Cast immobilization in bayonet position versus reduction and pin fixation of overriding distal metaphyseal radius fractures in children under ten years of age: a case control study

PurposeCompletely displaced distal radius fractures in children have been traditionally reduced and immobilized with a cast or pin fixed. Cast immobilization leaving the fracture displaced in the bayonet position has been recently suggested as a non-invasive and effective treatment alternative. This is a pilot comparative study between reduction and no reduction.MethodsWe assessed subjective, functional and radiographic outcome after a minimum 2.5-year follow-up in 12 children under ten years of age who had sustained a completely displaced metaphyseal radius fracture, which had been immobilized leaving the fracture in an overriding position (shortening 3 mm to 9 mm). A total of 12 age-matched patients, whose similar fractures were reduced and pin fixed, were chosen for controls. ResultsAt follow-up none of the 24 patients had visible forearm deformity and the maximal angulation in radiographs was 5° Forearm and wrist movement was restored (< 10° of discrepancy) in all 24 patients. Grip strength ratio was normal in all but three surgically treated patients. All patients had returned to their previous activities. One operatively treated boy who was re-operated on reported of pain (visual analogue scale 2).ConclusionThe results of this study do not demonstrate the superiority of reduction and pin fixation over cast immobilization in the bayonet position of closed overriding distal metaphyseal radius fractures in children under ten years with normal neurovascular findings.Level of evidenceIII     

Analysis of the seasonal pattern in suicide

BACKGROUND: Suicide has been attributed to social and psychological factors but also to geophysical effects. Of the latter, changes in solar radiation and geomagnetic activities may contribute to the frequency and the seasonal pattern of suicides. METHODS: We studied with a population-based, nationwide analysis all the individuals who committed suicide (n=27,469) in Finland during the period of 1979 to 1999. The daily data on the number of suicides, and the mean and maximum levels of geomagnetic activity were compiled and modelled with Poisson regression using the number of inhabitants in each province as the denominator. Time series analysis of monthly numbers of suicides was carried out using a seasonal-trend decomposition procedure. RESULTS: There was a strong seasonal effect on suicide occurrence (P<0.00001), the risk of suicide being greatest in spring. The seasonal effect was most pronounced when the number of suicides was relatively low. High levels of solar radiation activity were associated with the increased risk of suicide (P=0.00001), but the effect of geomagnetic activity was weak. LIMITATIONS: No individual data on alcohol consumption or mental disorders were available. CONCLUSIONS: Suicide occurrence varies markedly by season and needs attention where prevention is concerned.     

Developmental transition in plasticity properties of differentiating astrocytes: age-related biochemical profile of plasminogen activators in astroglial cultures

Plasminogen activator (PA) is a key enzyme in control of the cascade of extracellular proteolytic activities, proteases that degrade the extracellular components. Mammalian cells produce two molecular forms of PA, the urokinase type (u-PA) and the tissue type (t-PA); the u-PA type enzyme regulates cell migration/invasion and related tissue plasticity events. Thus, these plasticity properties of cells are defined by their PAs' biochemical profiles. The capacity of the differentiating glial cells of the central nervous system (CNS) to express and regulate the two types of PA activities has been examined as a function of cell age in culture. Results of the study suggest that only the immature astrocyte is endowed with these plasticity properties. Differentiating heterogeneous rat glial cells in culture express PA activity. Astroglia were identified as the primary source for the glial PA activity, as no PA activity was detected in the purified oligodendroglia. Cellular PA activity levels of differentiating rat and mouse astroglia are developmentally regulated. The specific activity of PA reached its highest level in rat astroglia at a cell age corresponding to 20-32 postnatal days (P20-P32) and in mouse astroglia at P8-P14; thereafter, this declined (three- to fourfold decrease) within 2 weeks to a low value. At comparable ages (P0-P35), the magnitudes of the PA specific activities of the differentiating rat astroglia and of the developing cerebrum, the tissue from which these cells were purified, were similar. Differentiating rat astroglia produce u-PA and t-PA, the cellular content of both is developmentally regulated, and the u-PA form is only found in the immature cells. u-PA is the predominant form in the immature astrocyte until age P13. Both forms are found in cells at ages P14-P30, and at later stages u-PA disappears while the t-PA type persists as the sole form. After 3 more weeks neither of the PA types was detected. Astroglia express also PA inhibitory activity; the rat astroglial PA inhibitor (PAI) seemed to be identical to PAI-1, one of the known types of PAIs. Stimulation of astroglial proliferation by their subculturing in contrast to Schwann cells did not lead to an increase; rather, beyond a certain cell age (P13) it resulted in a threefold irreversible decline in the PA specific activity of the daughter cells. It has been established that various biochemical properties of CNS mature glia appear on schedule with cell age in culture, thus defining "mature"glia in vitro.(ABSTRACT TRUNCATED AT 400 WORDS)     

