Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty

The purpose of this study was to determine if an intraoperative intraarticular and soft-tissue injection of local anaesthetic, epinephrine, and morphine has a beneficial effect for total knee arthroplasty. A control group of 138 patients (181 knees) received no intraoperative injection. The study group of 171 patients (197 knees) received intraoperative injection of 0.25% bupivacaine with epinephrine and morphine with 2/3 injected into the soft tissues and 1/3 injected into the joint. Patients having bilateral simultaneous procedures received a divided dose. The pain treatment protocol otherwise was identical. Pain, sedation, rescue narcotic usage, narcotic reversal and blood loss were examined. Pain levels during the immediate postoperative period, blood loss, and bleeding indices were reduced with injection. Considerably more control patients required rescue doses of narcotics. Preemptive analgesia with soft tissue and intra-articular injection of long-acting local anesthetic with epinephrine and morphine provides better pain control in the immediate postoperative period, decreases blood loss, and decreases the need for rescue narcotics and reversal agents. This simple, inexpensive method provides an effective adjunct to a multimodal approach in improving the postoperative course of primary total knee arthroplasty.     

Prediction of activity energy expenditure using accelerometers in children

PURPOSE: To validate two accelerometer-based activity monitors as measures of children's physical activity using energy expenditure as the criterion measure. METHODS: Actiwatch (AW) and Actical (AC) activity monitors were validated against continuous 4-h measurements of energy expenditure (EE) in a respiratory room calorimeter and 1-h measurements in an exercise laboratory using a portable calorimeter and treadmill in 32 children, ages 7-18 yr. The children performed structured activities including basal metabolic rate (BMR), playing Nintendo, using a computer, cleaning, aerobic exercise, ball toss, treadmill walking, and running. Equations were developed to predict activity energy expenditure (AEE = EE - BMR), and physical activity ratio (PAR = EE/BMR) from a power function of AW or AC, and age, sex, weight, and height. Thresholds were determined to categorize sedentary, light, moderate, and vigorous levels of physical activity. RESULTS: Activity counts accounted for the majority of the variability in AEE and PAR, with small contributions of age, sex, weight, and height. Overall, AW equations accounted for 76-79% and AC equations accounted for 81% of the variability in AEE and PAR. Relatively wide 95% prediction intervals suggest the accelerometers are best applied to groups rather than individuals. Sensitivities were higher for the vigorous threshold (97%) than the other thresholds (86-92%). Specificities were on the order of 66-73%. The positive predictive values for sedentary, light, moderate, and vigorous categories were 80, 66, 69, and 74% for AW, respectively, and 81, 68, 72, 74% for AC, respectively. CONCLUSION: Both accelerometer-based activity monitors provided valid measures of children's AEE and PAR, and can be used to discriminate sedentary, light, moderate, and vigorous levels of physical activity but require further development to accurately predict AEE and PAR of individuals.     

A longitudinal study of fitness and activity in girls predisposed to obesity

PURPOSE: To determine whether physical activity and fitness change in girls with and without a predisposition to obesity from 8 to 10 yr of age. METHODS: Normal-weight girls (N = 91) were recruited at 8 yr of age according to parental body mass index (BMI): LN = girls with two lean (BMI < 25 kg.m-2) parents, LNOB = girls with one obese and one lean parent, and OB = girls with two obese (BMI > 28 kg.m-2) parents. A longitudinal study was undertaken with annual assessments at 8, 9, and 10 yr of age. The primary outcomes were fitness ([OV0312]O2peak) measured by treadmill testing, and physical activity measured by heart rate monitoring and by questionnaire. Sedentary behavior was assessed by questionnaire. RESULTS: [OV0312]O2peak (mL.kg-1.min-1) did not change over time; however, [OV0312]O2peak (L.min-1 and mL.kg-1.min-1), time on the treadmill, and treadmill stage were different across groups (P < 0.02). Girls with LNOB parents had a lower absolute [OV0312]O2 than the LN girls by 2.5 mL.kg-1.min-1 (P < 0.05). The OB group had a 3.9 mL.kg-1.min-1 lower [OV0312]O2 than the LN group (P < 0.001). The girls of LN parents also exercised longer on the treadmill (P < 0.05) than girls with OB parents. The percent of the day spent active on the weekday and weekend did not change over time or between groups. Time spent watching TV during the school year and summer was similar over the study period and between groups. CONCLUSION: Our data suggest that fitness and physical activity remain fairly constant in girls from 8 to 10 yr of age, but girls of obese parents tend to be less fit.     

