 +/- 8.6%) and during rewarming (63 +/- 3%) were significantly lower than at baseline. SjO2 was significantly higher during hypothermic bypass (78 +/- 5%) than at baseline. SjO2 ranged from a low of 60 +/- 8% as CPB was initiated to a high of 78 +/- 5% during hypothermic CPB. Mean arterial pressure was significantly lower at the start of bypass (44 +/- 6 mmHg) than anesthetic induction (83.5 +/- 13.1 mmHg) and the decrease correlated with a significant decrease in SjO2. Changes in mean arterial pressure were unrelated to significant changes in SjO2 at other moments, however. Nor was there a significant relation between changes in temperature or hemoglobin and the evolution of SjO2. At least one episode of SjO2 desaturation (= 50%) occurred in 29% of the patients, with the lowest values being recorded at the start of CPB and during rewarming. CONCLUSIONS: The greatest risk of cerebral oxygen imbalance between supply and demand occurs at the start of CPB and during rewarming, as shown by decreases in SjO2 levels below baseline at those times.     

Pilot study of a visitor volunteer programme for community elderly people receiving home health care

There is a need to evaluate community support programmes for elderly people. In this randomized control trial (RCT), we determined the effectiveness of 'friendly visitors' in a volunteer programme of a visiting nurses organization in Southern Ontario, Canada. The Volunteer Friendly Visitor Programme was developed to support elderly people receiving homemaking and nursing care in the community. Volunteers are screened, trained, interviewed and matched to homebound elderly clients for general interest, visit expectations and personality. Volunteers spend three to four hours on average per week with clients socializing in mutually agreed-upon ways. The nursing staff identified clients who were lonely for this additional support. These newly-referred clients were randomly allocated to receive a friendly visitor or not for six weeks. Those receiving the volunteer visitor improved in life satisfaction and two social support measures: worth and social integration. Thus, the addition of volunteer visitors to planned homemaking and nursing care made a difference for elderly in the community.     

Kraepelin-oriented research-diagnosable schizophrenia,mania, and depression in schneider-negative schizophrenics

Summary The rigorous neo-Kraepelinean research criteria of the St. Louis/ Iowa and Taylor groups were applied to case record data of 116 first admissions of Schneider-negative schizophrenics—that is, those without first-rank symptoms (FRSs)—hospitalized in a strongly Schneider-oriented German University Psychiatric Clinic from 1962 to 1971. This sample had a total of 45.7% (53 cases) of psychiatric illness diagnosable by research methods. Indeed, only 31% (36 cases) of Schneider-negative schizophrenics turned out to have research-positive Kraepelin-oriented schizophrenia; and of these, 21 fulfilled both sets of research criteria for schizophrenia. It is important that 14.6% (17 cases) of Schneider-negative schizophrenia consisted of research-diagnosable affective disorder, with mania making up 5.2% and depression 9.4% of this figure. The findings suggest that a sample of Schneider-oriented schizophrenia without FRSs as routinely diagnosed in Germany does not seem to represent a clear-cut homogeneous and uncontaminated group of schizophrenics.     

The well-baby clinic

The termwell-baby clinic (literally, a clinic that concerns itself with healthy infants) is probably better known in the United States, where such clinics exist, than in central Europe, where, on the whole, they do not. For the convenience of readers accustomed to it a formal definition is proffered: A well-baby clinic is a service center, with emphasis on physical and mental hygiene and prophylaxis, where mothers are seen with their young, healthy infants and helped to understand and manage the infant's unfolding maturation [1: p. 5] and development [1: p. 5]. This may serve to differentiate well-baby clinics, on the one hand, from clinics for sick children and child guidance clinics (usually resorted to after disturbances have emerged) and, on the other hand, from maternity and child welfare clinics, whose primary object is to safeguard physical health. (Maternity and child welfare clinics are also known as family health clinics, child health clinics, and infant welfare clinics. The extent to which they can cater to the psychological needs of mother and infant depends on their staff's training.)This paper forms part of a research project entitled Childhood Pathology: Impact on Later Mental Health, which is being conducted at the Hampstead Child-Therapy Course and Clinic, London. The project is financed by National Institute of Mental Health Grant MH-05683-11. Appreciation is expressed to Anna Freud, Elizabeth Model, Professor A. J. Solnit, and Dr. Josefine Stross for their valuable suggestions. The authors acknowledge with gratitude the freedom to quote from the Well-Baby Clinic's annual reports, compiled by the clinic's pediatrician, Dr. Josefine Stross, with the active help of her past assistants, Annemarie Curson, Manna Friedmann, and Joyce Robertson, and her present assistants, Irene Freud and E. Model.This paper was originally published in German, in volume 2 of theJahrbuch der Psychohygiene, Ed. Gerd Biermann, Ernst Reinhardt Verlag, München/Basel, 1974.     