Dopamine transporters increase in human brain after alcohol withdrawal

Dopaminergic transmission has been suggested to be a main mechanism mediating reinforcement, withdrawal and craving associated with alcohol addiction. We measured here striatal dopamine (DA) transporter binding from 27 alcoholics within 4 days after cessation of prolonged heavy drinking and after a 4-week period of abstinence with single photon emission computed tomography (SPECT) using a cocaine analogue, iodine-123-beta-CIT. Controls were 29 healthy volunteers. Blind quantitative analyses of the SPECT data revealed markedly lower DA transporter binding in alcoholics on admission for detoxification than in the non-alcoholic controls. After a 4-week period of abstinence DA transporter binding increased significantly in the alcoholics (P<0.0001) reaching the levels of the healthy controls. The most substantial recovery in DA transporter binding occurred during the first 4 days of abstinence. The data indicate that prolonged heavy drinking decreases DA transporter binding and disturbs synaptic dopamine transport. This may sensitize alcoholics to dopaminergic transmission, which may lead to early relapse after ethanol withdrawal.     

Dopamine transporter and D2-receptor density in late-onset alcoholism

Rationale: Late onset type 1 alcoholism has been suggested to be associated with an underlying dopaminergic defect. Therefore, it is relevant to study both postsynaptic D₂-receptor and presynaptic dopamine transporter (DAT) densities among alcoholics. Objective: We investigated DAT densities, along with striatal and extrastriatal dopamine D₂-receptor densities, in nine non-violent late-onset male alcoholics, who had no major mental disorder nor antisocial personality disorder (ASPD), and nine healthy controls. Methods: [¹²³I]PE2I and [¹²³I]epidepride were used in SPECT imaging. Results: DAT occupancy ratios (striatum/cerebellum) were significantly lower among alcoholics than in controls. Extrastriatal D₂-receptor occupancy ratios (temporal pole/cerebellum) were not significantly different between the groups. Conclusions: Striatal presynaptic DAT densities are decreased among type 1 alcoholics, and this finding is not associated with recent alcohol abuse. Received: 22 March 1999 / Final version: 25 June 1999     

Striatal dopamine transporter density in major depression

Rationale: There are no previous data available regarding [¹²³I]β-CIT binding to the dopamine transporter sites in the basal ganglia in depressed patients. Objective: The present study tested the hypothesis that the brain DAT density in depressed patients is lower than that in matched healthy controls. Methods: Fifteen drug-naive outpatients with major depression and 18 healthy controls were investigated using single photon emission computerized tomography (SPECT) with a high-affinity dopamine transporter specific radioligand, ¹²³I-labeled β-CIT (2β-carbomethoxy-3β-(4-iodophenyl)-tropane). Results: We found a significantly higher [¹²³I]β-CIT uptake in both sides of the basal ganglia in patients with major depression than in the controls (Mann-Whitney U-test, P = 0.002 on the right and P = 0.003 on the left). Conclusions: The radioligand uptake reflecting the DAT density was significantly higher among the patients than in the controls. This finding is unexpected, since it is generally believed that monoaminergic neurotransmission is lower in depression, and therefore it could be assumed that a reduction in dopamine transmission would lead to secondary down-regulation of DAT density. However, it is possible that up-regulation of the DAT may be the primary alteration, which leads to lower intrasynaptic dopamine concentration and to lower dopamine neural transmission. Received: 20 October 1998/Final version: 25 January 1999     

A comparison of remifentanil and alfentanil for use with propofol in patients undergoing minimally invasive coronary artery bypass surgery

Most patients undergoing minimally invasive direct coronary artery bypass surgery can be awakened and tracheally extubated in the operating room. We have compared two techniques of total IV anesthesia in this patient population: 30 patients (aged 44 to 74 yr; 24 male) premedicated with temazepam were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 2 microg/kg or with alfentanil 40 microg/kg, with propofol, and maintained with remifentanil at 0.25 or 0.5 microg x kg(-1) x min(-1) or alfentanil at 0.5 or 1 microg x kg(-1) x min(-1). The stable maintenance infusion rate of propofol was adjusted for age. Times to awakening and tracheal extubation were recorded. Postoperatively, IV morphine provided by patient-controlled analgesia was used for 48 h. Times to awakening and tracheal extubation (mean +/- SD) were shorter (P < 0. 01) in patients receiving remifentanil, and interpatient variations in times to awakening and tracheal extubation smaller (awakening 25 +/- 7 vs 74 +/- 32 min, and extubation 27 +/- 7 vs 77 +/- 32 min). Analysis of variance revealed that postoperative consumption of morphine was dependent on both the intraoperative opioid and the time elapsed after surgery (P < 0.05): patient-controlled analgesia morphine use during the first 3 h after awakening was more in patients receiving remifentanil (P < 0.01). Implications: Recovery of patients undergoing Minimally Invasive Direct Coronary Artery Bypass Surgery is significantly shorter and more predictable after total IV anesthesia with remifentanil-propofol than with alfentanil-propofol, which may be important if the goal is that patients will be awakened and tracheally extubated in the operating room.     