Präoperative Nahrungskarenz

Zusammenfassung Die Anordnung einer strikten Nahrungskarenz nach Mitternacht vor operativen Eingriffen in Narkose ist die geläufige Praxis in chirurgischen Einrichtungen in Deutschland. Das damit verfolgte Ziel ist eine Reduktion des perioperativen Aspirationsrisikos. Seit mehreren Jahren wird die wissenschaftliche Grundlage dieser Verfahrensweise zunehmend kritisch diskutiert. Insbesondere für die präoperative Einnahme von Wasser und klarer Flüssigkeit zeigen experimentelle wie klinische Untersuchungen, dass von einer vollständigen Magenpassage innerhalb von 2 h sicher ausgegangen werden kann und das Risiko nach begrenztem Trinken bis 2 h vor elektiven Operationen in Allgemeinanästhesie nicht erhöht ist. Zudem sind perioperative Aspirationszwischenfälle sehr selten, haben eine gute Prognose und sind eher auf Faktoren wie mangelnde Narkosetiefe oder unzureichende Atemwegsprotektion zurückzuführen als auf den Nüchternheitsstatus des Patienten. Folglich haben zahlreiche nationale anästhesiologische Gesellschaften im Sinne eines verbesserten perioperativen Wohlbefindens der Patienten ihre offiziellen Leitlinien zur präoperativen Nüchternheit geändert und empfehlen unter Berücksichtigung definierter Einschränkungen und Kontraindikationen einen gelockerten Umgang mit der Einnahme flüssiger wie fester Nahrung vor elektiven Eingriffen. Die vorliegende Arbeit gibt eine zusammenfassende Übersicht über die Hintergründe, auf denen diese national erstellten Leitlinien beruhen, mit der Absicht auch für Deutschland eine Empfehlung zur Lockerung der präoperativen Nüchternheit für klare Flüssigkeiten vorzuschlagen.     

Tracheo-esophageal puncture (TEP) for voice rehabilitation in laryngectomised patients blom-singer® Vs Provox® Prosthesis: Our experience

Background: Stage III and IV cancers of larynx and hypopharynx often require total laryngectomy which leaves the patient with severe communication handicap. In such laryngectomised patients tracheo-esophageal puncture is the best way for voice rehabilitation using either Blom-Singer® prosthesis or Provox® indwelling valve.     

Lazy eyes zebrafish mutation affects Müller glial cells,compromising photoreceptor function and causing partial blindness

A behavioral assay based on the optokinetic reflex was used to screen chemically mutagenized zebrafish larvae for deficits in visual function. A homozygous recessive mutation, lazy eyes (lze), was isolated based on the observation that 5-day postfertilization (dpf) mutants displayed weaker and less frequent eye movements than wild-type fish in response to moving stripes. Electroretinographic (ERG) recordings revealed that mutants had severely reduced a- and b-wave amplitudes relative to wild-type fish, indicating outer retinal dysfunction. Retinal lamination and cellular differentiation were normal in the lze retina; however, mutant photoreceptor cells had small outer segments and pyknotic nuclei were occasionally observed in the outer retina and the marginal zone of lze. Cone, rod, amacrine, bipolar, and Müller cell marker analyses indicated that the typical lze retina contained fewer rod photoreceptors and fewer Müller cells than wild-type fish at 5 dpf. At 3 dpf, however, mutant retinas had normal numbers of rod photoreceptors and Müller cells, suggesting that the initial differentiation of these cell types occurred normally. Rod photoreceptor histology was normal at this early stage, but Müller cells were often hypertrophied, suggesting that they were unhealthy. Constant light rearing of mutant animals accelerated the Müller cell degeneration, severely worsened the visual deficit, but had no obvious affect on the photoreceptors. When ERG responses and Müller cell degeneration from the same mutant animals were analyzed, the extent of the Müller cell loss matched closely the degree to which ERG responses were reduced. In summary, the lze gene appears to be required for Müller cell viability and normal visual function. The lze mutant may be a model for the study of the involvement of Müller cells in photoreceptor development and function.     

