The effect of injection speed on the pain of lidocaine infiltration

OBJECTIVE

To determine whether reducing the speed of injection is effective in reducing injection pain for buffered and unbuffered lidocaine solutions.

METHODS

A prospective, single-blind, randomized, crossover, laboratory study was performed. Adult volunteers were recruited from ED staff at an urban teaching hospital to serve as subjects. Twenty-nine subjects each received 4 1-mL injections into the dorsum of the hands. Each subject received fast and slow injections of buffered and unbuffered lidocaine. Subjects rated the pain of each injection on a 100-mm visual analog scale (VAS). Mean pain scores for each intervention were compared using analysis of variance.

RESULTS

The mean pain VAS score for fast injection of buffered lidocaine was 14.1 mm. For slow buffered injection, the mean pain score was 11.4 mm (p = 0.98). For unbuffered lidocaine, the means were 28.7 mm for fast injection and 22.2 mm for slow injection (p = 0.40).

CONCLUSIONS

Reducing injection speed did not produce a statistically significant change in injection pain for either buffered or unbuffered solutions.

African American women in the workplace: relationships between job conditions, racial bias at work, and perceived job quality

Although studies have described work processes among employed African American women, few have examined the influence of these processes on job outcomes. This study examined relationships between African American women's exposure to a range of occupational stressors, including two types of racial bias--institutional discrimination and interpersonal prejudice--and their evaluations of job quality. Findings indicated that institutional discrimination and interpersonal prejudice were more important predictors of job quality among these women than were other occupational stressors such as low task variety and decision authority, heavy workloads, and poor supervision. Racial bias in the workplace was most likely to be reported by workers in predominantly white work settings. In addition, Black women who worked in service, semiskilled, and unskilled occupations reported significantly more institutional discrimination, but not more interpersonal prejudice, than did women in professional, managerial, and technical occupations or those in sales and clerical occupations.

Osteoporosis. Guidelines for general practitioners. Osteoporosis Australia

Osteoporosis and its associated problems are major health concerns in Australia, and are commonly encountered in general practice. As the population ages, the incidence of osteoporosis will continue to increase. Hence, it is important for general practitioners and healthcare professionals to remain up to date with the strategies involved in the prevention and treatment of osteoporosis. Over the last few years, there have been significant advances in our understanding and treatment of osteoporosis. It is now clear that osteoporosis is a problem for men as well as for women. Accurate and reliable measurements to diagnose osteoporosis, and effective medications to treat it, are now available. These guidelines have been prepared to help general practitioners identify people at risk of developing osteoporosis, and to inform general practitioners on the current diagnosis and treatment strategies of the condition. We commend these guidelines to you as a reference source for the treatment of people with osteoporosis.

Explaining oropharyngeal dysphagia after unilateral hemispheric stroke

BACKGROUND

Oropharyngeal dysphagia occurs in up to a third of patients presenting with a unilateral hemiplegic stroke, yet its neurophysiological basis remains unknown. To explore the relation between cortical motor function of swallowing and oropharyngeal dysphagia, mylohyoid, pharyngeal, and thenar electromyographic responses to stimulation of affected and unaffected hemispheres were recorded in dysphagic and non-dysphagic patients.

METHODS

The 20 patients studied had unilateral hemispheric stroke confirmed by computed tomography. Eight of them had associated swallowing difficulties. Electromyographic responses were recorded after suprathreshold transcranial magneto-electric stimulation of affected and unaffected hemispheres with a figure-of-eight coil.

FINDINGS

Stimulation of the unaffected hemisphere evoked smaller pharyngeal responses in dysphagic patients than in non-dysphagic patients (mean 64 microV, median 48, interquartile range 44-86 vs 118 microV, 81, 73-150) (p < 0.02). With stimulation of the affected hemisphere, the pharyngeal responses were smaller than for the unaffected hemisphere but similar between the two patient groups (26 microV, 0, 0-48 vs 54 microV, 0, 0-80). Dysphagic and non-dysphagic patients showed similar mylohyoid and thenar responses to stimulation of the unaffected hemisphere as well as to stimulation of the affected hemisphere-unaffected mylohyoid (269 microV, 239, 89-372 vs 239 microV, 163, 133-307), thenar (572 microV, 463, 175-638 vs 638 microV, 485, 381-764); affected mylohyoid (60 microV, 41, 0-129 vs 96 microV, 0, 0-195); thenar (259 microV, 258, 0-538 vs 451 microV, 206, 8-717).

