Local anaesthesia for fibreoptic bronchoscopy: transcricoid injection or the "spray as you go" technique?

Local anaesthesia for fibreoptic bronchoscopy should be given by a safe technique that is not unpleasant to the patient and should provide acceptable conditions for the bronchoscopist. Single injection transcricoid local anaesthesia was compared with the "spray as you go" technique in patients having day case fibreoptic bronchoscopy. Patients were randomised to receive either 100 mg lignocaine by a single cricothyroid puncture or 240 mg lignocaine instilled through the bronchoscope under direct vision. Further doses were given by the operator to both groups as required. The 30 patients receiving transcricoid lignocaine coughed less (3.56 (SD 3.1) coughs/min) than the 32 patients receiving lignocaine through the bronchoscope (5.89 (4.8)/min) despite receiving a lower total dose of lignocaine (322 (25.9) v 451 (20.9) mg). Cricothyroid puncture was not associated with any complications and was not unpleasant for the patients.     

The impact of the amended Ontario Mental Health Act (Bill 7) on patients discharging themselves from hospital against medical advice (AMA): a preliminary study

Bill 7, the most recent amendment to the Ontario Mental Health Act was introduced in December 1986. It has resulted in some major changes to the practice of psychiatry, especially in provincial hospitals. We compared patients who had discharged themselves against medical advice (AMA) during the six months before the Bill was enacted, with those who discharged themselves AMA in the 12 months following. Significantly more patients discharged themselves AMA in the post- than the pre-Bill period. The majority of these were potentially treatable, acutely ill individuals with schizophrenia or affective disorder. We argue that Bill 7 has largely failed in its objective to improve the overall "quality of care" to psychiatric patients, at least in the short term.     

Anemia and malnutrition in children at public schools in Osasco,São Paulo,Brazil

The authors studied a sample of students entering the first grade in the Osasco public school system in order to determine both the prevalence of anemia and nutritional status. Osasco is part of the Greater S o Paulo Metropolitan Area. Diagnosis of anemia was made through the hemoglobin concentration of blood from digital puncture. World Health Organization (WHO) levels were used to define anemia. Nutritional Status assessment. was made through weight/age and height/age indices, using Z score distribution and the National Center for Health Statistics (NCHS) reference levels. Prevalence of anemia was 51%. Prevalence levels varied according to the schools' geographic location: 56.9% in peripheral neighborhoods and 41.7% in central areas. Children with illiterate parents had a higher prevalence of this condition. Risk of anemia was higher for children who were over eight years of age when entering the first grade. Acute malnutrition was not found. Prevalence was higher than expected and points to the urgent need to establish an anemia control program for schoolchildren in this population.     

Clinical and alimentary history of children attending a pediatric gastroenterology outpatient clinic with functional chronic constipation and its possible complications

In order to better understand the natural history of chronic functional constipation, a questionnaire was applied to 163 children and infants, before beginning standardized treatment. Median age (range) at start was 3 mo(0-108 mo) but age at arrival at the Pediatric Gastroenterology Unit was 53 mo(2-146 mo). In 62.4% of the cases symptoms began before or up to 3 mo after cow's milk introduction and rarely around (-/+ 6 mo) toilet training. Possible complications appeared progressively, often at preschool or school age or as the first noticeable manifestation: recurrent abdominal pain (61.1%), fecal soiling (45.4%), fecal blood (35%), enuresis (23.3%), vomiting (19%), urinary infection (17.9%), urinary retention (8.6%). Abdominal distension was rarely detected on physical examination and was usually discrete. In conclusion, children attended in Botucatu begin their constipation at an early age, frequently associated with weaning,and important complications may ensue along years. This evolution should be avoided by prevention and early treatment of constipation.     

Characterization and prediction of IVF cycles generating “slow-cleaving” embryos

Purpose To characterize and predict cycles generating slowcleaving embryos in in vitro fertilization, 86 cycles were retrospectively divided into two groups (slow, n=41, and fast, n=45 according to whether the number of blastomeres per embryo on day 3 was or > than the mean of the distribution, respectively.Results Cycles generating slowcleaving embryos were treated with luteinizing hormonereleasing hormone agonist before ovarian stimulation for a shorter period (12.1±0.5 versus 15.6±1.1 days; P0.01) and had higher immaturity grade of oocyte-corona-cumulus complexes which resulted in embryos (1.6±0.1 vs 1.3±0.1; P0.05) when compared to cycles producing fastcleaving embryos. Both variables entered in a logistic regression model applied in order to predict the probability of a cycle generating slowcleaving embryos (goodness-of-fit chisquare=180.0, degrees of freedom (df)=80, P=0.4786. This model predicted correctly 86.7% (13 of 15) of cycles generating slowcleaving embryos and 83.3% (10 of 12) of cycles producing fastcleaving embryos when the estimated probability of a cycle producing slowcleaving embryos was 0.7 or 0.3, respectively.Conclusion Shorter treatment with hormone-releasing hormone agonist before ovarian stimulation and higher immaturity grade of oocyte-corona-cumulus complexes which result in embryos are predictive characteristics of in vitro fertilization cycles generating slow-cleaving embryos.     

How do normal subjects learn a simple adaptative task: How and why do paranoid schizophrenic patients fail?

