Effect of injection rate on hypotension associated with spinal anesthesia for cesarean section

Maternal hypotension is a common problem during cesarean section under spinal anesthesia. We evaluated in a prospective observational study the influence of injection speed on maternal hypotension. Hyperbaric bupivacaine 10 mg, sufentanil 2 microg and morphine 200 microg (total volume 4 mL) were injected either quickly (<15 s) or slowly (=120 s) in 50 women scheduled for elective cesarean section. Hypotension (systolic arterial pressure (SAP) <100 mmHg or <70% of baseline) was promptly treated with 5 mg ephedrine boluses. Slow injection significantly reduced the incidence of hypotension (68% in the 120 s group and 92% in the other, P =0.03). In addition, onset of hypotension was delayed, had a shorter duration and required less ephedrine for hypotension in the 120 s group (11.6 mg vs. 19.6 mg, P =0.019). Anesthesia was satisfactory for all women. We conclude that a 2 mL/min injection rate may be a simple and effective way to reduce the incidence and severity of hypotension during cesarean section under spinal anesthesia.

Central venous catheter placement in children: evaluation of electrocardiography using J-wire

Misplacement of a central venous catheter may lead to myocardial perforation and dysrhythmia. Atrial electrocardiography (ECG) through a saline column is an effective but complex method to determine the accurate location of catheters. We evaluated a simplified variant of this technique using the guidewire as an internal electrode in 23 children (5-16 years old) undergoing spinal surgery. Catheters were placed using a Seldinger technique after jugular or subclavian venous puncture. Each time the operator recognized the atrial signal, the catheter was found to be correctly placed on the chest radiograph (20/23). In three patients, the atrial signal was not obtained. A technical error was responsible in one case whereas the two others were related to aberrant migrations of the catheter either into a subclavian vein or into the pleura. In this latter case, the complication was unrecognized on the first radiograph despite malposition having been predicted by atrial ECG. We conclude that a method using atrial ECG guidance is sensitive and specific, and may be an alternative to the classical chest radiograph to detect accurate placement of central venous catheters in children.

Stereotypes and terror management: evidence that mortality salience enhances stereotypic thinking and preferences

If stereotypes function to protect people against death-related concerns, then mortality salience should increase stereotypic thinking and preferences for stereotype-confirming individuals. Study 1 demonstrated that mortality salience increased stereotyping of Germans. In Study 2, it increased participants' tendency to generate more explanations for stereotype-inconsistent than stereotype-consistent gender role behavior. In Study 3, mortality salience increased participants' liking for a stereotype-consistent African American and decreased their liking for a stereotype-inconsistent African American; control participants exhibited the opposite preference. Study 4 replicated this pattern with evaluations of stereotype-confirming or stereotype-disconfirming men and women. Study 5 showed that, among participants high in need for closure, mortality salience led to decreased liking for a stereotype-inconsistent gay man.

Stereotypes and terror management: evidence that mortality salience enhances stereotypic thinking and preferences

If stereotypes function to protect people against death-related concerns, then mortality salience should increase stereotypic thinking and preferences for stereotype-confirming individuals. Study 1 demonstrated that mortality salience increased stereotyping of Germans. In Study 2, it increased participants' tendency to generate more explanations for stereotype-inconsistent than stereotype-consistent gender role behavior. In Study 3, mortality salience increased participants' liking for a stereotype-consistent African American and decreased their liking for a stereotype-inconsistent African American; control participants exhibited the opposite preference. Study 4 replicated this pattern with evaluations of stereotype-confirming or stereotype-disconfirming men and women. Study 5 showed that, among participants high in need for closure, mortality salience led to decreased liking for a stereotype-inconsistent gay man.

[Dural taps in peridural analgesia for labor: management by French anesthesiologists in 1997]

OBJECTIVES

To assess prophylactic and curative managements of dural taps occurring during the setting of epidural analgesia (EA) for labour.

STUDY DESIGN

Nationwide French retrospective survey.

PATIENTS AND METHODS

From April to July 1997, a questionnaire was sent to 799 French obstetrical units located in both teaching and non-teaching public hospitals and private institutions.