The effect of erythromycin, fluvoxamine, and their combination on the pharmacokinetics of ropivacaine

We studied the effect of fluvoxamine and erythromycin on the pharmacokinetics of ropivacaine in a double-blinded, randomized, four-way cross-over study. Eight healthy volunteers ingested daily 1500 mg erythromycin for 6 days, 100 mg fluvoxamine for 5 days (Days 2-6), both erythromycin and fluvoxamine, or placebo. On Day 6, each subject received a single dose of 0.6 mg/kg ropivacaine IV over 30 min. Ropivacaine, 3-hydroxyropivacaine, and 2',6'-pipecoloxylidide in venous plasma and urine samples were measured for up to 12 h and 24 h, respectively. Fluvoxamine increased the area under the drug plasma concentration-time curve (AUC) of ropivacaine 3.7-fold (P: < 0.001), prolonged the elimination half-life (t(1/2)) from 2.3 to 7.4 h (P: < 0.01), and decreased the clearance by 77% (P: < 0.001). Erythromycin alone had only a minor effect on the pharmacokinetics of ropivacaine. However, when compared with fluvoxamine alone, the combination of fluvoxamine and erythromycin further increased the area under the drug plasma concentration-time curve and t(1/2) of ropivacaine by 50% (P: < 0.01). We conclude that inhibition of CYP1A2 by fluvoxamine considerably reduces elimination of ropivacaine. Concomitant use of fluvoxamine and CYP3A4 inhibitor erythromycin further increases plasma ropivacaine concentration by decreasing its clearance. Implications: Clinicians should be aware of the possibility of increased toxicity of ropivacaine when used together with inhibitors of CYP1A2. Concomitant use of CYP1A2 and CYP3A4 inhibitors further increases ropivacaine concentration.     

Gamma scintigraphic evaluation of the fate of hydroxypropyl methylcellulose capsules in the human gastrointestinal tract

The fate (movement and disintegration) of hard novel hydroxypropyl methylcellulose (HPMC) two-piece capsules in the human gastrointestinal tract was investigated using a gamma scintigraphic imaging method. Two different prolonged-release formulations without an active ingredient were used. The capsules contained different viscosity grades of HPMC powder (HPMC K100 and HPMC K4M). The aim was to determine the main reason why the pharmacokinetic profiles of model drugs change when the diluent was changed to a higher viscosity grade. The results were compared with our previous pharmacokinetic studies with corresponding capsules containing metoclopramide hydrochloride or ibuprofen as a model drug. The first observation was that the HPMC capsules had a tendency to attach to the oesophagus. Therefore, it is recommended that the HPMC capsules as well as gelatine capsules be taken with a sufficient amount of water (150–200 ml) in an upright position and maintaining the upright position for several minutes. The viscosity grade of the HPMC did not affect the transit times of the capsules in the GI tract. The major differences between the two formulations were the complete disintegration times of the capsules and the spreading of the capsules to the large intestine. Most of the HPMC K100-based capsules were completely disintegrated during the 8 h study, whereas the HPMC K4M-based capsules still exhibited plug formations in the large intestine. Also the HPMC K100-based capsules spread better to the ascending colon than the HPMC K4M-based capsules. The faster disintegration of the HPMC K100-based capsules explains the differences in the pharmacokinetic profiles of the model drugs between the HPMC K100- and K4M-based capsules in our previous studies. The main absorption site of the drugs from the capsules studied here is probably the large intestine when taken in a fasting state.     

Tracheal and laryngotracheal resections and reconstructions—a single-centre experience

BackgroundSurgical resection has proven to be the most effective long-term treatment in managing airway stenoses and has shown to decrease the risk of tumor recurrence and mortality in patients with tumor infiltration to the airways. However, there are only a few Nordic reports on the results of a tracheal resection (TR) and cricotracheal resection (CTR). This study aimed to evaluate the volume and short-term outcome of TR and CTR at our institution.MethodsRetrospective review of patients who underwent TR or CTR between 2004 and 2019 at the Helsinki University Hospital (Helsinki, Finland).ResultsForty-four patients were included, of which 21 (47.7%) underwent surgery for a tumor, whereas 23 (52.3%) were operated for a benign stenosis. The most common tumor type was thyroid carcinoma with tracheal invasion (15.9%). The distance between the upper margin of the stenosis or tumor infiltration and the vocal cords was in median 3 [interquartile range (IQR), 2–5] cm and the median length of resection 2.5 (IQR, 2–3.5) cm. Overall success rate was 75% (no need for reoperation or postoperative intervention). Complications occurred in 20 (45.5%) patients, of which 10 patients were operated for a tumor, and 10 for a benign stenosis.ConclusionsTracheal and CTRs were effective in treating tracheal and subglottic stenoses with variable etiology. However, complications were common especially following cricotracheal tumor resections. These procedures show a clear need for further centralization due to their complex nature and should therefore be performed primarily at institutes with highly experienced multi-professional teams.