Cyclosporin A induced internalization of the bile salt export pump in isolated rat hepatocyte couplets.

Isolated rat hepatocyte couplets were used to perform the comparative study of two widely used immunosuppressors, cyclosporin A (CsA) and tacrolimus (FK506) on hepatocanalicular function. We assessed canalicular function by counting the percentage of couplets that were able to accumulate the fluorescent cholephile, cholyl-lysyl-fluorescein (CLF), into the canalicular vacuole between the two cells, i.e., canalicular vacuole accumulation (CVA) of CLF. Compared to controls (DMSO-treated cells), CsA, in the approximate range of concentrations used therapeutically, caused inhibition of CVA of CLF, disorganization of the bile salt export pump (Bsep) localization at canalicular level resulting in its relocation into the cell, and disruption of the pericanalicular F-actin cytoskeleton. In contrast, FK506, at both approximately therapeutic and supratherapeutic concentrations, had no deleterious effect upon CVA of CLF, upon the localization of the bile salt transporter at the canalicular membrane, or on the organization of the pericanalicular F-actin cytoskeleton. These results point to transporter and cytoskeletal disorganization as contributors or determinants of CsA-induced cholestasis at canalicular level, whereas FK506 does not appear to produce these cholestasis-determining responses even at supratherapeutic concentrations.     

Genetic variants of GPX1 and SOD2 and breast cancer risk at the Ontario site of the Breast Cancer Family Registry.

There are several genes that code for enzymes, including various forms of superoxide dismutase and glutathione peroxidase, that protect the cell against oxidative damage that, in turn, can lead to carcinogenesis. There are a few common genetic polymorphisms in these genes that lead to altered proteins. Three that have been identified are SOD2 Val-9Ala, GPX1 Pro198Leu, and the GPX1 GCG repeat (three alleles with four, five, or six repeats). The SOD2 variant has been associated with increased breast cancer risk in two studies. The GPX1 variants have not been studied with respect to breast cancer, but Pro198Leu has been associated with lung cancer. We conducted a case-control study of these three polymorphisms in incident, invasive breast cancer in Caucasian women under 55. There were 399 cases and 372 controls genotyped, of whom 488 were premenopausal, 208 postmenopausal, and 75 of unknown menopausal status. We were unable to replicate the previously observed association with SOD2 Val-9Ala and also found no association between breast cancer and GPX1 Pro198Leu. However, the allele of GPX1 containing four GCG repeats was significantly associated with breast cancer risk in premenopausal women (odds ratio, 1.55; 95% confidence interval, 1.04-2.30 for carriers versus noncarriers). There is a significant trend of increasing risk with increasing number of alleles with four GCG repeats (P = 0.03). This variant has not previously been reported to be associated with breast cancer.     

Patterns and predictors of inpatient falls and fall-related injuries in a large academic hospital.

OBJECTIVES: Most research on hospital falls has focused on predictors of falling, whereas less is known about predictors of serious fall-related injury. Our objectives were to characterize inpatients who fall and to determine predictors of serious fall-related injury. METHODS: We performed a retrospective observational study of 1,082 patients who fell (1,235 falls) during January 2001 to June 2002 at an urban academic hospital. Multivariate analysis of potential risk factors for serious fall-related injury (vs no or minor injury) included in the hospital's adverse event reporting database was conducted with logistic regression to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CI95) RESULTS: The median age of patients who fell was 62 years (interquartile range, 49-77 years), 50% were women, and 20% were confused. The hospital fall rate was 3.1 falls per 1,000 patient-days, which varied by service from 0.86 (women and infants) to 6.36 (oncology). Some (6.1%) of the falls resulted in serious injury, ranging by service from 3.1% (women and infants) to 10.9% (psychiatry). The most common serious fall-related injuries were bleeding or laceration (53.6%), fracture or dislocation (15.9%), and hematoma or contusion (13%). Patients 75 years or older (aOR, 3.2; CI95, 1.3-8.1) and those on the geriatric psychiatry floor (aOR, 2.8; CI95, 1.3-6.0) were more likely to sustain serious fall-related injuries. CONCLUSIONS: There is considerable variation in fall rates and fall-related injury percentages by service. More detailed studies should be conducted by floor or service to identify predictors of serious fall-related injury so that targeted interventions can be developed to reduce them.