Lateral recumbent head-down posture for epidural catheter insertion reduces intravascular injection

PURPOSE: The unintentional and unrecognized cannulation of an extradural vein is a potentially serious complication of an epidural anesthetic. The present study was undertaken to assess the incidence of blood vessel puncture related to epidural catheterization performed in three different body positions. METHODS: The study was conducted in 900 (three groups of 300) obstetric patients undergoing continuous epidural analgesia during their labour and who were randomly allocated to three groups. Epidural catheterization was performed with patients in the sitting, lateral recumbent horizontal, or lateral recumbent head-down position. RESULTS: There was a lower incidence of vessel cannulation when this procedure was performed in the lateral recumbent head-down position (2%) than in the lateral recumbent horizontal (6%) and in the sitting position (10.7%). CONCLUSION: Adoption of the lateral recumbent head-down position for the performance of lumbar epidural blockade, in labour at term, reduces the incidence of lumbar epidural venous puncture.     

How long do intrinsic and extrinsic visual cues take to exert their effect on the perceptual upright?

We determined the amount of time it took for intrinsic and extrinsic visual cues to determine the perceptual upright. The perceptual upright was measured using a probe, the identity of which depended on its perceived orientation (the Oriented Character Recognition Test). A visual background that filled the field of view and contained both intrinsic and extrinsic cues was presented in different orientations and for presentation times of between 50 and 500 ms followed by a mask. The contribution of each class of cue was identified by exploiting their different degrees of ambiguity. Intrinsic cues include scene structure (e.g., walls, floor and ceiling of an indoor scene) which indicates four potential up directions, and the horizon which indicates two possibilities. Extrinsic cues, which rely on information not in the image such as a surface acting as a support structure for an object, signal the direction of up unambiguously. The contribution of each class of visual cue could thus be identified from the number of cycles its effect showed as the background was presented in all orientations round the clock. While the more high-level extrinsic cues to up exerted a larger influence on the perceptual upright than the intrinsic cues, the magnitude of each cue’s effect increased with presentation time at approximately the same rate with a time constant of about 60 ms. This finding poses a challenge for bottom-up theories of scene perception and suggests that low-level and high-level information are processed in parallel at least insofar as they indicate orientation.     

Detection of right-coronary-artery disease using stress thallium scintigraphy: Importance of considering the right ventricle

Retrospective analyses of the stress thallium studies of 51 patients with a history of previous infarctions or definite stable angina were performed in order to determine the extent of the coronary-artery disease (CAD). The results were correlated with recent coronary-angiography findings in order to assess the effect of including rightventricule (RV) visualization on the accuracy of the detection of right coronary-artery (RCA) disease, as well as the effect of graded stenosis or occlusion of the RCA and the presence of disease of the other coronary vessels on the visualization of the RV. Eight patients had normal coronary arteries. The other 43 patients had CAD, only 5 of whom had single-vessel RCA disease. With regard to the RV, 6 patients had nonvisualization, 30 had patchy visualization, and 15 had normal visualization in the stress thallium studies. Nonvisualization indicated 100% occlusion of RCA in 6 out of 6 patients. Patchy visualization indicated significant occlusion of the RCA in 25 out of 30 patients (83%), while normal visualization indicated a normal RCA in 13 out of 15 patients (86%). Normal visualization did not mean that the possibility of RCA disease could be excluded. When RV visualization data were added to LV images, the sensitivity for detecting RCA increased from 66% to 94% (P<0.05), the specificity decreased from 89% to 72% (P<0.1), and the predictive accuracy increased from 75% to 86% (P>0.1).     

