Aortocaval compression in the sitting and lateral decubitus positions during extradural catheter placement in the parturient

We prospectively studied the incidence of concealed aortocaval compression in parturients at term during identification of the extradural space. Forty ASA I or II parturients, at term and in active labour, who requested extradural analgesia were randomly allocated to one of two groups. Parturients in the first group (n = 22) were positioned in the left lateral decubitus position and those in the second group (n = 18) were in the sitting position. Cardiac output (CO) was recorded at one-minute intervals for five minutes before extradural catheter placement (supine position with a 15° wedge under the right side), and during and thereafter for five minutes (in the supine wedged position), using the BoMED NCCOM3-R7 thoracic electrical bioimpedance (TEB) monitor. The average of five CO_TEB recordings before positioning the patient were compared with the average of five CO_TEB measurements during and after extradural space identification. A change of >25% CO_TEB was considered beyond machine variability. Upper limb arterial pressure was recorded at one-minute intervals. In the left lateral decubitus position, 17 of 22 patients demonstrated a >25% reduction in CO_TEB compared with five of 18 patients in the sitting position (X²,P <0.01). The percentage change in CO_TEB in the lateral decubitus position (?29.8%, 95% CI ?17% to ?44%) was greater than the sitting position (?9.8%, 95% CI +36% to ?32%) (P <0.01). A decreased incidence of aortocaval compression during identification of the extradural space was demonstrated in the sitting position when compared with the left lateral decubitus position.     

Cure of duodenal ulcer after eradication of Helicobacter pylori

Eighty-two patients, whose duodenal ulcers were recurrent or resistant to H2-receptor antagonist therapy, were entered in a treatment protocol of ranitidine followed by a four-week "triple therapy" course to eradicate Helicobacter pylori (HP) infection. The triple therapy consisted of colloidal bismuth subcitrate, tetracycline and metronidazole. Duodenal ulcer healed in all 78 patients available for endoscopy and H. pylori infection was shown to be eliminated in 75 patients (96%) at rebiopsy four weeks after cessation of therapy. In these 75 remaining patients the relapse rates for H. pylori infection and duodenal ulcer were studied endoscopically, yearly and at any recurrence of symptoms. At Year 1, 71 of 73 patients remained free of H. pylori infection (HP-negative) and duodenal ulcer. The corresponding figures subsequently were: Year 2, 57/57; Year 3, 34/34; Year 4, 15/15. No duodenal ulcers recurred in HP-negative patients who were followed for up to four years. Two patients of the original cohort of 75 HP-negative patients were HP-positive with endoscopic duodenitis at 12 months, and one at 36 months, but all were without reulceration. Distorted duodenal caps gradually returned to near-normal appearance in 80% of patients by two years. From this four-year follow-up study we conclude that duodenal ulcer disease will not recur provided the patient remains free of H. pylori.     

Intraoperative radiotherapy in the treatment of neuroblastoma: Report of a pilot study

Background: External beam radiotherapy in advanced neuroblastoma is limited by the volume of normal radiosensitive tissues included in the radiation field. Limitations to external radiation are the late effects to these tissues. Intraoperative radiotherapy (IORT) delivers a single high-radiation dose to a tumor while displacing normal tissues that would have been included in an external field. Standard external radiotherapy can still be done after boost IORT. Methods: Eight advanced-stage neuroblastoma patients who received IORT as part of their multimodality therapy were reviewed to identify the impact of IORT on operative time, complications, and tumor control in the treatment field. The IORT was accomplished by patient transport from the OR to the radiation therapy suite; these were separated by three floors. Results: IORT added 30–75 min to the operative procedure. Tumors in the resection/IORT fields showed no evidence of disease (one), stable tumor size (six), and tumor recurrence (one). Two complications were identified: a urinary fistula and CO₂ retention, which was detected and corrected before the IORT. Neither of these complications was related to the IORT. Two patients who had subsequent tumor resection after IORT demonstrated tumor differentiation to ganglioneuromatous tissue. Conclusions: IORT usually can be completed in less than an hour. No IORT-associated complications were identified. IORT along with maximal tumor resection, external radiation, and chemotherapy enhances local tumor control.Presented in part at the 47th Annual Symposium of The Society of Surgical Oncology, Houston, TX, March 17–20, 1994.     