INTERPRETATION

The findings indicate that dysphagia after unilateral hemispheric stroke is related to the magnitude of pharyngeal motor representation in the unaffected hemisphere.

Cost-effectiveness of different ACE inhibitor treatment scenarios post-myocardial infarction

AIMS

To assess the cost-effectiveness of three different treatment strategies for the use of ACE inhibitors after myocardial infarction. These were (a) a high risk (AIRE type) strategy, (b) an intermediate risk (SAVE type) strategy, and (c) initial, short-term treatment of all patients followed by long-term treatment according to (a) or (b).

METHODS AND RESULTS

Incremental costs per life year gained were calculated for each of the above scenarios. The most optimistic cost per life year gained over 10 years, for (a) was L1752 and for (b) was L2962. Strategy (c) increased the cost per life year gained of (a) to L2017 and (b) to L3110. The incremental cost-effectiveness ratio was found to be very sensitive to drug cost.

CONCLUSIONS

If a low cost ACE inhibitor is used, initial treatment of relatively unselected patients followed by long-term treatment of those at high and medium risk maximizes benefit at an acceptable cost. Use of an ACE inhibitor after myocardial infarction is very cost-effective by comparison with many other treatments.

Does the term carcinogen send the wrong message?

The term carcinogen has been used by scientists and health regulatory officials for decades. During the last 20 years there have been attempts to redefine the term to make it more rigorous. But, as predicted two decades ago by a benchmark-setting subcommittee of the National Cancer Advisory Board, advances in scientific understanding have brought about dramatic changes in the way we are able to view the term carcinogen. These changes, their scientific bases and their effect on defining the term carcinogen are described. An alternative to the use of the term carcinogen is suggested by the recently proposed US Environmental Agency's guidelines for cancer risk assessment which appear to be in accord with current scientific understanding and the importance of considering the factors affecting the term carcinogen. The guidelines set forth four questions, the answers to which could, in our judgment, replace the need to define or use the term carcinogen which, in light of new scientific knowledge, has become more misleading than useful.

Relation between psychiatric disorder and abnormal illness behaviour in patients undergoing operations for cervical discectomy

OBJECTIVE

To test the hypothesis that depression in patients being considered for cervical disc surgery is associated with severe organic pathology. Secondly, to test whether depression and abnormal illness attitudes recorded preoperatively would predict poorer recovery.

METHODS

Seventy four patients with pain and disability from cervical arthrosis were examined during investigations before potential cervical surgery. The prevalence of psychiatric disorder was assessed using the SCAN, and attitude to illness using the illness attitude scale.

RESULTS

There was a rate of depressive disorder in the sample of 37%. The depressed patients did not have more severe organic pathology, more neurological symptoms or signs, or more disablement. They reported more pain and displayed more abnormal illness behaviour. Fifty patients went on to cervical surgery. Outcome four to eight months postoperatively was not related to the presence of psychiatric disorder or illness attitude recorded preoperatively.

CONCLUSION

Depressive disorder is not secondary to severe pathology; the outcome of surgery is predominantly determined by physical factors.

Prevention of normally occurring and deafferentation-induced neuronal death in chick brainstem auditory neurons by periodic blockade of AMPA/kainate receptors

The role of glutamate receptors in regulating programmed neuronal death and deafferentation-induced neuronal death in the brainstem auditory nuclei was studied by in ovo drug administration to chick embryos. The nucleus laminaris (NL) undergoes programmed developmental cell death of 19% between embryonic day 9 (E9) and E17. The AMPA/kainate receptor antagonist CNQX, when administered at doses of 200-300 microg/d from E8 to E15, prevented programmed neuronal death in NL through at least posthatching day 8, without producing anatomical or behavioral abnormalities. 3-((RS)-2-Carboxypiperazin-4-yl)-propyl-1-phos-phonic acid, an antagonist of NMDA receptors, had no effect on normal cell death in the NL. CNQX, given from E8 to E15 or only from E8 to E10, also blocked the 33% neuronal loss in the nucleus magnocellularis (NM) that follows surgical destruction of the otocyst on E3, a procedure that deafferents NM neurons by preventing formation of the cochlear nerve. Treatment either with CNQX or the more highly selective NBQX from E8 to E10, before the onset of synaptic transmission in NM and NL, was also effective in preventing normal neuronal death in NL. Analysis of the effects of CNQX or NBQX on spontaneous embryonic motility at E10 showed that the doses effective in preventing neuronal death suppressed motility for <8 hr. We conclude that periodic blockade of AMPA/kainate receptors can protect CNS neurons against subsequent programmed cell death or deafferentation-induced death.