RESULTS

Answers were obtained from 267 units (response rate of 33%). Although management of dural taps was similar in 52% of the institutions, only 8% had produced a written protocol. After a dural puncture, EA was still performed in 95% of the units, but usually in another interspace (87%). Large oral fluid intake was the most frequent prophylactic measure (81%). To prevent postdural puncture headache (PDPH), bed rest was largely used (76%) and lasted 24 hours in 46% of the institutions. Prophylactic epidural blood patch (EBP) was performed in 14% of the units. To treat PDPH, a majority of anaesthesiologists performed an EBP (92%) and most of them after a delay of 48 hours (62%). Intravenous and oral caffeine was used in 31 and 24% of the units respectively. Prior to EBP, coagulation status was assessed in about 20% of the units and blood culture in less than 3%. In 65% of the units the injection of EBP was discontinued when the patients felt backache. A large range of volumes were injected, but usually less than 20 mL were administered (81%). In 60% of the units the patients were discharged home after an overnight stay in the hospital. If the first EBP failed, a second one was performed in 61% of the cases.

CONCLUSION

Management of dural taps occurring after EA for pain relief in labour differs widely from one French obstetrical unit to another.

Sound propagation in urban areas: a periodic disposition of buildings

A numerical simulation of background noise propagation is performed for a network of hexagonal buildings. The obtained results suggest that the prediction of background noise in urban spaces is possible by means of a modified diffusion equation using two parameters: the diffusion coefficient that expresses the spreading out of noise resulting from diffuse scattering and multiple reflections by buildings, and an attenuation term accounting for the wall absorption, atmospheric attenuation, and absorption by the open top. The dependence of the diffusion coefficient with geometrical shapes and the diffusive nature of the buildings are investigated in the case of a periodic disposition of hexagonal buildings.

[Diagnosis of reflex sympathetic dystrophy]

Reflex sympathetic dystrophy syndrome is a peculiar rheumatological pathology whose diagnosis at times is evident, but other times it is complex. This difficulty compels us to have a good knowledge of the syndrome and to take it into account when faced with any rheumatological differential diagnostic. In this work we revise the major aspects of diagnostic.

Comparative study of the neuronal plasticity along the neuraxis of the vibrissal sensory system of adult rat following unilateral infraorbital nerve damage and subsequent regeneration

The aim of the present study was to examine the physiological consequences of a unilateral infraorbital nerve lesion and its regeneration at different levels of the somatosensory neuraxis. In animals whose right infraorbital nerve had been crushed, a large unresponsive area was found in the main brainstem trigeminal nucleus (Pr5). Responses evoked by ipsilateral vibrissal deflection in the middle of Pr5 reappeared only on days 22-35 after the nerve had been transected, whereas recovery from the nerve crush took only 7-9 days. However, no sign of short-term neuronal plasticity was observed in Pr5 after peripheral nerve injury. An enlargement of the receptive fields in two-thirds of the units and a lengthening in the delay of the evoked responses were observed as long-term plastic changes in Pr5 neurons after peripheral-nerve regeneration. In the ventral posteromedial nucleus of the thalamus (VPM) of partly denervated animals, however, only minutes or hours after the nerve crush, certain units were found to respond in some cases not only to the vibrissae, but also to mechanical stimulation of the face over the eye (two units), the nose (one unit), and the midline (one unit). Apart from the experiments involving incomplete denervation, the vibrissal representation areas of the VPM were unresponsive to stimulation of both the vibrissae and other parts of the face until nerve regeneration had occurred. In the somatosensory cortex, an infraorbital nerve crush immediately resulted in a large cortical area being unresponsive to vibrissal deflection. It was noteworthy, however, that shortly after the nerve crush, this large unresponsive whisker representation cortical area was invaded from the rostromedial direction by responses evoked by stimulation of the forepaw digits. In spite of the reappearance of vibrissa-evoked responses 7-10 days after the nerve crush, an expanded digital representation could still be observed 3 weeks after the nerve crush, resulting in an overlapping area of digital and vibrissal representations. The withdrawal of the expanded representation of forepaw digits was completed by 60 days after the nerve crush. The results obtained in Pr5, the VPM, and the cortex strongly suggest that the higher the station in the neuraxis, the greater the degree of plasticity after infraorbital nerve injury.

[Intratracheal intubation without muscle relaxant with the use of remifentanil-propofol]

OBJECTIVES

To assess tracheal intubation conditions after induction of anaesthesia with remifentanil and propofol, using itemized scoring criteria.

