A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 microg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery

Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl.

IMPLICATIONS

Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.

Lack of evidence for systemic toxicity following topical chloramphenicol use

There has been considerable controversy regarding the safety of topical chloramphenicol in ophthalmic practice. The evidence for associated haematopoietic toxicity in idiosyncratic and dose-dependent forms was reviewed. The 7 cases of idiosyncratic haematopoietic reactions associated with topical chloramphenicol reported in the literature are refutable evidence for the existence of such a response. In Scotland, despite extensive prescription of topical chloramphenicol, the incidence of acquired aplastic anaemia was found to be low, as were associated reports of blood dyscrasias throughout the UK. The epidemiology of acquired aplastic anaemia failed to make an association with topical chloramphenicol use. High-performance liquid chromatography (minimum detection limit 1 mg/l) was used to investigate whether serum accumulation of chloramphenicol occurred after topical therapy in 40 patients. The mean dose of chloramphenicol eye drops used after 1 week of treatment was 8.0 mg, and after 2 weeks, 15.3 mg. As expected, chloramphenicol failed to accumulate to detectable levels. This supported the view that topical chloramphenicol was not a risk factor for inducing dose-related bone marrow toxicity. Calls for the abolition of treatment with topical chloramphenicol based on current data are not supported.

Event-related potential correlates of primed and unprimed words in children co-morbid for disruptive behaviour disorders and academic delay

Children with disruptive behaviour disorders and academic delay (DD-AD) were compared to children with disruptive behaviour disorders only (DD) and normal control children with no psychiatric disturbance or academic delay (NO) with respect to scalp-recorded event-related electrical potentials (ERPs) elicited by semantically primed and unprimed words. Primed words were preceded by spoken words having a related meaning, while unprimed words were preceded by nonassociated spoken words. For normal controls, the unprimed words elicited greater N400 amplitudes at frontal-central recording sites than primed words. Primed vs. unprimed N400 differences were not evident at frontal sites in DD and the DD-AD group failed to exhibit differences in primed vs. unprimed N400 amplitudes at either frontal, central or parietal sites. These findings suggest that DD-AD children may represent a unique neuroelectric subgroup of learning disabilities.

Electron dose calculation using multiple-scattering theory: a hybrid electron pencil-beam model

We have embedded the bipartition model into Fermi-Eyges multiple-scattering theory to produce a more accurate hybrid electron pencil-beam model, by using the fact that away from the edges of a large field, the electron distribution function exactly equals that for an infinitely wide electron beam. The bipartition model calculates various electron transport quantities in a homogeneous or horizontally layered medium with very high accuracy, for an infinitely broad beam. In our hybrid model, we use the bipartition model to calculate the longitudinal part of the pencil-beam distribution function, and the Fermi-Eyges theory to calculate its transverse part. Doing this allows calculation not only of dose distribution, but also of such quantities as electron fluence distribution, energy spectrum, angular distribution, and electron-charge distribution. Using the hybrid electron pencil-beam model, we have calculated the dose distribution for collimated electron beams and compared them with experimental data, for rectangular fields.

[Anal gland carcinoma with osteoblastic metastases]

HISTORY AND CLINICALLY FINDINGS

A 52-year-old woman was admitted because of anal pain of 6 weeks duration. Physical examination was unremarkable except for a cherry-sized swelling, painful to pressure, on rectal examination. As the erythrocyte sedimentation rate and C-reactive protein were increased (69/115 and 12.1 mg/dl, respectively) and abscess was diagnosed. Carcinoembryonic antigen was within normal limits.

INVESTIGATIONS

At rectoscopy a fluctuating abscess-linked swelling was found at 3 cm and a submucous tumour at 5 cm from the anus.

TREATMENT AND COURSE

The abscess was cut open and at the level of the dentate line a submucous adenocarcinoma about 3 cm in diameter was resected. A small residual tumour was removed by abdomino-perineal rectal extirpation. As histologically it was an adenocarcinoma not of colorectal type, without relationship to rectal mucosa but in close contact to the anal glands, and the further course did not indicate a metastasis from another primary tumour, the diagnosis of anal gland adenocarcinoma was established. A local recurrency was resected 6 months later, followed by combined radio- and chemotherapy. A diffuse osteoblastic metastasis was discovered later and the patient died 21 months after diagnosis.

