Distribution of local anesthetics injected into the interpleural space, studied by computerized tomography

Twenty-one patients were given interpleural analgesia for postoperative pain relief after cholecystectomy, or renal or breast surgery. The patients were classified randomly into two groups: an interpleural injection of 20 ml of 0.375% bupivacaine mixed with 10 ml contrast medium was given to 11 patients in the supine position, and 10 in the lateral position. The patients remained in this position for 1 h. There was no significant difference in the rostrocaudal distribution of the contrast on computerized tomography taken 20 min later: Th3-L1 in the supine group vs. Th5-L1 in the lateral group. In the supine group the mean level of contrast medium reached significantly higher medially along the mediastinum (51 +/- 11 mm) than laterally (27 +/- 11 mm).     

Cutaneous and subcutaneous blood flow rates in paraplegic humans investigated by 133Xenon wash-out. Methodological considerations

Summary. In a methodological study including 14 paraplegics and seven normal controls cutaneous and subcutaneous blood flow rates were investigated by ¹³³Xenon wash-out after atraumatic labelling. In paraplegics, areas suffering pressure sores were included. The method was found applicable for the authors' purposes. In seven paraplegics median (95% confidence limits) cutaneous blood flow was 5–2 (2–4–8–5) ml (100 g min)“¹ and subcutaneous 4–3 (2–0–13–2) ml (100 g min)^-1. This did not differ from normal controls. In seven paraplegics with ischial pressure sores a trend for increased cutaneous blood-flow rates from areas adjacent to sores was obvious (P= 0–06). During 704 head-up tilt, elimination-rate constants were reduced by a factor of 0–54 (0–50–0–70). A proximal blockade or infiltration of the ¹³³Xenon depots with lidocaine did not inhibit employment of the method. The proximal block did not alter the local blood flow rate, but infiltration increased it in both paraplegics and normal individuals. Intra- and interdepot coefficients of variation were about 11% and 40% respectively. Interindividual coefficients of variation varied between 25% and 46%.     

Self-report and psychophysiological effects of five pain-coping strategies

One hundred nulliparous college female undergraduates were randomly assigned to a series of 10 treatment groups that comprised a variety of cognitive-behavioral pain-coping strategies designed as part of a labor preparation analogue. The efficacy of these treatments was subsequently assessed during a one-hour session involving twenty 80-sec exposures to a laboratory pain stimulus patterned to resemble labor contractions. Dependent variables included self-reported pain, systolic and diastolic blood pressure, frontalis EMG, and heart rate. One of the cognitive strategies--sensory transformation--was found to have a significant effect on self-reported pain. Analyses conducted on the other five dependent variables failed to show significant treatment effects.     

Bone Histomorphometry in Male Idiopathic Osteoporosis

The pathogenesis of male osteoporosis at the cellular level is still elusive. We performed histomorphometric analysis of bone biopsy samples from 51 eugonadal men with idiopathic osteoporosis. Their median age was 54 (range 29–73) years. Eighty-two percent of the patients had a fracture history, and 57% had vertebral fractures. Bone volume, trabecular thickness, wall thickness, and osteoid thickness were significantly reduced in osteoporotic men compared with healthy men. Erosion depth was similar, as were the bone remodeling parameters such as bone formation rate, mineral apposition rate, and activation frequency. In the osteoporotic men, osteoid thickness was correlated to bone mineral density at the lumbar spine (R ² = 0.19, P < 0.01); together with wall thickness, the two parameters could explain 27% of the variation in lumbar spine bone mineral density. The osteoid thickness was correlated to anthropometric variables such as body weight (R ² = 0.24, P < 0.001) and body mass index (R ² = 0.14, P < 0.01), as well as to serum estradiol levels (R ² = 0.14, P < 0.01) and to the ratio insulin-like growth factor-1 (IGF-1) to IGF-binding protein-1 (IGFBP-1) (R ² = 0.12, P < 0.01). Regression analysis showed that 36% of the variation in osteoid thickness could be predicted by body weight and estradiol levels. In conclusion, bone histomorphometry in male idiopathic osteoporosis was characterized by thin bone structural units, which might suggest osteoblast dysfunction. Bone histomorphometry parameters were associated with low body weight, low estradiol levels, and increased levels of IGFBP-1, supporting the notion that estrogens and IGFs play regulatory roles in male bone turnover.     

Disproportional geometry of the proximal femur in patients with Turner syndrome: a cross-sectional study