"Ruling in" and "ruling out": two approaches to the micro-rationing of health care

Much of the implicit rationing said to characterise British health care occurs as doctors decide what resources to allocate to individual patients. This paper examines this process using data from case studies of selection of patients for cardiac surgery and admission to a specialist neurological rehabilitation centre. The analysis focuses on cardiac catheterisation conferences in which cardiologists present surgical candidates to a cardiac surgeon, and neuro-rehabilitation admissions conferences in which a multidisciplinary team assess the suitability of head injury and stroke patients referred by hospital doctors. For much of the time participants in both settings discuss patients within a clinical discourse that relies on technical assessments of coronary anatomy, ADL scores and the like. However, there are many examples where the discourse "frame" shifts to address patient characteristics of a social or moral nature. Information of this kind tends to be deployed in two ways: it can be used to signal the patient's unsuitability, usually on the basis that past behaviour implies poor prognosis ("ruling out"), or it can be used to suggest that a patient is especially deserving of help ("ruling in"). Analysis of the data suggests that "ruling out" is more salient within the cardiac catheterisation conferences, and "ruling in" within the neuro-rehabilitation admissions conferences. The authors suggest that this reflects differences in the work organisation of the two specialties, including the division of labour, the organisation of waiting lists as a queue or a pool, and the putative significance of patient agency in the genesis of disease and recovery.

Patterns of graft infiltration and cytokine gene expression during the first 10 days of kidney transplantation

Understanding of the events preceding acute cellular rejection of kidney transplants would be useful in the development of immunosuppressive strategies to prevent rejection. Information about these events in humans has been scarce, because of the lack of early, serial, biopsy samples. We took daily fine needle aspirates from kidney allografts for the first 10 days after transplant. Samples were analyzed by morphological cytology of graft-infiltrating cells, and reverse transcriptase-polymerase chain reaction for detection of interleukin (IL)-2, IL-4, IL-6, IL-10, and gamma-interferon gene expression. During the first 4 days, all of the grafts developed a low-grade monocyte-rich mononuclear cell infiltrate, accompanied by IL-10 gene expression. Thereafter, the infiltrates either remained stable or intensified. Of the 13 grafts with dense infiltrates, seven developed graft dysfunction. The remaining six did not, despite significant interstitial infiltrates. Both rejecting and nonrejecting dense infiltrates were associated with a biphasic pattern of IL-2 and gamma-interferon gene expression, preceding and accompanying lymphocytic graft infiltration. Grafts that did not develop dense infiltrates had no detectable IL-2 or gamma-interferon gene expression and did not suffer cellular rejection during the study period. The development of both rejecting and nonrejecting infiltrates was strongly associated with DR mismatches between donor and recipient. IL-2 and gamma-interferon gene expression are necessary, but not sufficient, for the development of acute cellular rejection in the first 10 days of kidney transplantation, and are more closely associated with the period leading up to rejection than with the period of graft dysfunction.

The cost of depression in the elderly. Effects of drug therapy

Depression is a widespread and debilitating illness that affects an individual's ability to carry out their usual activities. It is therefore likely to represent a considerable economic and social burden to society. The prevalence of depression in the elderly has been estimated at around 10%, although it has been suggested that the level of undetected and untreated depression may be especially high in this group. The direct and indirect costs associated with depression in the elderly are therefore likely to be considerable. The application of economic analysis to drug therapy in the treatment of depression has so far been limited. There are no economic studies of the cost effectiveness of antidepressant drug therapy that concentrate exclusively on the treatment of the elderly. Available evidence across all groups suggests that selective serotonin reuptake inhibitors may be more cost effective than tricyclic antidepressants. This is primarily attributable to the lower incidence of adverse effects with the former. Whilst these results may be replicated in the elderly, there are specific characteristics of the elderly population which suggest that it may not be possible to generalise results. These include adverse effects, the costs of detection, the costs of noncompliance, and indirect costs and benefits. Therefore, further research and careful economic evaluation of the treatment of depression in the elderly is necessary to take account of these characteristics.