CONCLUSION

An osteoblastic metastasis from an anal gland carcinoma, as occurred in this case, has not been previously reported.

Physical therapists' perception of patients' pain and its effect on management

BACKGROUND AND PURPOSE

The purpose of this qualitative study was twofold: (1) to determine the factors that affected physical therapists' (PTs) perception of patients' pain and (2) to determine how this perception affected the management of patients.

METHODS

Forty-six PTs with at least two years' experience practicing in pain management clinics, outpatient clinics or sports medicine clinics were interviewed. The data collected were transcribed, coded and analyzed for main themes.

RESULTS

The most predominant factors found to affect PTs' perception of patients' pain were the therapist's personal and professional experience, area of practice and evaluative findings.

CONCLUSIONS

In this sample there exists a common link between experience and evaluative findings: the longer PTs have been practicing the more proficient they become in performing and interpreting a thorough subjective and objective evaluation. PTs practicing in pain clinics were found to have a more holistic and multidisciplinary approach to patient care, whereas therapists practicing in outpatient and sports medicine facilities were more apt to focus on patients' physical symptoms and complaints. Four main themes of perceived patient pain and their corresponding management were developed: (1) patients presenting with legitimate/acute pain profiles render a slow, conservative approach by the PT; (2) patients presenting with debilitating/chronic pain were most often treated with an approach that stressed functional gains and patient independence; (3) the preferred treatment of patients characterized with a non-legitimate pain profile was an aggressive and multidisciplinary approach; (4) 'special cases' and their management were dependent upon the patient's functional level and pain tolerance.

Orthopaedic patients' reporting of pain management

Advances in pain management have occurred in recent years through the development of patient-controlled and epidural analgesia, while the conventional regime of intramuscular analgesia has also continued to be used. This article describes a study comparing orthopaedic patients' experiences of postoperative pain using the three methods of analgesia.

The solution structure of the DNA-binding domain of Skn-1

Skn-1 is a maternally expressed transcription factor that specifies the fate of certain blastomeres early in the development of Caenorhabditis elegans. It has been reported that the DNA-binding domain is a molten globule and that the structure cannot be defined because there are no long-range nuclear Overhauser effects (NOEs). Working with short Skn domain fragments and using 13C-labeled proteins, we have been able to identify 28 long-range NOEs that establish a tertiary fold for the Skn domain. The internal region of the Skn domain consists of three stable helices and one conformationally labile helix organized into a nascent helix-turn-helix-turn-helix-turn-helix motif. The N and C termini of the Skn domain are unstructured and emerge from the same end of the folded domain. This structure is consistent with biochemical data on binding of the Skn domain to DNA, which shows that the N and C termini bind in the adjacent minor and major grooves from the same face of the DNA helix. The NMR solution structure of the Skn domain should be useful for developing a complete understanding of the DNA recognition event, including any conformational changes that take place upon binding.

The diagnosis and initial treatment of asthma in young children in New Zealand and the United Kingdom

AIMS

To conduct a pilot study to test methodology in ascertaining if there are differences between New Zealand and the UK in the symptom and circumstance set that influences a general practitioner in the initial diagnosis of asthma, and to ascertain the treatment prescribed at the time that the diagnosis is made.

METHODS

Questionnaires were mailed to 110 general practitioners in each country. General practitioners from the Otago region in New Zealand and from the Nottingham region in Britain were contacted. A follow-up reminder was sent to all non-responders three weeks after the initial mail out. Questions were asked about the symptoms and signs that were considered important, as well as other influences (e.g., passive smoking) when making a diagnosis of asthma in a child under the age of five years. The doctors were also asked what treatment they prescribed at the time of the actual diagnosis of asthma.

