Use of postoperative chest x-ray after elective adult tracheotomy

Surgeons have been creating tracheotomies since at least 124 AD, when first reported by Asclepiades (Price HC, Postma DS. Ear Nose Throat J 1983;62:44-59). Intraoperative and postoperative complications specifically associated with this procedure have been well established. The incidence of pneumothorax ranges from 0% to 17%, depending on the age group studied. To evaluate this complication, it is generally accepted that a postoperative chest film should routinely be obtained after a tracheotomy in adult patients. In adult nonemergent tracheotomies, the routine use of a postoperative chest film has a low yield for detecting a pneumothorax in patients without clinical findings of pneumothorax. To evaluate the use of postoperative chest x-ray in adult tracheotomy patients, a retrospective review of tracheotomies performed at the Boston Medical Center from January 1994 to June 1996 was undertaken. Data examined consisted of age, sex, surgical indication, urgency, operating service, intraoperative and postoperative complications, difficulty of procedure, anesthetic technique, findings on postoperative chest film, signs and symptoms of pneumothorax, and specific treatment of pneumothorax if present. In total, 250 patients were identified. The main indication for tracheostomy in this study was ventilator dependence, accounting for 77% of the procedures. A complication rate of 11.6% was encountered, with no deaths. Postoperative hemorrhage was the most common complication (3.6%). Pneumothorax was documented by chest x-ray in 3 (1.2%) patients, 1 of whom had bilateral pneumothoraces. The most common symptom of a pneumothorax was tachycardia, with 8.8% of the patients exhibiting at least 1 episode. Of the 3 cases of pneumothorax in this study, only 1 was clinically relevant and required treatment. Furthermore, the clinical signs and symptoms in this patient clearly supported the diagnosis of pneumothorax before a postoperative chest film was obtained. Thus postoperative chest radiographs did not change the treatment or outcome of any of the patients undergoing a tracheotomy. This suggests that postoperative chest x-ray after adult tracheotomy is not required in routine cases. Chest radiographs should be obtained after emergent procedures, after difficult procedures, or in patients exhibiting signs or symptoms of pneumothorax.     

INTRARECTAL LIDOCAINE DURING TRANSRECTAL PROSTATE BIOPSY: RESULTS OF A PROSPECTIVE DOUBLE-BLIND RANDOMIZED TRIAL

PURPOSE: Recent reports have indicated the benefit of anesthesia during prostate biopsy. To assess this finding objectively we performed a prospective randomized double-blind study to compare patient pain with and without local anesthesia during transrectal ultrasound guided prostate biopsies. MATERIALS AND METHODS: Between August 2000 and March 2001, 108 men undergoing transrectal ultrasound guided biopsy of the prostate were randomized in double-blind fashion to receive intrarectal 2% lidocaine gel or intrarectal lubricant alone. No patient received pre-procedure narcotics or sedation. Pain associated with biopsy was determined using a horizontal linear visual analog pain scale. Pain scores in the 2 treatment groups were compared and possible predictors of increased pain were examined. RESULTS: The 2 groups were similar in demographic characteristics. There was no significant difference in pain score in the 2% lidocaine and lubricant alone groups (28.3 versus 28.9 mm., p = 0.88). Previous biopsy, time since previous biopsy, physician, number of biopsies and prostate volume did not correlate with pain score, while age correlated negatively with the score (r = -0.27, p = 0.005). A single complication involving a vasovagal episode resolved spontaneously. CONCLUSIONS: Intrarectal lidocaine gel provides no significant therapeutic or analgesic benefit compared with lubricant alone for transrectal ultrasound guided biopsy of the prostate. In younger patients more discomfort is associated with this procedure.     

Why Is Catheter Ablation Less Successful than Surgery for Treating Ventricular Tachycardia that Results from Coronary Artery Disease?