Objective Patients with Turner syndrome (TS) have altered growth and increased risk of osteoporosis due to oestrogen deficiency and possibly a host of other factors. Thus, TS patients have a 4·9‐fold increased risk of femoral neck fractures. Most patients are treated with oestrogen during puberty and adolescence to facilitate pubertal development and prevent secondary osteoporosis. The geometry of the hip is a predictor for hip fractures independent of bone mineral density (BMD). The purpose of the present study was to investigate the variation of the geometry of the hip in patients with TS in comparison with healthy controls. Patients The study population comprised 58 patients with TS (aged 22–67 years) and 60 age‐matched healthy women (aged 21–65 years). Measurements Hip axis length (HAL), neck width (NW), neck shaft angle (NSA), and femoral head‐radius (HR) on dual‐energy X‐ray absorptiometry (DXA) screen images. These parameters related to age of oestrogen supplementation, menarche, and duration of oestrogen exposure. Results Height was 146·6 ± 6·9 cm and 167·1 ± 6·2 cm (P < 0·1) and weight 57·4 ± 13·9 kg and 62·3 ± 8·3 kg (P < 0·001) in patients and controls, respectively. After adjustment for differences in height, HAL was not significantly different (9·4 ± 0·5 vs. 9·5 ± 0·5 cm; NS) in TS compared with controls while NW was significantly increased (3·5 ± 0·4 cm vs. 3·3 ± 0·2 cm, P < 0·001), NSA was similar (129 ± 4°vs. 130 ± 4°, NS), and HR was significantly decreased (4·1 ± 0·4 vs. 4·5 ± 0·3 cm, P < 0·001). The duration of oestrogen exposure was significantly shorter among TS, but did not correlate significantly with the geometrical parameters in either TS or controls. Conclusion Our data demonstrates that hip geometry is disproportionate in TS compared with normal controls. The altered hip geometry, however, cannot explain the increased risk of hip fracture in TS.     

A screening and intervention program aimed to reduce mortality and serious morbidity associated with severe neonatal alloimmune thrombocytopenia

The study's objective was to identify HPA 1a-negative women and to offer them an intervention program aimed to reduce morbidity and mortality of neonatal alloimmune thrombocytopenia (NAIT). HPA 1 typing was performed in 100 448 pregnant women. The HPA 1a-negative women were screened for anti-HPA 1a. In immunized women, delivery was performed by Cesarean section 2 to 4 weeks prior to term, with platelets from HPA 1a-negative donors reserved for immediate transfusion if petechiae were present and/or if platelet count was less than 35 x 10(9)/L. Of the women screened, 2.1% were HPA 1a negative, and anti-HPA 1a was detected in 10.6% of these. One hundred seventy pregnancies were managed according to the intervention program, resulting in 161 HPA 1a-positive children. Of these, 55 had severe thrombocytopenia (< 50 x 10(9)/L), including 2 with intracranial hemorrhage (ICH). One woman with a twin pregnancy missed the follow-up and had one stillborn and one severely thrombocytopenic live child. In 15 previous prospective studies (136 814 women) there were 51 cases of severe NAIT (3 intrauterine deaths and 7 with ICH). Acknowledging the limitation of comparing with historic controls, implementation of our screening and intervention program seemed to reduce the number of cases of severe NAIT-related complications from 10 of 51 to 3 of 57.     

Urgent carotid endarterectomy is safe in patients with few comorbid medical conditions

Recent reports from single institutions have confirmed the efficacy of carotid endarterectomy (CEA) performed in the urgent or emergent setting, although with higher perioperative mortality and morbidity. We determined the results of urgently performed CEA in academic and community hospitals and whether patient or hospital factors affected outcome. The records of patients undergoing CEA in all nonfederal hospitals in the state of Connecticut between 1992 and 2002 were reviewed, and symptomatic patients who presented in an urgent or emergent fashion were compared to patients treated electively. Multivariable logistic regression was used to determine the effect of patient risk factors on perioperative mortality, stroke, and cardiac complications. Patients undergoing urgent CEA (n = 764, 6.3%) had higher perioperative mortality (2.0% vs. 0.3%, p < 0.0001) and stroke (2.9% vs. 1.1%, p < 0.0001) but not cardiac complications (3.0% vs. 2.2%, p = 0.14) compared to patients undergoing elective CEA (n = 11,312). Patients undergoing urgent CEA and with high rates of associated comorbidity had a higher risk of perioperative mortality (7.8% vs. 0.4, p = 0.001), stroke (10.9% vs. 0.8%, p = 0.0002), and cardiac complications (14.1% vs. 0.8%, p < 0.0001) compared to patients presenting urgently but with little comorbidity. Perioperative mortality was associated with performance of the procedure in hospitals with low bed capacity (odds ratio [OR] = 4.6, p = 0.01). Perioperative stroke was associated with renal insufficiency (OR = 5.3, p = 0.04). Perioperative cardiac complications were associated with diabetes (OR = 2.6, p = 0.03) and performance in hospitals with low bed capacity (OR = 5.0, p < 0.01). Urgent admission was associated with age >/=80 (OR = 1.2, p = 0.04), renal disease (OR = 1.8, p = 0.05), and cardiac disease (OR = 1.3, p < 0.01). Urgently performed CEA has higher perioperative mortality and stroke compared with electively performed cases. However, the subset of patients with low rates of associated comorbid medical conditions but urgently needing CEA is associated with low rates of perioperative complications. Patients with severe associated comorbid medical conditions who present urgently for CEA may form a high-risk group of patients to be considered for referral to large treatment centers or possibly alternative therapy.     

Anal endosonographic findings in the follow-up of primarily sutured sphincteric ruptures.

Twenty-four women with primary suture of an obstetric tear of the anal sphincter were examined with anal endosonography a median of 12 (range 3-18) months after delivery. Endosonography was normal in ten patients, of whom one was incontinent. The examination showed a defect in the external anal sphincter in 13 patients; six of these were incontinent, two of whom had normal findings on palpation. An isolated internal sphincter defect was found in a continent patient. Since anal endosonography causes no more discomfort than digital examination, it may be useful to identify patients who would benefit from surgical reconstruction of the anal sphincter.