RESULTS

British doctors considered night cough (p = 0.05) and cough associated with emotion (p = 0.004) more diagnostic of asthma. New Zealand doctors rated cough associated with temperature change (p = 0.05) as being important and they had a lower threshold in diagnosing asthma with respect to history of similar attacks (p = 0.008) compared to their British counterparts. More New Zealand doctors reported using prophylactic/anti-inflammatory agents as first line therapy (59% vs 28%; p = 0.002).

CONCLUSIONS

We conclude that there are only minor differences in general practitioners' diagnostic criteria for asthma in the two countries with reference to this small sample. We believe, however, that differing diagnostic criteria could account for different reported incidences of childhood asthma in some countries. There is need for internationally accepted diagnostic criteria.

Mental health. Wait not, want not?

The rise in numbers of young people with mental health problems meant that one trust had a waiting list of 143 patients in this group, some of whom had been waiting for over a year. Only 30 per cent of parents of children on the list responded positively to a letter asking them if they wanted their child to remain on the list, resulting in 100 patients being removed. Of these patients, 10 were re-referred within two years, four of them with more severe symptoms. The average time of treatment was longer than for children who had remained on the list, requiring more clinical resources.

Treatment of intrahepatic cancers with radiation doses based on a normal tissue complication probability model

PURPOSE

To attempt to safely escalate the dose of radiation for patients with intrahepatic cancer, we designed a protocol in which each patient received the maximum possible dose while being subjected to a 10% risk of radiation-induced liver disease (RILD, or radiation hepatitis) based on a normal tissue complication probability (NTCP) model. We had two hypotheses: H1; with this approach, we could safely deliver higher doses of radiation than we would have prescribed based on our previous protocol, and H2; the model would predict the observed complication probability (10%).

PATIENTS AND METHODS

Patients with either primary hepatobiliary cancer or colorectal cancer metastatic to the liver and normal liver function were eligible. We used an NTCP model with parameters calculated from our previous patient data to prescribe a dose that subjected each patient to a 10% complication risk within the model. Treatment was delivered with concurrent hepatic arterial fluorodeoxyuridine (HA FUdR). Patients were evaluated for RILD 2 and 4 months after the completion of treatment.

RESULTS

Twenty-one patients completed treatment and were followed up for at least 3 months. The mean dose delivered by the current protocol was 56.6 +/- 2.31 Gy (range, 40.5 to 81 Gy). This dose was significantly greater than the dose that would have been prescribed by the previous protocol (46.0 +/- 1.65 Gy; range, 33 to 66 Gy; P < .01). These data are consistent with H1. One of 21 patients developed RILD. The complication rate of 4.8% (95% confidence interval, 0% to 23.8%) did not differ significantly from the predicted 8.8% NTCP (based on dose delivered) and excluded a 25% true incidence rate (P < .05). This finding supports H2.

CONCLUSION

Our results suggest that an NTCP model can be used prospectively to safely deliver far greater doses of radiation for patients with intrahepatic cancer than with previous approaches. Although the observed complication probability is within the confidence intervals of our model, it is possible that this model overestimates the risk of complication and that further dose escalation will be possible. Additional follow-up and accrual will be required to determine if these higher doses produce further improvements in response and survival.

A nonparametric approach to a survival study with surrogate endpoints

A nonparametric estimator for the joint distribution of a survival time and surrogate response time, which may occur earlier during follow-up, is presented. In the absence of the surrogate response variable, the estimator reduces to the Kaplan Meier nonparametric estimator for the survival time alone. The estimator derived in this paper is done so in a particular novel way using an exchangeable process (reinforced random walks) to model individual observations. The methodology introduced in the paper is readily extended to modelling multiple state processes.

A prospective randomized trial comparing 2 diuresis renography techniques for evaluation of suspected upper urinary tract obstruction in children

PURPOSE

We compare the diagnostic impact of 2 diuresis renography techniques for evaluation of suspected upper urinary tract obstruction in children.

