Relaxation and music reduce pain after gynecologic surgery.

The purpose of this randomized controlled trial was to investigate the effect of three nonpharmacologic nursing interventions: relaxation, music, and the combination of relaxation and music on pain following gynecologic (GYN) surgery. A total of 311 patients, ages 18 to 70, from five Midwestern hospitals, were randomly assigned using minimization to either three intervention groups or a control group and were tested during ambulation and rest on postoperative days 1 and 2. Pain sensation and distress were measured using visual analogue scales. Multivariate analysis of covariance of posttest sensation and distress was used with pretest control and a priori contrasts. The intervention groups had significantly less posttest pain than the control group (p =.022-.001) on both days. The three interventions were similar in their effect on pain. Patients who received the interventions plus patient-controlled analgesia (PCA) had 9% to 29% less pain than controls who used PCA alone. Reduced pain was related to amount of activity (ambulation or rest), mastery of the use of the intervention, and decreased pulse and respiration. Those who slept well had less pain the following day. Nurses who care for GYN surgical patients can provide soft music and relaxation tapes and instruct patients to use them during postoperative ambulation and also at rest on days 1 and 2.     

On the possibility of ventral root fibers undergoing ephaptic excitation under conditions of very severe spinal hyperreflexia

Monosynaptic discharges by ventral roots were studied in rats under conditions of pronounced spinal hyperreflexia 5 days after simultaneous transection of the sciatic nerve and spinal cord. In 40% of tests with such rats, an enhanced monosynaptic discharge of a ventral root was found to be followed by a synchronized and high-amplitude discharge similar in shape and amplitude to the response of the ventral root to electrical stimulation of its fibers. The threshold amplitude for elicitation of these extra discharges was close to the amplitude of the ventral root's monosynaptic discharges at which high-amplitude discharges occurred. It is concluded that when the excitability of spinal reflex ares is excessively high, ephaptic transmission of excitation probably occurs in ventral roots from fibers involved in the enhanced reflex discharge to unexcited fibers. Translated fromByulleten' Eksperimental'noi Biologii i Meditsiny, Vol. 119, N ^o 6, pp. 581–583, June, 1995 Presented by G. N. Kryzhanovskii, Member of the Russian Academy of Medical Sciences     

Sedation and analgesia in critically ill neurologic patients

Critically ill neurologic patients can pose a challenge when it comes to providing sedation and analgesia, primarily with the balance of maintaining sedation to provide patient comfort while still allowing a neurological examination. Determination of the optimal agent requires assessment and understanding of the underlying requirement for sedation: provision of analgesia, anxiolysis, or treatment of delirium. Pharmacological options exist that can affect individual or multiple underlying sedation requirements. Numerous evaluation tools exist to monitor the efficacy of sedation as well as help clinicians titrate agents to predefined goals; these tools allow the safe administration of drugs that can otherwise have serious adverse effects. Sedation regimens must ultimately be individualized to each patient to account for differences in pharmacokinetics and dynamics of the various agents, and this is particularly true in sedating neurologically injured patients. The agents frequently used to provide sedation and analgesia in the critically ill neurologic patient will be reviewed.     

Practice Variations in the Management of Status Epilepticus

Background

Numerous anticonvulsant agents are now available for treating status epilepticus (SE). However, a paucity of data is available to guide clinicians in the initial treatment of seizures or SE. This study describes the current strategies being employed to treat SE in the USA.

Methods

Fifteen American academic medical centers completed a retrospective, multicenter, observational study by reviewing 10?C20 of the most recent cases of SE at their institution prior to December 31, 2009. A multivariate analysis was performed to determine factors associated with cessation of seizures.

Results

A total of 150 patients were included. Most patients with SE had a seizure disorder (58?%). SE patients required a median of 3 AEDs for treatment. Three quarters of patients received a benzodiazepine as first-line therapy (74.7?%). Phenytoin (33.3?%) and levetiracetam (10?%) were commonly used as the second AED. Continuous infusions of propofol, barbiturate, or benzodiazepine were used in 36?% of patients. Median time to resolution of SE was 1?day and was positively associated with presence of a complex partial seizure, AED non-compliance prior to admission, and lorazepam plus another AED as initial therapy. Prolonged ICU length of stay and topiramate therapy prior to admission were negatively associated with SE resolution. Mortality was higher in patients without a history of seizure (22.2?vs 6.9?%, p?=?0.006).

Conclusions

The use of a benzodiazepine followed by an AED, such as phenytoin or levetiracetam, is common as first and second-line therapy for SE and appears to be associated with a shorter time to SE resolution. AED selection thereafter is highly variable. Patients without a history of seizure who develop SE had a higher mortality rate.     