Summary The authors studied the behavior of normal subjects and paranoid schizophrenic patients in a simple problem-solving situation. The schizophrenics were divided into two sample groups, one of individuals under treatment and the other of individuals not under treatment.The learning process involved in this problem-solving situation is very similar to an instrumental conditioning, and can be understood by means of the following assumptions: (1) the subjects use decision functions in reacting to the stimuli, although they may be not fully aware of this; (2) learning is the result of successive transformations of these decisions in the course of time; (3) the changes have specific probabilities and are related to (a) those responses which are made to the latest stimuli, and (b) a differential probability for decision functions which were effective, or only interrupted painful reinforcement, or were completely ineffective.In schizophrenics further factors of importance were (1) an inertia factor and (2) the rigidly continued use of unsuccessful or only partially successful decision criteria.The authors used a systems theory based on Galois field theory and a calculus of operators specifying three groups of subjects. A computer program based on these hypotheses was tested in a simulation experiment.The statistical evaluation of the results showed a congruence between the theoretical approach and the experimental data.This work was carried out with financial support from the Institute de Alta Cultura, Lisbon, between 1970 and 1974     

Anesthetic experience with cardiac transplantation.

The anesthetic management of 17 patients undergoing cardiac transplantation is described. Recipients had severe biventricular failure and pulmonary hypertension. Careful administration of diazepam and morphine was the preferred induction method, and pancuronium was the favored relaxant for both intubation and maintenance. Sterile technique was used in placing endotracheal tubes. Relatively small doses of morphine and diazepam, combined with 50 percent nitrous oxide, were satisfactory for the maintenance of anesthesia. Postperfusion problems were few but included poor tolerance of hypovolemia and an exaggerated hypotensive response to protamine. Isoproterenol was required to support ventricular performance, but no other cardiac stimulants were needed. Postoperative courses were uneventful. There were no operative deaths and no recall of awareness during the operation with the described method of "light" anesthesia.     

Noradrenaline transport by rat heart sympathetic nerves: A re-examination of the role of sodium ions

Summary The effect of sodium ion on ³H-(–)-noradrenaline (0.0875 to 0.5 M) transport by rat heart atrial hemi-appendages incubated in vitro has been studied, and the following observations made: a) When sodium was omitted (choline and lithium substitution) there was no evidence for active noradrenaline transport, and only a component that did not show saturation kinetics up to 1 M noradrenaline, remained. b) Omission of sodium or addition of 4×10^–5 M desipramine inhibited noradrenaline transport to exactly the same extent, and their effects were not additive. Alprenolol did not reduce this sodium-independent transport, but tropolone lowered it somewhat. c) No evidence for corticosterone-sensitive noradrenaline transport (uptake-2) was found in this preparation at the low amine concentrations used. d) In control medium, the kinetic parameters of transport were: K _m: 0.59 ± 0.063 M and V _max: 2.44 ± 0.43 (pmoles/mg protein/min). With 26 mM sodium and the rest substituted by choline, K _m:2.26 ± 0.70 M (P0.001) and V _max: 2.74 ± 0.43 (pmoles/mg protein/min) (not significant). Also with 26 mM sodium, but with sucrose substitution, K _m: 0.76 ± 0.13 M (N.S.) and V _max: 1.06 ± 0.13 (pmol/mg/min) (P<0.05). Such results indicate that sodium only modifies the affinity of the transport system for noradrenaline, without changing V _max, and that changes in the latter are only a consequence of a reduction of the ionic strength. e) When noradrenaline transport was studied at different concentrations of external sodium, at constant ionic strength and with precautions to minimize the noradrenaline-releasing effect of low sodium, it was found that the data could be best represented by two hyperbolas placed in series. This suggests that the noradrenaline carrier has two sites for sodium, that do not interact with each other. When the same experiments were repeated in the absence of chloride, it was found that the noradrenaline transport system had lost virtually all its affinity for sodium. f) The effect of prolonged tissue incubation in the absence of sodium was found to produce a relatively small inactivation of noradrenaline transport. Such phenomenon was enhanced by raising the calcium concentration to 2 mM.     

Treatment of solitary cysts of the humerus

Summary The classical surgical treatment of unicameral bone cysts of the humerus with curettage and bone grafting is unreliable with approximately 40% failure rate. The author describes a technique of subperiosteal diaphyseal and metaphyseal resection and replacement with a section of fibula maintained in position with an intramedullary nail and further supported by massive tibial cortical and cancellous grafting. Consistent incorporation of the graft and excellent remodelling were observed in 36 patients so treated. No complications or recurrence were reported.

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Résumé Le traitement chirurgical «classique» des kystes solitaires de l'humérus par curettage et greffe osseuse ne donne pas des résultats constants, puisqu'il comporte environ 40% d'échecs. L'auteur décrit une technique de résection sous-périostée, diaphysaire et métaphysaire, avec remplacement par un fragment de péroné maintenu par enclouage centro-médullaire et complété par des greffons tibiaux cortico-spongieux. Une parfaite incorporation de la greffe et un excellent remodelage ont été obtenus dans les 36 cas traités de cette manière. Il n'y a eu ni complications, ni récidives.