Intravenous theophylline decreases post-dural puncture headaches

Post-dural puncture headache (PDPH) is a common complication of lumbar puncture. As invasive treatments for PDPH have known complications, pharmacologic management may be preferable. The aim of this study was to evaluate and to compare the efficacy of intravenous theophylline treatment for PDPH, in comparison with a placebo. We found that intravenous theophylline infusion was effective for decreasing the painfulness of PDPH compared with the control group. The mean visual analogue scale (VAS) value was 7.05+/-1.47 before the theophylline infusion and 2.88+/-2.31 after infusion. An average of 59.1% relief of pain was obtained in the group treated with theophylline infusion. The improvement in VAS in the study group was significant (p<0.001), whereas that in the control group was not (p=0.15). The mean VAS decrease after theophylline infusion was 4.17+/-2.03 in the study group and 0.41+/-0.71 in the control group; the difference in improvement between the groups was significant (p<0.001). Intravenous theophylline infusion is an easy, rapid, minimally invasive, an effective treatment for PDPH. It may be attempted in PDPH patients before invasive techniques are used. To the best of our knowledge, this is the first report on the effect of intravenous infusion of theophylline compared with a placebo in the treatment of PDPH.     

Aminoglycoside usage and monitoring in a Saudi Arabian teaching hospital: a ten-year laboratory audit

BACKGROUND AND OBJECTIVE: In 1989, a therapeutic drug monitoring service was established in Assir Central Hospital, Abha, Saudi Arabia, by the Department of Clinical Pharmacology and Therapeutics of the College of Medicine, King Saud University Abha Branch (now King Khalid University). We report a 10-year follow-up of the results of monitoring the commonly used aminoglycosides (amikacin, gentamycin and tobramycin) obtained from our adult patients on first monitoring. METHOD: Two educational seminars for doctors and nurses were conducted 6 months before the initiation of this study. Drug assay requests were made on specially designed forms. Drug dosages were determined by the attending physicians. Samples for peak and trough drug level determinations were drawn after the fourth dose. The results of first time monitoring were sent to the wards with appropriate comments for dosage modifications where indicated. RESULTS: The results for 2022 patients were analysed. Of these, 929, 899 and 194 were for amikacin, gentamycin and tobramycin, respectively. Therapeutic trough concentrations were 71.2%, 28.3% and 28.3% of patients on amikacin, gentamycin and tobramycin, respectively. A total of 8.8%, 17.6% and 11.9% had trough concentrations considered toxic for amikacin, gentamycin and tobramycin, respectively. Peak therapeutic concentrations were achieved in 31.6%, 42.3% and 39.7% of patients on amikacin, gentamycin and tobramycin. A total of 53.3% of patients on amikacin, 50.3% on gentamycin and 57.2% on tobramycin had peak serum drug concentrations in the subtherapeutic range. Toxic concentrations were noticed mainly in patients aged over 60 years and in the critically ill in the intensive care, coronary care and bums units of the hospital. CONCLUSION: To be cost-effective, intensive therapeutic monitoring of aminoglycosides in adults should continue to be monitored mainly for the old and sick patients in critical care units to optimize patient management.     

Risk factors in community-acquired urinary tract infections caused by ESBL-producing bacteria in children

In this study, risk factors were investigated in children with community-acquired urinary tract infections (UTI) caused by extended-spectrum beta-lactamases (ESBL)-producing E. coli or Klebsiella spp. One hundred and fifty-five patients were diagnosed with ESBL-positive UTI (case group) in the outpatient clinics of Hacettepe University Children’s Hospital between 1 January 2004 and 31 December 2006. A control group, 155 out of 4,105 children, was matched by age and sex among children with ESBL-negative UTI. A total of 310 patients’ files were evaluated retrospectively. As regards the symptoms of UTI, no statistical differences were seen between the two groups. Although the most frequently isolated microorganism was E. coli in both groups, Klebsiella spp. was found to be more frequent in those diagnosed with ESBL(+) UTI (p?<?0.001). Having an underlying disease and hospitalization, infections, and use of antibiotics within the last 3 months were found to be potential risk factors (p?<?0.001). With conditional logistic regression analysis, having an underlying disease and hospitalization within the last 3 months were identified as independent risk factors for ESBL(+) UTI. In conclusion, the recognition of risk factors for UTI, caused by ESBL(+) bacteria in children, may aid in the identification of high-risk cases and may enable proper management of these patients.