Effective Connectivity of Cortical Sensorimotor Networks During Finger Movement Tasks: A Simultaneous fNIRS,fMRI, EEG Study

Recently, interest has been growing to understand the underlying dynamic directional relationship between simultaneously activated regions of the brain during motor task performance. Such directionality analysis (or effective connectivity analysis), based on non-invasive electrophysiological (electroencephalography—EEG) and hemodynamic (functional near infrared spectroscopy—fNIRS; and functional magnetic resonance imaging—fMRI) neuroimaging modalities can provide an estimate of the motor task-related information flow from one brain region to another. Since EEG, fNIRS and fMRI modalities achieve different spatial and temporal resolutions of motor-task related activation in the brain, the aim of this study was to determine the effective connectivity of cortico-cortical sensorimotor networks during finger movement tasks measured by each neuroimaging modality. Nine healthy subjects performed right hand finger movement tasks of different complexity (simple finger tapping-FT, simple finger sequence-SFS, and complex finger sequence-CFS). We focused our observations on three cortical regions of interest (ROIs), namely the contralateral sensorimotor cortex (SMC), the contralateral premotor cortex (PMC) and the contralateral dorsolateral prefrontal cortex (DLPFC). We estimated the effective connectivity between these ROIs using conditional Granger causality (GC) analysis determined from the time series signals measured by fMRI (blood oxygenation level-dependent-BOLD), fNIRS (oxygenated-O₂Hb and deoxygenated-HHb hemoglobin), and EEG (scalp and source level analysis) neuroimaging modalities. The effective connectivity analysis showed significant bi-directional information flow between the SMC, PMC, and DLPFC as determined by the EEG (scalp and source), fMRI (BOLD) and fNIRS (O₂Hb and HHb) modalities for all three motor tasks. However the source level EEG GC values were significantly greater than the other modalities. In addition, only the source level EEG showed a significantly greater forward than backward information flow between the ROIs. This simultaneous fMRI, fNIRS and EEG study has shown through independent GC analysis of the respective time series that a bi-directional effective connectivity occurs within a cortico-cortical sensorimotor network (SMC, PMC and DLPFC) during finger movement tasks.     

A prospective randomized study of Chop versus Chop plus alpha-2B interferon in patients with intermediate and high grade non-Hodgkin's lymphoma: the International Oncology Study Group NHL1 Study .

The addition of a brief alpha interferon regimen to each CHOP induction cycle, plus one year of alpha interferon thrice weekly maintenance therapy, has no early effect on response rates or survival in patients with Intermediate or High grade cell NHL. BACKGROUND: The CHOP (Cyclophosphamide, Adriamycin. Vincristine, Prednisone) regimen is the most widely used first-line therapy for patients with Intermediate or High Grade (IG/HG) non-Hodgkin's lymphoma (NHL). Alpha 2b interferon (INF) enhances response rates and improves survival in low-grade NHL. The International Oncology Study Group (IOSG) conducted a prospective randomized study comparing CHOP alone or combined with INF in patients with IG/HG-NHL. The primary study aim was to compare the objective response rates in these patient cohorts. PATIENTS AND METHODS: Patients with a confirmed diagnosis of measurable NHL of International Working Formulation (IWF) groups D to H histology were randomized to receive CHOP alone or CHOP with 5Mu INF s.c. for 5 days on days 22 to 26 of each 28 day cycle with INF 5 million units (Mu) given three times per week subcutaneously for 52 weeks in those patients who responded to CHOP plus INF. RESULTS: The overall response rates were equivalent in both groups: CHOP alone (214 patients) 81% (complete 55%, partial 26%); CHOP plus INF (221 patients) 80% (complete 54%, partial 26%). At 36 months, the actuarial survival rate was equivalent in both groups. CONCLUSIONS: There is no apparent early advantage in terms of response or survival conferred by adding the study INF regimen to CHOP therapy for patients with IG/HG-NHL.     

Muscle oxygenation of vastus lateralis and medialis muscles during alternating and pulsed current electrical stimulation

This study compared between alternating and pulsed current electrical muscle stimulation (EMS) for muscle oxygenation and blood volume during isometric contractions. Nine healthy men (23–48 years) received alternating current EMS (2500 Hz) modulated at 75 Hz on the knee extensors of one leg, and pulsed current EMS (75 Hz) for the other leg separated by 2 weeks in a randomised, counter-balanced order. Pulse duration (400 μs), on–off ratio (5–15 s) and other stimulation parameters were matched between conditions and 30 isometric contractions were induced at the knee joint angle of 100° (0° full extension). Changes in tissue oxygenation index (∆TOI) and total hemoglobin volume (∆tHb) of vastus lateralis and medialis muscles over 30 contractions were assessed by a near-infrared spectroscopy, and were compared between conditions by a two-way repeated measures ANOVA. Peak torque produced during EMS increased over 30 contractions in response to the increase in the stimulation intensity for pulsed current, but not for the alternating current EMS. The torque during each isometric contraction was less stable in alternating than pulsed current EMS. The changes in ∆TOI amplitude during relaxation phases and ∆tHb amplitude were not significantly different between conditions. However, the decreases in ∆TOI amplitude during contraction phases from baseline were significantly (P < 0.05) greater for the pulsed current than alternating current from the 18th contraction (−15.6 ± 2.3 vs. −8.9 ± 1.8%) to 30th contraction (−10.7 ± 1.8 vs. −4.8 ± 1.5%). These results suggest that the muscles were less activated in the alternating current EMS when compared with the pulsed current EMS.     