STUDY DESIGN

Clinical, prospective, open, non comparative trial.

PATIENTS

One hundred consecutive patients undergoing surgery not requiring muscle relaxation, during the study period extended over 12 months.

METHODS

After premedication with lorazepam (2 mg) the day before and hydroxyzine (100 mg) one hour before surgery, anaesthesia was induced with remifentanil administered continuously with a syringe pump at a rate of 1.20 +/- 0.06 micrograms.kg-1.min-1 and propofol (3 mg.kg-1 IV bolus). The trachea was intubated two minutes later and mouth opening, glottis exposure, glottis opening, movements, additional anaesthetic agents and chest rigidity were recorded.

RESULTS

Intubation conditions were excellent in 87% of patients, and the tube was inserted rapidly, within two minutes. However in 38% of patients the cuff inflation caused cough. In 13%, glottis opening was delayed and intubation required three minutes. A major decrease of arterial pressure and heart rate was recorded in 9 and 6% of patients respectively.

CONCLUSION

Induction of anaesthesia using remifentanil and propofol allows satisfactory tracheal intubation without a muscle relaxant. However this technique is contraindicated: a) in patients with a full stomach, as intubation is not always successful at the first attempt; b) in patients scheduled to undergo neurosurgery or ophthalmic surgery, as tracheal intubation may elicit cough, increasing intra-cranial and intra-ocular pressure; c) in patients in poor circulatory status, as it decreases significantly arterial pressure and heart rate.

Imaging in rheumatoid arthritis: results of group discussions

None of the current scoring methods for radiological damage in rheumatoid arthritis (RA) is ideal. The objective for RA imaging at OMERACT IV was to start discussion about the problems and applicability of the current scoring methods for radiological damage and to start discussion on the challenge of new imaging techniques. The RA imaging module comprised preconference reading material, plenary sessions, small group discussions, and a plenary report of the group sessions, combined with interactive voting. The OMERACT filter guided the discussions. Priorities for further research in imaging studies were: (1) pathologies versus features on radiographs; (2) relation with longterm outcome; and (3) definition of minimum clinically important difference.

Randomized clinical trials and longitudinal observational studies in systemic lupus erythematosus: consensus on a preliminary core set of outcome domains

The OMERACT module on systemic lupus erythematosus (SLE) dealt with the definition of preliminary core sets of outcome domains for randomized clinical trials (RCT) and longitudinal observational studies (LOS). After lectures introducing the problems and addressing the key issues, 6 discussion groups, 3 each for LOS and RCT, discussed and weighted more than a dozen possible items for use as outcome domains. The means of the respective 3 groups were calculated. For both RCT and LOS the same outcome domains received more than 10 of a total maximum of 100 points: disease activity, health related quality of life (HRQOL), damage, and toxicity/adverse events. However, the weights for HRQOL and damage were different for LOS and RCT. A final vote led to the acceptance of these 4 variables as a preliminary core set for outcome in SLE by more than 80% of the participants. This core set will allow for improved design, performance, and evaluation of future studies in SLE. However, a number of domains not included in the core set were regarded as important for further analysis and research.

B lymphocyte antigen D8/17 and repetitive behaviors in autism

OBJECTIVE

Monoclonal antibody D8/17 identifies a B lymphocyte antigen with expanded expression in rheumatic fever, Sydenham's chorea, and subgroups of obsessive-compulsive disorder and Tourette's syndrome with repetitive behaviors. The authors examined the rate of D8/17 expression in children with autism and its correlation with severity of repetitive behaviors.

METHOD

Blood samples from 18 patients with autism and 14 comparable medically ill children were evaluated for percentage of D8/17-positive B cells by immunofluorescence and for streptococcal antibodies. Severity of repetitive behaviors was also determined.

RESULTS

The frequency of individuals with > or =11% D8/17-positive cells was significantly higher in the autistic patients (78%) than the comparison subjects (21%), severity of repetitive behaviors significantly correlated with D8/17 expression, and D8/17-positive patients had significantly higher compulsion scores than D8/17-negative patients.

CONCLUSIONS

D8/17 expression is high in patients with autism and may serve as a marker for compulsion severity within autism.

[Toward a medical approach to the evaluation of activity in a physician-staffed mobile intensive care unit]

OBJECTIVE

To test the ability of various medical criteria for classifying the patients in a physician-staffed mobile intensive care unit (MICU) by referring to intervention times.

