Intra-articular (IA) catheter administration of postoperative analgesics. A new trial design allows evaluation of baseline pain,demonstrates large variation in need of analgesics,and finds no analgesic effect of IA ketamine compared with IA saline

All previous studies of intra-articular (IA) analgesic drugs for postarthroscopy pain have administered test-drugs at the end of the arthroscopic procedure, before any baseline pain could be assessed. Assay sensitivity has often not been documented or has been assumed to be present if a placebo control group had significant pain during the observation period. We present an improved study design employing an IA catheter for test-drug administration only in patients with moderate-to-severe baseline pain within 2h postoperatively. Using this technique we explored the incidence of moderate-to-severe pain and possible predisposing factors for pain through a close follow-up of all patients. The study incorporated an explanatory study of IA ketamine. A double-blind, double-dummy technique was used. Summed pain intensity differences 0-120 min after test medication was the primary outcome variable. Of 77 patients assessed for inclusion, only 45 had moderate or severe pain. Significantly more women (78%) than men (45%) had moderate-to-severe pain (P<0.005). Those not included continued to have no or mild pain and consumed less rescue analgesics than those who had high baseline pain. Mean baseline pain in the patient group with moderate or severe pain was 50mm on a 0-100 m visual analogue scale (VAS) (SD=15.1)(n=45). Mean VAS in the patient group with no or mild pain was 7.5mm (SD=8.7)(n=32).The new method for IA analgesic trials solves the problem with undesirable inclusion of patients with no or mild pain. We observed rapid onset and significant pain relief after IA injection of 10 ml saline with or without ketamine 10mg, but no difference between these two test medications. Intra-muscular ketamine 10mg showed significantly better early pain relief, global evaluation, and longer time to rescue analgesic, compared with IA ketamine 10mg.     

Post-traumatic stress reactions among individuals with visual impairments: a systematic review

Purpose: To conduct a systematic review of post-traumatic stress reactions among individuals with visual impairment (VI).

Materials and methods: Qualitative and quantitative studies were identified through searches in MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Libraries. The literature search was limited to humans, of English and Scandinavian languages and publication year between 1980 and 2017. Study quality was assessed for all the included studies and extracted data were synthesized using narrative analysis.

Results: Of 4235 records identified through literature search, eleven were included in the analyses. Results from the qualitative studies illustrated multiple physical, behavioral, emotional, and cognitive manifestations of trauma. Four out of five quantitative studies showed that various types of potentially traumatic events were significantly associated with mental health adversities (p?<?0.05). The prevalence of post-traumatic mental disorders was 4–21.2% for depression, 0.9% for dysthymia, and 32% for substance misuse. The quality of the reviewed studies was considered low to moderate.

Conclusion: Traumatic experiences appear to have a great impact on the mental health in people with visual impairment (VI) and these results highlight their need for mental health care. Future studies with higher methodological rigor are recommended.

• Implications for rehabilitation

• Visual impairment entails a greater susceptibility to some types of potentially traumatic events, especially threats in everyday life. This calls for a greater emphasis on safe community environments and universal design in public spaces.

• In rehabilitation after serious accidents or potentially traumatic events, professionals working with people with vision impairment should be aware of the different manifestations of post-traumatic stress responses and that some stress responses may cause additional disability.

• The high prevalence of traumatic events and their impact on mental health in individuals with visual impairments highlights a need of mental health care.

     

Laparoscopic pyloromyotomy is both safe and effective in a district hospital

INTRODUCTION: Functional operations of the gastrointestinal tract are ideal indications for minimal-access surgery. The aim of this paper was to assess the safety and potential benefits of the laparoscopic Ramstedt pyloromyotomy using the experience of a single surgeon in a district general hospital. METHODS: 90 consecutive infants underwent pyloromyotomy: 35 open procedures and 55 laparoscopic procedures. This is a retrospective study but the operative data of the laparoscopic group were collected prospectively. RESULTS: There were no differences in demographic data between the groups. The open group had a shorter mean operating time, 22.14 min, than the laparoscopic group, 26.04 min (p = 0.022). There was no significant difference in the time to full feed between the two groups (p = 0.076). 62.9% of the infants in the open group vomited compared with only 43.4% in the laparoscopic group (p = 0.058). The laparoscopic group had shorter postoperative stay, 62.33 hours, compared to 91.89 hours (p = 0.001). There was one reoperation in each group: for complete wound dehiscence in the open group and for incomplete myotomy in the laparoscopic group. CONCLUSIONS: Laparoscopic pyloromyotomy (LPM) is as safe as the open procedure and has the potential benefits of shorter hospital stay and improved cosmesis.     