Biceps brachii muscle oxygenation in electrical muscle stimulation

The purpose of this study was to compare between electrical muscle stimulation (EMS) and maximal voluntary (VOL) isometric contractions of the elbow flexors for changes in biceps brachii muscle oxygenation (tissue oxygenation index, TOI) and haemodynamics (total haemoglobin volume, tHb = oxygenated‐Hb + deoxygenated‐Hb) determined by near‐infrared spectroscopy (NIRS). The biceps brachii muscle of 10 healthy men (23–39 years) was electrically stimulated at high frequency (75 Hz) via surface electrodes to evoke 50 intermittent (4‐s contraction, 15‐s relaxation) isometric contractions at maximum tolerated current level (EMS session). The contralateral arm performed 50 intermittent (4‐s contraction, 15‐s relaxation) maximal voluntary isometric contractions (VOL session) in a counterbalanced order separated by 2–3 weeks. Results indicated that although the torque produced during EMS was approximately 50% of VOL (P<0·05), there was no significant difference in the changes in TOI amplitude or TOI slope between EMS and VOL over the 50 contractions. However, the TOI amplitude divided by peak torque was approximately 50% lower for EMS than VOL (P<0·05), which indicates EMS was less efficient than VOL. This seems likely because of the difference in the muscles involved in the force production between conditions. Mean decrease in tHb amplitude during the contraction phases was significantly (P<0·05) greater for EMS than VOL from the 10th contraction onwards, suggesting that the muscle blood volume was lower in EMS than VOL. It is concluded that local oxygen demand of the biceps brachii sampled by NIRS is similar between VOL and EMS.     

Questionnaire survey about an anesthesia information sheet

BACKGROUND: The anesthesia information sheet used in our hospital describes the anesthetic management and complications in a simple style. Patients scheduled for operations receive it from their doctor with some explanation about anesthesia. The written informed consent on the sheet is obtained from the patients. METHODS: One hundred and one patients undergoing elective operations were interviewed after receiving explanations during the anesthesiologist's preoperative rounds. RESULTS: From this survey, 85% of the patients read it before the anesthesiologist's preoperative rounds and 75% of them understood the contents. After the anesthesiologist's explanation, 94% of the patients who had read it understood enough. About a third of the patients who had read the information sheet had anxiety about anesthesia. After the anesthesiologist's explanation, the percentage of patients who had anxiety decreased to 8%. 98% of the patients who read the information sheet answered that it should be read before the anesthesiologist's preoperative rounds. CONCLUSIONS: In view of this survey we concluded that reading the information sheet before the anesthesiologist's preoperative rounds is useful to increase the patients understanding of anesthesia.     

Attenuation of muscle damage by preconditioning with muscle hyperthermia 1-day prior to eccentric exercise

This study investigated the hypothesis that muscle damage would be attenuated in muscles subjected to passive hyperthermia 1 day prior to exercise. Fifteen male students performed 24 maximal eccentric actions of the elbow flexors with one arm; the opposite arm performed the same exercise 2–4 weeks later. The elbow flexors of one arm received a microwave diathermy treatment that increased muscle temperature to over 40°C, 16–20 h prior to the exercise. The contralateral arm acted as an untreated control. Maximal voluntary isometric contraction strength (MVC), range of motion (ROM), upper arm circumference, muscle soreness, plasma creatine kinase activity and myoglobin concentration were measured 1 day prior to exercise, immediately before and after exercise, and daily for 4 days following exercise. Changes in the criterion measures were compared between conditions (treatment vs. control) using a two-way repeated measures ANOVA with a significance level of P < 0.05. All measures changed significantly following exercise, but the treatment arm showed a significantly faster recovery of MVC, a smaller change in ROM, and less muscle soreness compared with the control arm. However, the protective effect conferred by the diathermy treatment was significantly less effective compared with that seen in the second bout performed 4–6 weeks after the initial bout by a subgroup of the subjects (n = 11) using the control arm. These results suggest that passive hyperthermia treatment 1 day prior to eccentric exercise-induced muscle damage has a prophylactic effect, but the effect is not as strong as the repeated bout effect.