Nearly 80% of patients with coronary artery disease who have map-directed surgery for control of ventricular tachycardias require no drug therapy to prevent recurrences, while fewer than 50% of patients undergoing catheter ablation have similar outcomes. Catheter ablation will fail if arrbythmogenic sites are incompletely ablated by lesions that are too small or too far away from the reentrant pathway or if all arrbythmogenic sites are not identified. The underlying assumptions used to guide site selection are that: (a) ventricular tachycardias arise from reentrant mechanisms; (b) monomorphic ventricular tachycardias with similar QRS morphologies arise from the same pathway; (c) the ventricular tachycardia initiated during the procedure represents the patient's spontaneous arrhythmia; (d) the endocardial site that should be ablated can be identified from cardiac activation maps produced during induced ventricular tachycardia or from ancillary techniques; and (e) the patient has only one or two reentrant pathways. Relying on incorrect assumptions may account for the difference in success rates. Patients may have similar appearing ventricular tachycardias that arise from different pathways, and the entire thin layer of viable tissue between the infarct and the endocardium may contain many reentrant pathways. Some ventricular tachycardias may arise from the myocardium away from the endocardium, while others may arise from the epicardium. Small lesions may not be large enough to eliminate all possible reentrant pathways. Catheter ablation may be less successful because the lesions are inadequate, the assumptions guiding the selection of arrhythmogenic tissue are incorrect, or all arrhythmogenic sites are not identified. The primary reason catheter ablation is less successful than surgery in the treatment of ventricular tachycardias is that catheter ablation does not ablate as much tissue as is removed by surgery. The success rate of catheter ablation probably can be improved if the amount of tissue ablated is increased.     

Purification and mass spectrometry-based sequencing of yellow mustard (Sinapis alba L.) 6 kDa proteins Identification as antifungal proteins

Three basic proteins, M1, M2A and M2B, that are substrates for plant Ca²⁺ -dependent protein kinase (CDPK) were purified from seeds of yellow mustard (Sinapis alba L.) by a protocol involving batchwise chromatography on carboxymethylcellulose (CM52), cation-exchange HPLC on an SP5PW column and reversed-phase HPLC on a C18 column. The complete amino-acid sequences of these proteins have been determined employing Edman sequencing and electrospray ionization mass spectrometry (ESMS) applied to the proteins and their tryptic and chymotryptic fragments. M1 (observed mass 5676.8 ± 1.0 Da; calculated mass 5677.57 Da), M2A (observed mass 5704.8 ± 0.8 Da; calculated mass 5704.60 Da) and M2B (observed mass 5839.5 ± 1.2 Da; calculated mass 5838.78 Da) have been identified as γ-thionins, which are potent antifungal proteins. M1, M2A and M2B are phosphorylated by plant CDPK on Ser residues, the site of phosphorylation on M2A being S⁸ as directly confirmed by Edman sequencing and mass spectrometry of the chymotryptically generated phosphopeptide CQRPS(HPO₃)GTW¹¹. M1 and M2A have apparent calmodulin (CaM) antagonist activity with IC₅₀ values of 4.8 ± 1.3 μM and 5.5 ± 1.5 μM, respectively, for inhibition of CaM-dependent myosin light chain kinase (MLCK). M2A and/or M2B interacts with dansyl-CaM in both the presence and absence of calcium. © Munksgaard 1996.     

Possible Influence of Physical Activity on Musculoskeletal Symptoms of Menopausal and Postmenopausal Women

A theoretical framework from which nurses might operate to explain the cause of bone, joint, and muscle pains suffered by menopausal women and to identify behaviors that will prevent and/or reduce the musculoskeletal pathologies and symptomatology associated with decreased estrogen production is presented. Also, recommendations for future research are offered.     

SPONTANEOUS PERFORATION OF THE COMMON HEPATIC DUCT: A NEW PRESENTATION

A case is reported of spontaneous perforation of the common hepatic duct in a patient presenting with a six-day history of painless jaundice and a one-day history of nausea and vomiting. An endoscopic retrograde cannulation of the common bile duct revealed a large stone in the distal end of the grossly dilated biliary tree. At operation a large collection of bile, sealed off by omentum, was found beneath the liver. A perforation was present in the common hepatic duct close to its junction with the cystic duct.     

EFFECT OF ADRENALINE ON VENOUS PLASMA CONCENTRATIONS OF BUPIVACAINE AFTER INTERPLEURAL ADMINISTRATION

Bupivacaine 2.5 mg kg^–1 (0.5 ml kg^–1 of 0.5% solution),with or without adrenaline 5 µg ml^–1, was administeredby interpleural injection to 12 patients after elective cholecystectomy.Non-compartmental analysis indicated that the addition of adrenalinehad no effect on total body clearance, apparent volume of distributionat steady state or elimination half-life of bupivacaine. However,peak plasma concentrations were lower in the adrenaline group(mean (SD) [range]: 2.57 (0.61) [1.52–3.11] VS 3.22 (0.27)[2.84–3.53] µg ml^–1, P < 0.05) and thetime to maximum concentration was delayed (median [range]: 25[15–30] VS 15 [10–20] min, P < 0.05). Analgesiawas variable and no differences were detected between the twogroups. The addition of adrenaline appears prudent to minimizepossible bupivacaine toxicity.