A PACU crisis: a case study on the development and management of methemoglobinemia.

The development of methemoglobinemia requires rapid recognition, confirmation, and treatment. This case study describes the development, diagnosis, and management of a 63-year-old male scheduled for a laparoscopic cholecystectomy with an intraoperative cholangiogram who developed methemoglobinemia after benzocaine was given for intubation.     

Increase in plasma beta endorphins precedes vasodepressor syncope.

BACKGROUND--Endogenous opioids have a tonic inhibitory effect on sympathetic tone and have been implicated in the pathophysiology of vasodepressor syncope. Plasma beta endorphin concentrations increase after vasodepressor syncope induced by exercise or by fasting. AIMS--To take frequent samples for plasma beta endorphin estimation during tilt testing, and to determine whether plasma beta endorphin increased before the start of syncope. PATIENTS--24 patients undergoing tilt testing for investigation of unexplained syncope. SETTING--Tertiary referral centre. METHODS--Blood samples were obtained during 70 degrees head up tilt testing. Plasma beta endorphin concentrations were estimated by radioimmunoassay (mean(SD) pmol/l). RESULTS--Patients with a positive test showed a rise in beta endorphin concentrations before syncope baseline 4.4(1.5) v start of syncope 8.5(3.1), p < 0.002). In contrast, patients with a negative test showed no change in beta endorphin concentrations (baseline 3.4(1.0) v end of test 4.5(2.3), NS). After syncope all patients showed a large secondary increase in beta endorphins (32.3(18.6)). CONCLUSION--An increase in plasma beta endorphins precedes vasodepressor syncope. This finding supports a pathophysiological role for endogenous opioids.     

Nine Years of the Freebase Cocaine Epidemic in the Bahamas

Nine years after the beginning of the epidemic of freebase (crack) cocaine abuse in the Bahamas, this historical study was done to characterize the natural course of the epidemic and to estimate the effectiveness of control measures. The authors' data include the incidence of new cases at the only psychiatric hospital in the Bahamas and at the primary community psychiatric clinic in the nation. The Bahamian response included 1) demand reduction, 2) supply reduction, and 3) reduction of money laundering. The annual number of new cases of crack abuse presenting for treatment declined from 1987 to mid-1991 in both facilities, but in 1992 it began rising again in the inpatient setting only. The changes in recent years have been accompanied by an increase in violent crimes against persons, especially robberies. (American Journal on Addictions 1994; 3:14–24)     

Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia.

The lowest recurrence rates after inguinal hernia repair have been achieved by specialized hernia clinics. The Shouldice repair achieves success through application of a meticulous standardized operation carried out by specialist hernia surgeons. In a trial designed to rule out surgeon-dependent variables, 322 inguinal hernias were randomized prospectively to Shouldice repair or plication darn. Fifteen general surgeons operated on 322 patients. Fourteen surgeons in training not familiar with Shouldice repair received constant supervision for six repairs before independent operation. The mean (s.d.) patient age was 58.3(1.5) (range 20-84) years for Shouldice repair and 57.0(1.2) (range 18-85 years) for plication darn. The sex ratio (M:F) was 17:1 and right side to left side ratio 1.8:1. Six-week complication rates for wound infection (Shouldice repair, 5 per cent; plication darn, 4 per cent) and haematoma (Shouldice repair, 7 per cent; plication darn, 5 per cent) were similar in both groups. There were a similar number of sliding hernias in the Shouldice repair (14) and plication darn (20) groups. After a mean follow-up of 30 (range 24-48) months there were seven recurrences in the Shouldice group and four in the plication darn group (P > 0.05). The recurrences suggest that additional supervision of junior surgeons is required during the Shouldice repair learning period.     

Comparison of pressure ulcer treatments in long-term care facilities: clinical outcomes and impact on cost.

This study compared clinical outcomes and nursing labor costs associated with (a) balsam Peru, hydrogenated castor oil, and trypsin (BCT) ointment; (b) BCT + Other; and (c) Other treatments in 2014 wound episodes occurring in 861 patients (mean 2.34 wounds/patient). Treatment with BCT ointment or BCT + Other was associated with a higher healing rate (P < .05). No Stage 1 or 2 ulcer treated with BCT ointment progressed, compared with 13.8% treated with BCT + Other and 13.4% treated with Other. The reported mean duration of treatment and time to heal were shorter for ulcers treated with BCT ointment, but differences did not reach significance, possibly because of the variability in reported treatment times. Mean daily nursing labor costs were lower for treatment with BCT than Other ($50.8 vs $61.7, P < .05). These data suggest that treatment of Stage 1 or 2 ulcers with BCT may be associated with shorter treatment time and time to heal and a potential reduction in treatment-related nursing labor costs.     

Scale-up of Adhesive Transdermal Drug Delivery Systems

Pharmaceutical Research -     

Dislocation after total hip arthroplasty. Causes and prevention

In this prospective study, a technique of positioning the acetabulum by bony landmarks of the pelvis in the standing position was developed using a standing lateral preoperative roentgenogram with the X-ray tube centered over the trochanter. Since 1984, 441 total hip arthroplasties (THAs) were done through the posterior approach with a 1.14% dislocation rate through 1988 and no dislocations in 1989. To prevent impingement and dislocation, it was determined that the safest range for cup position was 30 degrees-50 degrees abduction and 20 degrees-40 degrees flexion from the horizontal. To measure postoperative cup position, a standing true lateral roentgenogram of the operated hip allowed direct measurement of cup flexion and was reproducible within 10 degrees. No special instruments are necessary for this technique, which can be used with any THA system.