Acute hyperthermia following stereotactic radiosurgery for pituitary adenoma

A 71-year-old male presented with a large pituitary adenoma with superior extension into the optic chiasm and suprasellar cistern. He was treated with stereotactic radiosurgery to a dose of 16 Gy. Approximately 1 h after radiosurgery he developed fever; his temperature peaked at 105.1 degrees F and normalized about 20 h later. This case demonstrates that acute hyperthermia is a potential complication following high dose stereotactic radiosurgery for large pituitary tumours.     

Pulled between contradictory expectations: Norwegian mother/child service and the ‘new’ public health discourse

In public health discourses in Western societies from the late 1970s onwards, redistribution of power from health professionals to individuals has been defined as a key strategy to foster what is called ‘healthy citizens’. The idea of changing the power relations between ‘experts’ and ‘non-experts’ by ‘empowering’ the latter, however, has not been problematized within the ‘new’ public health literature to any real extent. The present paper focuses on the mother/child service in Norway, and the discussion touches on some of the challenges and tensions that arise when the rhetoric of such notions as ‘empowerment’ is put into practice. This study indicates that the ‘new’ public health discourse is not in harmony with the problematic everyday life of the health service. The analysis is based on qualitative data drawn from interviews with public health nurses.     

The GABA(B) agonist CGP 44532 decreases cocaine self-administration in rats: demonstration using a progressive ratio and a discrete trials procedure

Previous self-administration experiments have shown that baclofen, the prototypical GABA(B) agonist, produces an apparent attenuation in the reinforcing effects of cocaine in rats. The present experiments examined the effects of CPG 44532, a novel and highly specific GABA(B) agonist, on cocaine self-administration using two distinctly different procedures. CGP 44532 (0.063-0.5 mg/kg) produced a dose dependent decrease in break point on a progressive-ratio (PR) schedule. A low dose of CGP 44532 (0.125 mg/kg) produced an apparent shift of the cocaine dose-response curve to the right. In contrast there was comparatively little effect on food-reinforced responding on the same PR schedule. Using a discrete-trials procedure that engendered a circadian pattern of self-administration, CPG 44532 (0.063-0.5 mg/kg) produced a dose-dependent suppression of cocaine intake in the 4 h period following treatment. When a concurrently available food reinforced lever was added to the discrete trials paradigm CGP 44532 failed to disrupt responding for food at any of the doses tested. Data from the PR and discrete-trials procedures taken together indicate that CGP 44532 produced a specific decrease in the motivation to self-administer cocaine.     

Discriminative stimulus properties of the benzodiazepine receptor partial agonist beta-carbolines abecarnil and ZK 95962: a comparison with chlordiazepoxide

Separate groups of rats were trained to discriminate one of three benzodiazepine receptor ligands from vehicle. The three ligands used, the benzodiazepine chlordiazepoxide, and the beta-carboline partial agonists ZK 95962 and abecarnil, have been reported to have different agonistic profiles. All three ligands formed specific benzodiazepine-receptor mediated discriminative stimuli antagonizable by at least one benzodiazepine antagonist. Different patterns of generalization were observed for each cue. As reported previously full and partial agonists substituted for chlordiazepoxide, whereas generalization to ZK 95962 was obtained more readily with partial agonists and antagonists with weak partial agonist activity. In contrast to the other two cues, the abecarnil discriminative stimulus was difficult to train and was unstable over time. Additionally, the abecarnil cue showed commonalities only with sedative or BZ1 receptor agonists. These results demonstrate qualitative differences between different benzodiazepine receptor ligands dependent on the intrinsic activity of the compound used.     

Access to hospital care for California and Michigan Medicaid recipients

This article is a comparison of the characteristics of hospitals serving the general population and Medicaid recipients in California and Michigan, using data from Medicaid uniform claims files and the American Hospital Association Annual Survey for 1984. A greater concentration of discharges in a small number of "high Medicaid volume" urban and rural hospitals in each State was observed for Medicaid recipients compared with the general population. In addition, discharge data suggest that Supplemental Security Income crossovers (individuals covered by both Medicaid and Medicare) and other recipients (mostly children not enrolled in the Aid to Families with Dependent Children program) receive inpatient care in different hospitals from the general population as well as from other Medicaid eligibility groups. Medicaid cost-containment policies and differential access to hospital care are discussed.