A review of the economic analysis of obesity

There are indications that the treatment costs arising from obesity are significant. However, the cost-of-illness studies undertaken to data also highlight two other important points. First, the cost of treatment in sensitive to the body mass index (BMI) cut-off used. Given that there is no definitive definition of obesity as based on BMI, a range of costs reflecting differing BMI cut-offs may be more appropriate than the use of a single figure. Second, the costs are, not surprisingly, also sensitive to the defined associated diseases. Again there is little agreement on these and also little information on the relative risks of attributable diseases arising from obesity. The calculations of the cost-of-illness arising from the treatment of obesity, and its associated conditions must, therefore, remain indicative rather than authoritative.

Effect of aluminium on expression and processing of amyloid precursor protein

The environmental agent aluminium has been extensively investigated for a potential role in the aetiology of Alzheimer's disease. Despite many investigations there is at present no definite proof for any involvement. If aluminium is involved it is possible that its action is mediated through interaction with the synthesis or processing of amyloid precursor protein (APP). The present study compared aluminium loaded IMR-32 neuroblastoma cells and rat brains with control cells and brains to determine if aluminium affected APP expression and/or processing. In the IMR-32 model system aluminium had no effect on steady-state APP mRNA levels or on the ratio of individual isoforms. It also had no quantitative or qualitative effect on APP-immunoreactive bands detected in protein extracts from conditioned medium of these cells. In total cell extracts, aluminium reduced the intensity of APP-immunoreactive bands between 120-105 kDa but had no effect on a 9 kDa band. In rat brains, aluminium had no effect on APP-immunoreactive bands from soluble or insoluble-membranous extracts. The results, in general, provide no evidence for any effect of aluminium on APP expression or processing.

Serum alpha 1-antitrypsin concentration in dogs with panniculitis

OBJECTIVE

To measure serum alpha 1-antitrypsin (alpha 1AT) concentration in dogs with histologically confirmed panniculitis to determine whether serum deficiency could cause or exacerbate panniculitis in dogs.

DESIGN

Cross-sectional, descriptive study.

ANIMALS

9 dogs (5 with multiple lesions and 4 with solitary lesions).

PROCEDURE

Serum samples were obtained by means of cephalic or jugular venipuncture and frozen at -20 C until assayed. Serum alpha 1AT concentration was measured by means of radial gel immunodiffusion.

RESULTS

In all dogs, serum alpha 1AT concentration was within the previously established reference range.

CLINICAL IMPLICATIONS

In the small number of-dogs studied, panniculitis was not associated with serum alpha 1AT deficiency.

Comparison of modified TECRA visual immunoassay with AOAC method 989.14 and reference culture methods 967.25-967.28 for detection of Salmonella in foods and related samples

A validation study was conducted to compare a new modified version of the TECRA Salmonella Visual immunoassay (Mod. VIA) with the original immunoassay (AOAC Method 989.14) and the reference culture methods (967.25-967.28). The Mod. VIA was supplemented with polyclonal antibodies to Salmonella pullorum and S. gallinarum, and compared favorably with AOAC Method 989.14 in sensitivity, inclusivity, and exclusivity studies. The ability of the Mod. VIA to recover Salmonella from artificially contaminated samples was not significantly different from that of the reference method. It is recommended that the Mod. VIA be adopted as Official First Action.

The cost-effectiveness of condoms in the prevention of HIV infection in England and Wales: should condoms be available on prescription?

OBJECTIVES

HIV and AIDS represent a considerable challenge to the British National Health Service, and the resources devoted to treatment and prevention of HIV/AIDS are significant and likely to increase. The focus of recent campaigns promoting safer sexual practices to prevent the spread of HIV have focused on the use of condoms, since condom use reduces the probability of infection. Furthermore, it has also been suggested that condoms should be provided routinely on prescription by general practitioners (GPs). The objective of this study was to evaluate the cost-effectiveness of GP-provision of condoms in the prevention of HIV infection. Since risk factors for HIV infection differ across population groups, cost-effectiveness ratios for three at-risk groups were considered.

METHODS

Estimates of the cost per infection prevented and the cost per life year gained were made for female heterosexuals, male heterosexuals, and male homosexuals in England and Wales. Sensitivity analysis was conducted on a number of key parameters.

RESULTS

The costs per infection prevented were 2,327,744 Pounds for female heterosexuals, 9,709,987 Pounds for male heterosexuals and 1315 Pounds for male homosexuals. The corresponding costs per life year gained were 56,774 Pounds, 269,722 Pounds and 37 Pounds. When savings from the costs of care were taken into account the use of condoms resulted in cost savings of nearly 50,000 Pounds for homosexual males.

