Can we reduce morphine use in elderly,proximal femoral fracture patients using a fascia iliac block?

Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity.     

The utility of ultrasound in late pregnancy compared with clinical evaluation in detecting small and large for gestational age fetuses in low-risk pregnancies

Objective: To determine the utility of ultrasound (US) in late pregnancy for identifying fetuses with growth disturbances.

Methods: This study was designed as a retrospective study of birth weights over a 12-month period at the Royal Hobart Hospital (RHH) and Barwon Health (BH). Data were collected from the discharge summaries and medical records at both hospitals targeting abnormal fetal weight below 10th percentile (small for gestational age – SGA) and above 90th percentile (large for gestational age – LGA).

Results: There were 4079 study patients from both hospitals. After weight adjustment by gender and gestational age, an abnormal fetal weight was detected in 741 cases (babies over the 90th percentile or below 10th percentile). One hundred and twenty-eight patients with high-risk pregnancies were excluded. Therefore, a total of 613 patients remained that were considered to be low-risk pregnancies with abnormal foetal growth; 305 patients from RHH and 308 from BH. The antenatal detection rate for LGA was 35.9%, at RHH by combination of US and clinical evaluation, while for BH it was 34.8% by clinical evaluation alone (p?=?0.910). The antenatal detection rate for SGA was 36.8% via US and clinical evaluation at RHH and 54.5% by clinical evaluation alone at BH (p?=?0.006).

Conclusion: This study shows no benefit in the use of routine US for the antenatal diagnosis of LGA compared with clinical evaluation in low-risk pregnancies. US evaluation was inferior to clinical evaluation in the antenatal diagnosis of SGA in low-risk pregnancies.     

Historical Implant or Current Best Standard? Minimum Five Year Follow-Up Outcomes of Cemented Thompson Hemiarthroplasties

UK NICE guidelines recommend abandoning the Thompson hemiarthroplasty (TH) in favour of a ‘proven prosthesis’ such as the Exeter Trauma Stem. The aim of this study was to assess the hip fracture treatment with the TH. Between 2002 and 2006, 430 cemented THs were performed (minimum 5 year follow-up). Death rates at 1 year and 5 years were 26.6% and 67.4% with low complication (Dislocation 1.4%) and revision rate (1.2%). The TH remains a reliable and proven implant in appropriate patients (over the age of 80, with low activity levels, low ambulatory status and who maybe cognitively impaired), due to low complication and revision rates. Modern implants may provide better function or longevity, but there is little evidence to support abandoning the TH.     

Approaches for drawing causal inferences from epidemiological birth cohorts: A review

Large-scale population-based birth cohorts, which recruit women during pregnancy or at birth and follow up their offspring through infancy and into childhood and adolescence, provide the opportunity to monitor and model early life exposures in relation to developmental characteristics and later life outcomes. However, due to confounding and other limitations, identification of causal risk factors has proved challenging and published findings are often not reproducible. A suite of methods has been developed in recent years to minimise problems afflicting observational epidemiology, to strengthen causal inference and to provide greater insights into modifiable intra-uterine and early life risk factors. The aim of this review is to describe these causal inference methods and to suggest how they may be applied in the context of birth cohorts and extended along with the development of birth cohort consortia and expansion of “omic” technologies.     

Exaggerated MK-801-induced motor hyperactivity in rats with the neonatal lesion of the ventral hippocampus

Neonatal lesions of the ventral hippocampus in rats produce changes in spontaneous and pharmacologically induced dopamine-dependent behaviors that emerge in early adulthood. Neural mechanisms underlying these changes may have implications for understanding the neurobiology of schizophrenia, putatively a neurodevelopmental disorder. In this study, we evaluated the effects of MK-801 (dizocilpine), on automated measures of distance traveled and stereotypies in adult rats with neonatal (postnatal day 7) lesions, and tested the effects of haloperidol, clozapine and an alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic (AMPA) antagonist LY293558 on the MK-801-induced behaviors. The lesioned rats showed significantly greater increases in motor activity after 0.05 and O.1 mg/kg of MK-801 than did controls. Both haloperidol (0.1 and 0.4 mg/kg) and clozapine (4 and 10 mg/kg) reduced hyperlocomotion elicited by 0.2 mg/kg MK-801 in the ventral hippocampus (VH)-lesioned and sham rats. Haloperidol was more potent than clozapine in decreasing MK-801-induced stereotypy, especially in the lesioned rats. Moreover, an AMPA antagonist normalized exaggerated MK-801-induced hyperolocomotion in the lesioned rats at doses that had no effect in controls. These results demonstrate that the lesioned rats are more sensitive to MK-801 during adulthood than control rats, and that antidopaminergic drugs as well as AMPA antagonists antagonize the MK-801-induced behaviors. The neonatal lesion rat model may be useful to further our understanding of the interactions between dopamine and glutamate and their role in the pathophysiology of schizophrenia.     

Chronic dizocilpine or apomorphine and development of neuropathy in two animal models II: effects on brain cytokines and neurotrophins

Dopaminergic and glutamatergic mechanisms are involved in the development and modulation of neuropathy. Cytokines and neurotrophins can be also involved in the supraspinal maintenance of neuropathic pain. We assessed the effects of chronic intraperitoneal (ip) injection of dizocilpine (MK-801), a N-methyl-d-Aspartate (NMDA) noncompetitive receptor antagonist, or apomorphine (APO), a dopamine (DA) D1 and D2 receptor agonist, on neuropathic manifestations in the chronic constriction injury (CCI) and the spared nerve injury (SNI) models of neuropathy in rats. Six groups of rats were subjected to SNI or CCI (3 groups each) neuropathy and 5–7 days later received daily ip injections of saline, MK-801, or APO for two weeks. An additional control group was subjected to sham surgery without nerve lesion or injections. Rats were then sacrificed, and levels of IL-1β, IL-6, NGF, BDNF and GDNF were determined in the cingulum, striatum, and hippocampus. In both models, the neuropathy seen in the saline group was associated with decreased BDNF and an increase in IL-1β, IL-6, NGF and GDNF in most brain regions when compared to sham group. Chronic systemic MK-801 or APO injections decreased the neuropathic manifestations in both models, increased the BDNF level and modulated the other cytokines and neurotrophins. This modulation depended on the neuropathy model and the region/side of the brain studied. Our results showed that the changes in surpraspinal cytokines and neurotrophins could parallel neuropathic manifestations. These changes and the observed hyperalgesia can be modulated by chronic systemic injections of NMDA antagonists or DA agonists.