Quality of emergence from anesthesia and incidence of vomiting with remifentanil in a pediatric population.

We conducted a randomized trial to compare the incidence of vomiting and the quality of emergence from anesthesia associated with the use of remifentanil versus a nonopiate. It was expected that remifentanil would provide smoother emergence from anesthesia with a comparably low rate of vomiting. The study sample consisted of 115 pediatric patients undergoing dental restoration and extraction who were randomly assigned to the nonopiate or remifentanil groups based on their hospital admission numbers. The nonopiate patients received sufficient desflurane to prevent movement, typically 7%-9%. The remifentanil group received remifentanil 0.2 microg x kg(-1) x min(-1) and enough desflurane to prevent movement, typically 3.2%-3.6%. A trained postanesthesia care unit nurse, blinded to the anesthetic technique, assessed the quality of emergence and incidence of vomiting. Sixty-three patients received remifentanil and 52 received the nonopiate. The groups were not significantly different in either quality of emergence or incidence of vomiting. Remifentanil provided results comparable to a nonopiate with no increase in emesis. IMPLICATIONS: A randomized, controlled clinical trial of 115 patients undergoing dental restoration indicated that an anesthetic technique using remifentanil provided quality of emergence comparable to and no greater incidence of vomiting than a nonopiate technique.     

Length changes of the hamstrings and adductors resulting from derotational osteotomies of the femur.

Derotational osteotomies of the femur are frequently performed to treat persons with cerebral palsy who walk with excessive internal rotation of the hip. However, whether these procedures stretch or slacken the surrounding muscles appreciably is unknown. Determination of how muscle lengths are altered by derotational osteotomies is difficult because the length changes depend not only on the osteotomy site and the degree of derotation, but also on the anteversion angle of the femur and the rotational position of the hip. We have developed a three-dimensional computer simulation of derotational osteotomies, tested by anatomical experiments, to examine how femoral anteversion, hip internal rotation, and derotation affect the lengths of the semitendinosus, semimembranosus, biceps femoris long head, adductor longus, adductor brevis, and gracilis muscles. Simulation of derotational osteotomies at the intertrochanteric, subtrochanteric, or supracondylar levels decreased the origin-to-insertion lengths of the hamstrings and gracilis in our model by less than 8 mm (1.8%). Hence, the lengths of the hamstrings and gracilis are not likely to be altered substantially by these procedures. The origin-to-insertion lengths of the adductor longus and adductor brevis decreased less than 4 mm (1.9%) with subtrochanteric correction in our model, but the length of adductor brevis increased 8 mm (6.3%) with 60 degrees of intertrochanteric derotation. These muscles are also unlikely to be affected by derotational osteotomies, unless a large degree of intertrochanteric derotation is performed.     

THE PROPHYLACTIC AND THERAPEUTIC PROPERTIES OF THE ANTITOXIN FOR BACILLUS WELCHII

1. It has been possible to confer on guinea pigs a passive immunity of about 2 weeks'' duration to Bacillus welchii toxin through a protective administration of the antitoxin. 2. Guinea pigs which bad received a prophylactic dose of Bacillus welchii antitoxin exhibited pronounced resistance to infection with the virulent bacilli for a period of 12 days. 3. Established infections in guinea pigs with Bacillus welchii have been arrested and controlled by treatment with the antitoxin. 4. The opinion has been expressed that it will be possible to prevent Bacillus welchii infection in man through the prophylactic use of the antitoxin and developed cases of the infection may be controlled by therapeutic injections of the same agent.     

Positive- and negative-acting promoter sequences regulate cell type-specific expression of the rat synapsin I gene.

The phosphoprotein synapsin I is expressed exclusively in neuronal cells. We are interested in elucidating the promoter sequences involved in cell type-specific expression of the synapsin I gene. The PC12 cell line expresses the 3.4 kb and 4.5 kb synapsin I mRNAs and is used to analyze cell type-specific gene expression. A series of deletion fragments of the rat synapsin I gene promoter were fused to the promoterless reporter gene encoding bacterial chloramphenicol acetyltransferase (CAT) for transfection analysis in PC12 cells and in HeLa cells, which do not express the gene. A -349 bp to +110 bp rat synapsin I promoter fragment contains a positive regulator, shown to be 33-times more active in PC12 cells than HeLa cells. Transfection of reporter plasmids containing up to 4.4 kb of rat synapsin I gene promoter sequences exhibit significantly reduced CAT activity in PC12 cells. The reduction in CAT expression was attributed to a negative regulator located between -349 bp and -1341 bp in the rat synapsin I promoter. Our results suggest that both positive and negative-acting sequence elements regulate cell type-specific expression of the rat synapsin I gene.     

Posttraumatic ulnar subluxation of the extensor tendons: a reconstructive technique

Ulnar subluxation of the extensor digitorum communis over the metacarpal head can compromise the function of the extensor mechanism to the affected digit. Extensor displacement can be posttraumatic, developmental, congenital, or caused by arthritis of the metacarpophalangeal joint. A tendon centralizing procedure was performed on five digits in three patients who had posttraumatic ulnar subluxation of the extensors at the metacarpophalangeal joint after conservative management failed. No recurrences of subluxation have been noted in this series, and all patients have regained full range of motion.     

Evaluating an educational approach to improve pain assessment in hospitalized patients

Pain assessment is a multifaceted process. A common assumption is that all nurses have the same baseline knowledge about pain, a potentially erroneous assumption that influences clinical practice. Nurses have varied experiences in education and pain management. This article describes a research project conducted by the hospital's clinical nurse specialist group to evaluate the effects of a nursing education program on pain assessment and pain management of hospitalized patients in an 841-bed academic medical center.     

Management strategies to meet the core heart failure measures for acute decompensated heart failure: a nursing perspective

Despite enormous advances in the medical management of heart disease, heart failure (HF) persists as a leading cause of hospitalization in our elderly. In 2001, the American Heart Association and the American College of Cardiology published Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease. The guidelines proactively responded to a growing body of evidence confirming that comprehensive risk factor management and risk reduction improve quality of life and survival, while reducing recurrent cardiovascular events. In spite of the well-crafted, comprehensive HF guidelines, morbidity, mortality, and hospital readmission rates for acute decompensated heart failure remain high, and adherence to HF guidelines is not always optimal. The Joint Commission has implemented a number of quality care performance indicators based on the Guidelines for Secondary Prevention; among them are the Core HF Measures for hospitalized HF patients. The Core HF Measures are endorsed by the Center for Medicare and Medicaid and has been adopted as a national benchmark for measurement and public reporting of healthcare performance and for Medicare payments (Joint Commission). The implementation and monitoring of Core HF Measures has prioritized attention toward patient education and risk factor modification to prevent future hospitalization. Critical care nurses are on the frontline to champion uptake and adherence of Core HF Measures. The purpose of this article is to highlight the critical component that nursing care, guided by the Core HF Measures, can offer to improve the quality of patient care in acute decompensated heart failure.