Intrathecal fentanyl prolongs sensory bupivacaine spinal block

The purpose of investigation was to study the effect of intrathecal fentanyl on the onset and duration of hyperbaric bupivacaine-induced spinal block in adult male patients. Fortythree patients undergoing lower extremity or genitourinary surgery were enrolled to receive either 13.5 mg hyperbaric bupivacaine 0.75% + 0.5 ml CSF it, (Group I) or 13.5 mg hyperbaric bupivacaine 0.75% + 25 μg fentanyl it, (Group II) according to a randomized assessor-blind protocol. The onset and duration of sensory block were assessed by pinching the skin with forceps in the midclavicular line bilaterally every two minutes for first twenty minutes and then every five to ten minutes. Similarly, the onset and duration of motor block were assessed and graded at the same time intervals using the criteria described by Bromage. The time required for two sensory segment regression and sensory regression to L₁ dermatome was 74 ± 18 and 110 ± 33 min vs 93 ± 22 and 141 ± 37 min in Groups I and II, respectively (P < 0.05). Intrathecal fentanyl did not enhance the onset of sensory or motor block, or prolong the duration of bupivacaine-induced motor spinal block. Fewer patients demanded pain relief in the fentanyl-treated group than in the control group in the early postoperative period (19% vs 59%; P < 0.05). Episodes of hypotension were more frequent in the fentanyl-treated group than in the control group (43% vs 14%; P < 0.05). We conclude that fentanyl, 25 μg it, prolonged the duration of bupivacaine-induced sensory block (sensory regression to L₁ dermatone) by 28% and reduced the analgesic requirement in the early postoperative period following bupivacaine spinal block.     

Suppression of experimental allergic encephalomyelitis by the encephalitogenic peptide, in solution or bound to liposomes

We have investigated the ability of liposome-bound encephalitogenic peptide to suppress experimental allergic encephalomyelitis (EAE) in the guinea pig. EAE was induced by challenge with the encephalitogenic peptide, residues 113-122 of human myelin basic protein (MBP) in complete Freund's adjuvant. The peptide was acylated with stearic acid in order to anchor it to the lipid bilayer. The liposomal-bound peptide effectively suppressed clinical signs of EAE at relatively low doses, when given subcutaneously or intraperitoneally without incomplete Freund's adjuvant, several days after challenge. In vitro proliferation of lymphocytes from treated, protected animals in response to the peptide was greatly decreased but that to the purified protein derivative of tuberculin antigen was not, indicating an antigen-specific effect. However, histological signs of EAE were not reduced. The free peptide in solution was somewhat less effective when given intraperitoneally but was as or nearly as effective as liposome-bound peptide when given subcutaneously. Binding to liposomes may decrease the rate of clearance or degradation of the peptide when given intraperitoneally.     

Cervical Cancer Prevention: Asian-American Women's Knowledge and Participation in Screening Practices

ObjectiveThe purpose of this study was to compare cervical cancer knowledge and prevention strategy participation among Chinese-American women compared with Southeast–Asian-American women.MethodsWe performed a cross-sectional survey of Chinese and Southeast Asian women in Rhode Island. Anonymous surveys were administered following informed consent. The survey included demographics and questions related to health care practices, cervical cancer, and the human papilloma virus (HPV). Categorical variables were compared by Fisher's exact test. Mean scores of correct answers on the knowledge questions were compared by Student's t-test and analysis of variance.ResultsNinety-six Chinese women and 132 Southeast Asian women were included in the analysis. Sixty-seven percent of Chinese women had at least a college education compared with 37% of Southeast Asian women (p < .0001). Nineteen percent of Chinese women reported annual household incomes of greater than $100,000 compared with 3% of Southeast Asian women (p = .0003). Twenty percent of Southeast Asian women did not have health insurance compared with 10% of Chinese women (p = .06). Among both groups, 25% of participants either never had a pap test or did not know if they ever had a pap test. There was a greater lack of knowledge about the relationship between HPV and cervical cancer among Chinese (mean 2.9 out of 8 questions) compared with Southeast Asian (mean 3.6 out of 8 questions; p = .02).ConclusionsRegardless of ethnic subgroup, education, or income, all participants had a poor knowledge of cervical cancer and HPV. This study supports the need for improvement in cervical cancer prevention education among all Asian women.     

Special Education Services for Children Involved with Child Welfare/Child Protective Services

This paper examines educational and behavioral characteristics and special education service use for a subsample of 2477 children enrolled in the National Survey of Child and Adolescent Wellbeing (NSCAW), the first national, longitudinal study of youth following investigation for alleged maltreatment through the child welfare system (CW). Almost one-fifth of children were characterized as severe on educational indices and 47% as severe on behavioral indices. Nineteen percent were currently receiving special education services, 17% had previously received these services, and the remainder had never received them. Over half (51%) of children characterized as severe on educational or behavioral indices were not receiving special education services. Caregivers indicated that youth were being served primarily under categories of Emotional Disturbance (35%) and Speech and Language Impairment (30%). Further exploration of the role of schools, particularly school psychologists, in providing supports for children involved with CW is discussed.     