STUDY DESIGN

Prospective, open study.

PATIENTS AND METHODS

For all the on-scene interventions of the MICUs over a 10-month period, the following data were prospectively collected: pre-hospital diagnosis, initial severity score, medical care score, immediate outcome and three intervention times: on-scene time (OS), time spent with the patient by the MICU team (MT), total duration of intervention (TD).

RESULTS

A total of 3,672 MICU interventions were included. Median times were 45 min (32-59) for OS, 66 min (41-91) for MT and 85 min (61-116) for TD. The amount of interventions in a city was correlated with the population (R = 0.95; P < 0.001). The medical care score was greater than one in more than half of the patients. It defined five groups of patients which were different for the three intervention times (P < or = 0.001). A third of the patients were directly transported by the MICU to an ICU. For the median test, immediate outcome groups were different for the three intervention times (P < 0.001). After exclusion of patients with initial cardiac arrest, initial severity score defined five groups of patients which were different for the three intervention times (P < 0.002). Initial severity score and medical care score were correlated (R = 0.37; P < 0.001).

CONCLUSION

A classification of the patients based on immediate outcome would be a more accurate indicator of the variability in medical care and consumption of resources in a physician-staffed MICU. In addition, a medical intervention score should be developed to better characterise this medical activity.

Studies on pullulan extracellular production and glycogen intracellular content in Aureobasidium pullulans

Pullulan is a well known extracellular polysaccharidic product of the hyphomycete Aureobasidium pullulans coming into more and more frequent use in commercial and industrial applications. Nevertheless, its cellular origin and biosynthesis pathways still remain uncertain. As pullulan synthesis is increasing while glycogen production is decreasing during growth, it should be possible that the kinetics of production of both polysaccharides, whose cellular locations differ, might be correlated. To check this hypothesis, we have performed biochemical analyses and microscopic studies of the biomass removed at regular intervals during growth. The ultrastructural data have shown that glycogen units were present in all the different cellular types (conidia, swollen cells, chlamydospores) and at all the stages of cellular development. Moreover, analytical studies have shown that glycogen level is time dependent, decreasing in the early exponential stage, whereas the extracellular pullulan content increases. The correlation coefficient (r) calculated between intracellular glycogen and extracellular pullulan levels by the chi2 method suggests that these products are inversely correlated. Ultrastructural and confocal fluorescence data indicate that glycolipids could be implicated in the pullulan biosynthetic pathway.Key words: Aureobasidium pullulans, pullulan, glycogen, metabolism, microscopy.

[Prolonged curarization with suxamethonium in a four-week old infant]

A case of a 28-day-old infant who developed suxamethonium apnoea is described. He was found to be homozygous for atypical cholinesterase. Main characteristics of this disorder are reviewed. Other causes of prolonged apnoea in infants recovering from anaesthesia for surgery of pyloric stenosis are discussed.

[Evaluation of hemostasis before obstetrical epidural anesthesia: a survey in 435 French obstetric departments]

OBJECTIVES

To specify by which means French anaesthesiologists evaluate the haemostasis profile of pregnant women before epidural analgesia.

STUDY DESIGN

Nationwide retrospective survey.

MATERIAL

Questionnaire sent of 847 French obstetrical units.

METHODS

Comparison of categorical qualitative parameters using a chi 2 test.

RESULTS

Answers from 435 centres, including 1,834 anaesthesiologists, performing 227 x 10(3) epidurals for 411 x 10(3) deliveries/year were obtained. A preanaesthetic clinical assessment was performed systematically in two out of three units, and blood samples for PT, aPTT and platelet count were taken in more than 90% of the centres. These laboratory examinations were often made during the 9th month of pregnancy (74%). For more than one-third of the anaesthesiologists, biological data are not essential before epidural puncture. In addition, the lower limits considered as being safe before epidural puncture were highly variable between the teams.

CONCLUSIONS

Coagulation laboratory tests are almost always ordered before epidural obstetrical analgesia in France. The rationale to perform them is not always related to pregnancy induced haemostatic changes. Therefore, this problem should be clarified by a consensus conference for both practical and economical reasons.