Early detection of regional myocardial ischemia in ex vivo piglet hearts: MR imaging with magnetization transfer

The effects of regional myocardial ischemia and reperfusion on magnetization transfer (MT) contrast were investigated in an ex vivo perfused piglet heart model. The extent of the ischemic area was defined with perfusion magnetic resonance (MR) studies performed with use of extracellular contrast agents. Relative MT contrast was calculated for a total of 106 regions of interest in nine hearts. In the areas defined as being severely ischemic in the perfusion studies, a small but significant increase in the MT contrast of 18% ± 9 (standard deviation) (n = 35) was found as early as 10 minutes after the start of ischemia. This contrast difference was reduced to 11% ± 10 after 2 hours of total occlusion. The contrast between normal and ischemic tissue can be explained in part by the effect of inflowing blood, which leads to changes in both equilibrium magnetization and the apparent T1 of the perfused tissue. However, theoretical estimation suggests that these flow-related changes would produce a maximal relative change in MT contrast of approximately 4%. The most likely explanation for the rest of the observed changes is alteration in the distribution of cellular water related to the so-called intracellular edema that is known to be associated with the acute phase of myocardial ischemia.     

Immunogenicity and safety of a combination of two serogroup B meningococcal outer membrane vesicle vaccines

MenBvac and MeNZB are safe and efficacious vaccines against serogroup B meningococcal disease. MenBvac is prepared from a B:15:P1.7,16 meningococcal strain (strain 44/76), and MeNZB is prepared from a B:4:P1.7-2,4 strain (strain NZ98/254). At 6-week intervals, healthy adults received three doses of MenBvac (25 microg), MeNZB (25 microg), or the MenBvac and MeNZB (doses of 12.5 microg of each vaccine) vaccines combined, followed by a booster 1 year later. Two-thirds of the subjects who received a monovalent vaccine in the primary schedule received the other monovalent vaccine as a booster dose. The immune responses to the combined vaccine were of the same magnitude as the homologous responses to each individual vaccine observed. At 6 weeks after the third dose, 77% and 87% of the subjects in the combined vaccine group achieved serum bactericidal titers of > or = 4 against strains 44/76 and NZ98/254, respectively, and 97% and 93% of the subjects achieved a fourfold or greater increase in opsonophagocytic activity against strains 44/76 and NZ98/254, respectively. For both strains, a trend of higher responses after the booster dose was observed in all groups receiving at least one dose of the respective strain-specific vaccine. Local and systemic reactions were common in all vaccine groups. Most reactions were mild or moderate in intensity, and there were no vaccine-related serious adverse events. The safety profile of the combined vaccine was not different from those of the separate monovalent vaccines. In conclusion, use of either of the single vaccines or the combination of MenBvac and MeNZB may have a considerable impact on the serogroup B meningococcal disease situation in many countries.     

Widespread Hyperalgesia in Adolescents With Symptoms of Irritable Bowel Syndrome: Results From a Large Population-Based Study

Widespread hyperalgesia is well documented among adult patients with irritable bowel syndrome (IBS), but little is known about pain sensitivity among adolescents with IBS. We examined pain sensitivity in 961 adolescents from the general population (mean age 16.1 years), including pain threshold and tolerance measurements of heat (forearm) and pressure pain (fingernail and shoulder) and cold pressor tolerance (hand). Adolescents with IBS symptoms (Rome III criteria) had lower heat pain thresholds compared to controls after adjustments for sex, comorbid pain, and psychological distress (mean difference = –.8°C; 95% confidence interval [CI] = ?1.6 to ?.04). Similar results were found for pressure pain threshold at the shoulder (mean difference = ?46 kPa; 95% CI = ?78 to ?13) and fingernail (mean difference = –62 kPa; 95% CI = ?109 to ?15), and for an aggregate of all 3 threshold measures (z-score difference = ?.4; 95% CI = ?.6 to ?.2), though pressure pain threshold differences were nonsignificant after the final adjustments for psychological distress. No difference of pain tolerance was found between the IBS cases and controls. Our results indicate that adolescents in the general population with IBS symptoms, like adults, have widespread hyperalgesia.PerspectiveThis is the first report of widespread hyperalgesia among adolescents with IBS symptoms in the general population, with lower pain thresholds found to be independent of sex and comorbid pain. Our results suggest that central pain sensitization mechanisms in IBS may contribute to triggering and maintaining chronic pain symptoms.     

Platelet Stain Preventing Factor in Serum or Plasma -An Early Sign of Leiomyosarcoma?

A macromolecular component, platelet stain preventing factor (PSPF), possessing the capacity to prevent staining of platelets in the presence of EDTA, was found in the serum of an apparently healthy person. Two years later, leiomyosarcoma with liver metastases was diagnosed at laparatomy in that particular person. Extract from the patient's leiomyosarcoma exhibited very strong PSPF activity. The observations suggest that PSPF was synthesized in the patient's tumour and that test for PSPF may become a useful tool in early diagnosis of leiomyosarcoma.     

Prognostic Value of Renal Vein Renin Determination in Suspected Renovascular Hypertension

ABSTRACT. Surgical correction of unilateral renal artery stenosis was performed in 31 hypertensive patients. Preoperative renal vein renin ratios (RVRR) before and after dihydralazine stimulation were measured in all patients. Postoperative blood pressures were normal in 12, improved in 17 and unchanged in 2 patients. Six patients did not have renin lateralization, but all were cured or improved after surgery. RVRR was a poor predictor of the results of surgery in patients with unilateral renal artery stenosis.