World Workshop on Oral Medicine VI: a systematic review of medication‐induced salivary gland dysfunction

The aim of this paper was to perform a systematic review of the pathogenesis of medication‐induced salivary gland dysfunction (MISGD). Review of the identified papers was based on the standards regarding the methodology for systematic reviews set forth by the World Workshop on Oral Medicine IV and the PRISMA statement. Eligible papers were assessed for both the degree and strength of relevance to the pathogenesis of MISGD as well as on the appropriateness of the study design and sample size. A total of 99 papers were retained for the final analysis. MISGD in human studies was generally reported as xerostomia (the sensation of oral dryness) without measurements of salivary secretion rate. Medications may act on the central nervous system (CNS) and/or at the neuroglandular junction on muscarinic, α‐and β‐adrenergic receptors and certain peptidergic receptors. The types of medications that were most commonly implicated for inducing salivary gland dysfunction were those acting on the nervous, cardiovascular, genitourinary, musculoskeletal, respiratory, and alimentary systems. Although many medications may affect the salivary flow rate and composition, most of the studies considered only xerostomia. Thus, further human studies are necessary to improve our understanding of the association between MISGD and the underlying pathophysiology.     

Supplementation of omega-3 fatty acids in parenteral nutrition beneficially alters phospholipid fatty acid pattern

BACKGROUND: The clinical safety and the uptake of omega-3 polyunsaturated fatty acids (PUFA) into the serum phospholipids and erythrocyte membranes after administration of fish-oil-supplemented parenteral nutrition (PN) was investigated in colorectal surgical patients. METHODS: Forty patients undergoing colorectal surgery (n = 40) and with an indication for PN were enrolled in a prospective, double-blind, randomized study to receive an omega-3 PUFA-supplemented 20% lipid emulsion (Lipoplus; B. Braun Melsungen, Melsungen, Germany; test group, n = 19) for 5 days postoperatively. The control group received a standard 20% fat emulsion (Lipofundin MCT/LCT, B. Braun Melsungen, Melsungen, Germany, control group, n = 21). Clinical outcome parameters and safety were assessed by means of adverse events recording clinical parameters and hematologic analyses. The contents of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as arachidonic acid (AA), in phospholipid fractions in plasma and in erythrocytes were analyzed preoperatively, on postoperative days 1, 6, and 10 using liquid gas chromatography. RESULTS: Both fat emulsions were well tolerated, and none of the adverse events was considered to be related to treatment. Postoperative infectious complications occurred in 4 patients of the omega-3 PUFA group vs 7 patients in the control group. As compared with the control group, the omega-3 PUFA group had significantly increased levels of EPA in the membranes of the erythrocytes in postoperative day 6 (2.0% +/- 0.9% vs 0.8% +/- 0.5% fatty acid methyl esters, [FAME]) and postoperative day 10 (2.1% +/- 0.8% vs 0.9% +/- 0.7% FAME, p < .05). Also, the EPA levels in the serum phospholipids were significantly higher than in the control group on the same postoperative days (7.0% +/- 2.6% vs 1.3% +/- 0.8% and 3.6% +/- 1.0% vs 1.0% +/- 0.4% FAME, p < .05). The DHA levels in the serum phospholipids were significantly higher in the omega-3 PUFA group compared with the control on postoperative days 6 and 10 (11.8% +/- 1.9% vs 8.4% +/- 1.5% and 11.2% +/- 1.6% vs 8.5% +/- 1.4% FAME, p < .05). AA levels were not significantly different in the both groups. CONCLUSIONS: Omega-3-fatty-acids-supplemented fat emulsions for parenteral administration are safe and very well tolerated. This study demonstrates that parenteral administration of omega-3-PUFA-enriched fat emulsions leads to increased incorporation of EPA and DHA into phospholipids in serum and erythrocytes, whereas AA levels remain unchanged. Thus, postoperative parenteral administration of omega-3-PUFA-enriched lipid emulsions could have an impact on the postoperative inflammatory response after abdominal surgery and could be used in standard postoperative care when PN is indicated.