Transepithelial transport of large particles in rat: a new model for the quantitative study of particle uptake

The transport of large particles across the intestinal mucosa and the mechanisms of transfer of the particles into the body are still little understood. Fluorescent polystyrene latex particles (2 microm diam.) were administered orally to young male Sprague-Dawley rats in doses of 2.33 x 10(3), 2.33 x 10(6) and 2.33 x 10(9) particles. After 60 min, Peyer's patches and Peyer's patch-free tissues were collected from the small intestine and colon. A novel technique was used to exclude non-translocated particles adherent to the mucosal surface; the intestinal epithelium was stripped from the intestine by immersion in Hanks' balanced salt solution containing 1.5 mM EDTA. Particles in solubilized samples of intact and epithelium-stripped Peyer's patches and Peyer's patch-free intestinal tissue and colon were quantified by fluorescence microscopy. The location of particles within the intact and epithelium-stripped gut samples was revealed by confocal microscopy. Particles were shown to have been taken up along the entire length of the small and large intestines via both Peyer's patches and the normal intestinal epithelium. The number of particles detected in the distal region was greater than in the proximal part of the small intestine, although the difference was not statistically significant. This study has revealed that large numbers of non-translocated particles adhered to the mucosal surface resulting in a high background count. The assay system was considerably improved by the epithelium-stripping technique. The process of transepithelial uptake is a potentially important route of uptake of toxic, immunologically active and radioactive substances. These particles are much larger than the conventionally accepted upper limit for absorbed materials.

Intestinal uptake of particulate material by dexamethasone-treated rats: use of a novel technique to avoid intestinal mucosal contamination

The aim of this study was to investigate the effect of immune suppression on the uptake of particles across the wall of the intestine and the dissemination of the particles to systemic organs. Normal and dexamethasone-immunosuppressed rats were dosed orally with 0.5 mL distilled water or fluorescent polystyrene latex particle suspension containing 2.33 x 10(9) 2-microm diameter particles. One hour after particle dosing, the animals were killed by CO2 asphyxiation. The intestinal tissues and systemic organs were sampled for particle quantitation. To avoid contamination by particles adherent to intestinal mucosa the epithelium of intestinal tissue samples was removed before quantification. The number of fluorescent particles in tissues was determined by fluorescence microscopy of digests of selected samples. The uptake of particulate material across the intestinal wall was significantly (P < 0.05) increased in rats treated with dexamethasone but the number of particles transferred to systemic organs did not differ from values found for control animals. The results suggest that although dexamethasone increased intestinal permeability the apparatus or mechanisms involved in particle transport to distal sites were not affected during immune suppression.

Detection of adenovirus in the waters of the Seine River estuary by nested-PCR

Several systems for isolating viruses from environmental samples have been tested. The most promising method is based on genomic amplification. The authors attempted to detect adenovirus in nucleic-acid extracts from the Seine River estuary by a two-step amplification of a 220-bp segment of the conserved coding region of type 2 adenovirus hexon protein L3. The primers used in this study detected the most prevalent adenovirus serotypes in human disease in France, but not other virus strains or bacteria. The sensitivity of the nested polymerase chain reaction (PCR) amplification was estimated to be 10(2) copies of the adenovirus target sequence per ml of Seine River water. Nucleic-acid extracts from Seine River estuary waters were analysed and some tested positive for the presence of adenoviruses.

Terror management and meaning: evidence that the opportunity to defend the worldview in response to mortality salience increases the meaningfulness of life in the mildly depressed

Previous terror management research has demonstrated that mildly depressed participants show a greater increase in worldview defense in response to reminders of their mortality than do nondepressed participants. Because the cultural worldview is posited to provide a meaningful conception of life, we hypothesized that mildly depressed participants who defend their worldview in response to mortality salience (MS) would increase their perception that the world is meaningful. A preliminary study first examined the Kunzendorf No Meaning Scale as a measure to assess perceptions of meaning. In the primary study, mildly depressed and nondepressed participants contemplated their own mortality or a neutral topic, evaluated two targets in a manner that either allowed them to defend their worldview or that did not, and then completed the Kunzendorf No Meaning Scale. As predicted, mildly depressed participants who had the opportunity to defend their worldview in response to mortality salience reported greater meaning in life than did mildly depressed participants who did not have the opportunity to defend their worldview, or mildly depressed participants not exposed to mortality salience. Implications for understanding and treating depression are briefly discussed.