CONCLUSIONS

The provision of GP-prescribed condoms is highly cost-effective for male homosexuals. Such provision is much less cost-effective for heterosexuals, primarily due to the relatively low prevalence of HIV in the heterosexual population and the low infectivity parameter. This suggests that routine GP-provision of condoms would be inappropriate for all at-risk groups, and should target high-risk groups, specifically male homosexuals.

Application of a classical model of competitive business strategy to orthodontic practice

This study explored how market forces might affect the business aspects of orthodontic practices; in particular, profitability. The forces identified were (1) intensity of rivalry, (2) threat of new entrants, and (3) bargaining power of buyers and suppliers. A mail survey instrument was used to collect the data. Results showed that more than half the surveyed practices show an increase in new case starts despite weak economic conditions. Although satellite offices and marketing increase the overhead, they do not add to net profit. New entrants are a threat to existing practices, as are the substitute discretionary spending by the consumer. Interestingly, while some orthodontic practices have joined the managed care programs, a majority of them realize neither increased patient load nor profit. Our data seem to indicate that orthodontic practices have not been successful in "cost containment" with their marketing, number of employees, computerization or inventory. Collectively, the results of this study suggest that success in an orthodontic office is primarily dependent on the practitioner's personality traits, rather than rigidly applied business principles.

TECRA Listeria Visual Immunoassay (TLVIA) for detection of Listeria in foods: collaborative study

A collaborative study involving 26 laboratories and 5 food types was performed to compare the TECRA Listeria Visual Immunoassay (TLVIA) with standard culture methods. Three foods (lettuce, ice cream, and fish fillets), under the jurisdiction of the U.S. Food and Drug Administration, and 2 foods (cooked chicken and cooked ground turkey), under the jurisdiction of the U.S. Department of Agriculture, were used to determine the effectiveness of the TLVIA. Of the 900 samples tested, 300 were inoculated with low levels (1-5 cells/25 g) of Listeria spp. and 300 were inoculated with high levels of Listeria spp. (10-50 cells/25 g). Method agreement between the conventional culture methods and TLVIA (visual) was 94.7%. Method agreement between the conventional culture methods and TLVIA (reader) was 93.6%. The colorimetric polyclonal enzyme immunoassay (TLVIA) for detection of Listeria in foods has been adopted first action by AOAC INTERNATIONAL.

Predictive utility of the CSQ in low back pain: individual vs. composite measures

Researchers have typically used factor-analytic composite measures of coping, instead of individual scales, to predict rehabilitation outcome. There are, however, both advantages and disadvantages to using individual or composite scores. This study extended the findings of Jensen et al. (1992), by prospectively comparing the individual and composite scores of the Coping Strategies Questionnaire (CSQ) in the prediction of 4 types of adjustment to low back pain. Two-hundred patients completed the CSQ, the Oswestry Index, the SCL-90R, and 4 lifting tasks at admission and discharge from a multidisciplinary pain clinic. Return to work was determined at 9-month follow-up. The CSQ scales were factor-analyzed to devise composite indices, and the 3 resultant factors were compared to the individual scales in the prediction of pain and other outcomes. The results indicated that the relative predictive utility of the composite or individual scales depended on which outcome measure was used to define adjustment.

MR imaged neurovascular relationships at the cerebellopontine angle

Improvements in MR imaging techniques allow visualisation of the anatomy of the cerebellopontine angle (CPA) in increasingly accurate detail, revealing the complex interrelationship of the neurovascular structures in this region. We wished to assess whether vessels and vascular loops intimately associated with cranial nerves VII and VIII, corresponded to any abnormality or symptom pattern, and thus had any clinical significance. The MR scans of 108 patients were retrospectively reviewed and the imaging status of VII, VIII, the vessels, presence of vascular loops and their relationship to the nerves, coded and recorded. The patients' records were independently reviewed and the presence and "sidedness' of asymmetrical hearing loss, tinnitus, vertigo, and the results of caloric and brain stem evoked responses recorded. The vessels were closely associated with VII and VIII in over 30% of this sample with vascular loops imaged in 21% of patients, and clearly imaged entering the IAM in 7% of both right and left CPAs studied. There was no statistically significant relationship demonstrated between the proximity of the vessels, or vascular loops, to the nerves and a symptom, or symptom pattern. These findings should be considered a normal variant on MR scanning.