Temporal and segmental distribution of constitutive and inducible nitric oxide synthases after traumatic spinal cord injury: effect of aminoguanidine treatment

Nitric oxide (NO) has been shown to play an important role in the pathophysiology of traumatic brain injury (TBI) and cerebral ischemia. However, its contribution to the pathogenesis of traumatic spinal cord injury (SCI) remains to be clarified. This study determined the time course of constitutive and inducible nitric oxide synthases (cNOS and iNOS, respectively) after SCI. Rats underwent moderate SCI at T10 using the NYU impactor device and were allowed to survive for 3, 6, or 24 h and 3 days after SCI (n = 5 in each group). For the determination of enzymatic activities, spinal cords were dissected into five segments, including levels rostral and caudal (remote) to the injury site. Other rats were perfusion fixed for the immunohistochemical localization of iNOS protein levels. cNOS activity was significantly decreased at 3 and 6 h within the traumatized T10 segment and at 3, 6, and 24 h at the rostral (T9) level (p < 0.05). Rostral (T8) and caudal (T11, T12) to the injury site cNOS activity was also decreased at 3 h after injury (p < 0.05). However, cNOS activity returned to control levels within 6 h at T8, T11 and T12 and at one day at T10 and T9 segments. iNOS enzymatic activity was elevated at all time points tested (p < 0.05), with the most robust increase observed at 24 h. Immunostaining for iNOS at 24 h revealed that a significant cellular source of iNOS protein appeared to be invading polymorphonuclear leukocytes (PMNLs). To assess the functional consequences of iNOS inhibition, aminoguanidine treatment was initiated 5 min after SCI and rats tested using the BBB open field locomotor score. Treated rats demonstrated significantly improved hindlimb function up to 7 weeks after SCI. Histopathological analysis of contusion volume showed that aminoguanidine treatment decreased lesion volume by 37% (p < 0.05). In conclusion, these results indicate that (1) cNOS and iNOS activities are regionally and temporally affected after moderate SCI, (2) the early accumulation of PMNLs are a potentially significant source of NO-induced cytotoxic products, and (3) acute aminoguanidine treatment significantly improves functional and histopathological outcome after SCI.     

Mycophenolic acid concentrations in long-term heart transplant patients: relationship with calcineurin antagonists and acute rejection

BACKGROUND: When used in conjunction with steroids and cyclosporin, mycophenolate mofetil (MMF) has been shown to significantly reduce mortality and incidence of rejection in the first year after heart transplantation. It also appears that in this early post-transplantation period, the monitoring of immunosuppressive therapies may be warranted. The current study was undertaken to determine if such monitoring is still useful more than 1 yr after heart transplantation. METHODS: Twenty-six patients who had survived the first year after orthotopic heart transplantation and had been on MMF therapy for more than 3 months were prospectively followed. At the time of their routine endomyocardial biopsy blood samples were taken to monitor immunosuppressive therapy. Most patients had two samples taken, on average 109 d apart. RESULTS: There were 22 episodes of asymptomatic rejection documented on a total of 48 biopsies. Of these, only two were of ISHLT (International Society for Heart and Lung Transplantation) grade 3A the remainder being of ISHLT grades 1 or 2. There was no relation between immunosuppressive regimen (tacrolimus and MMF or cyclosporin and MMF) and rejection. There was no relation between monitored immunosuppressive levels and rejection. Patients with the combination of MMF and tacrolimus had significantly higher plasma mycophenolic acid levels despite significantly lower daily MMF dose. CONCLUSION: There does not appear to be a benefit in continued monitoring of plasma mycophenolic acid levels beyond the first year of heart transplantation. There were significant differences in plasma mycophenolic acid levels depending on the type of calcineurin inhibitor concomitantly used.     

Management of the child with a learning disorder

The label "learning disabilities" is all-embracing; it describes a syndrome, not a specific child with specific problems. Parent involvement in and collaboration with pediatricians and schools in navigating service systems, accessing appropriate services, and case management are particularly relevant for children with LD. Comprehensive service delivery in school settings requires the interface of other service sectors, such as primary care, mental health,and other community agencies that also recognize and address children's problems. To date, marked differences exist among the assessment, classification and diagnostic, and treatment practices of these service systems, despite the fact that they address the same patient population--school-aged youth. Additionally, many of these agencies and systems operate in isolation with limited cross-sector communication or service collaboration. Parent involvement and advocacy, with assistance from pediatricians and knowledgeable school personnel, is necessary to ensure that appropriate resources available from these sectors are well coordinated and provided for children with an LD to improve their school performance and ongoing educational experience.     

Advanced presentation of melanoma in African Americans

BACKGROUND: Melanoma in African Americans is rare, and the diagnosis is often delayed, leading to advanced presentation and poor prognosis. OBJECTIVE: The purpose of this retrospective study is to determine whether African American patients diagnosed with melanoma at the Washington Hospital Center were initially seen with more advanced disease than white patients. METHODS: A retrospective chart review was performed on 36 African American patients who were diagnosed and/or treated for melanoma at the Washington Hospital Center between 1981 and 2000. Data obtained included patient age at presentation, sex, Breslow's depth and histologic subtype, stage at presentation, and tumor location. These data were compared with information obtained from white patients with melanoma during this period. RESULTS: A total of 649 African American and white patients were treated for melanoma at the Washington Hospital Center between 1981 and 2000. Of these, 36 (6.1%) patients were African American. African American patients were more likely to initially be seen with stage III/IV disease (32.1%) compared with (12.7%) the white patients initially seen with these disease stages. Of the white patients 60.4% were initially seen with melanoma in situ/stage I disease compared with 39.3% of the African American patients. The 5-year survival rate was 58.8% in African Americans compared with 84.8% in whites. CONCLUSIONS: In our series, African Americans are more likely than whites to be initially seen with advanced disease and have a subsequent worse prognosis. Physician training and patient education campaigns are crucial to improving the poor prognosis associated with melanoma in the African American community.