MATERIALS AND METHODS

A total of 72 children were randomly assigned to 1 of 2 standardized diuresis renography protocols. The protocols were identical, except for the time of furosemide (F) injection. In the F+20 scans furosemide was given 20 minutes after the 99mtechnetium pentetic acid radiopharmaceutical. With the modified F-15 scans furosemide was injected 15 minutes before renography. Hydration, bladder catheterization, urine output determination, radiopharmaceutical injection and scan acquisition were identical. Renography outcomes (obstructed, nonobstructed or equivocal) were analyzed for the investigated side(s) and for the contralateral side, which was used as a control in children with suspected unilateral obstruction. Chi-square test was used to compare the percentage of obstructed and nonobstructed scans of both protocols. Fisher's exact test was used to compare the nonobstructed scans and equivocal results of both protocols.

RESULTS

Of the 96 scans performed 8 were excluded because of technical problems. The remaining scans included 44 F+20 and 44 F-15. Of the 88 scans 10 were used to evaluate possible bilateral obstruction. A total of 48 boys and 24 girls were evaluated. Because 2 children had a solitary kidney each, the total number of renal units studied for outcome was 174. The F-15 scan showed 7 times more obstruction than the F+20 scan on the investigated side, and this difference was statistically significant. No obstruction was diagnosed on the contralateral side with either technique when used to investigate cases of suspected unilateral obstruction.

CONCLUSIONS

The timing of the furosemide injection (F-15 scan versus F+20) has a significant impact on the obstructive versus nonobstructive renography results when evaluating children with suspected upper urinary tract obstruction.

Amphotericin B in lipid emulsion: stability, compatibility, and in vitro antifungal activity

Newer formulations of amphotericin B (AmB) complexed with liposomes or lipid suspensions have been developed. Preliminary studies have suggested that AmB in Intralipid (IL) may be as effective as, but less toxic than, conventional formulations of AmB, but few data are available regarding its stability, compatibility, or in vitro antifungal activity. A compatibility study was done to evaluate the effects of AmB concentrations in IL containing either 10 or 20% soybean oil. The effects of temperature, shaking, and AmB and IL concentrations on the stability of AmB-IL suspensions were analyzed by visual inspection and liquid chromatography. The in vitro antifungal activity of AmB-IL, compared to that of AmB alone against reference strains of Candida species was determined by using a broth macrodilution method in accordance with National Committee for Clinical Laboratory Standards guidelines (M27-T). Samples of AmB-IL which were lightly shaken retained more than 90% of the AmB concentration over 21 days when stored at either 4 or 23 degrees C. Varying the AmB concentration did not appear to affect the stability of AmB-IL. However, a precipitate was formed when mixtures with more than 30% lipid as a proportion of the total volume were centrifuged. AmB-IL and AmB alone had similar in vitro antifungal activities against reference strains of yeasts. Further pharmacologic and clinical studies with AmB-IL are warranted, although AmB should not be combined with IL in concentrations capable of producing a precipitate.

Medium term results of lung transplantation for end stage pulmonary sarcoidosis

BACKGROUND

Lung transplantation is an accepted therapeutic option for patients with end stage pulmonary sarcoidosis. However, the medium term outcome of transplantation in this patient group is unknown.

METHODS

This study was performed to evaluate our experience with lung transplantation for end stage pulmonary sarcoidosis. Between July 1988 and July 1997 12 patients (nine men) underwent lung transplantation for sarcoidosis at our institution. Ten underwent single lung transplantation and two double lung transplantation.

RESULTS

Survival at three and five years was 70% and 56%, respectively. Three patients developed obliterative bronchiolitis at six, 18, and 45 months. One died at the time of retransplantation. Sarcoid granulomas have recurred in the donor organ in three patients. In one the development of granulomas has been associated with clinical deterioration, necessitating retransplantation. Mean (SD) forced expiratory volumes in one second at three and five years were 1.37 (0.67) 1 and 1.34 (0.13) 1, respectively.

CONCLUSIONS

Lung transplantation is a viable option for patients with end stage pulmonary sarcoidosis. The medium term results are comparable with patients undergoing lung transplantation for other indications. Despite histological recurrence of sarcoidosis, the risk of clinically important recurrence is low.

Site-specific data confirm arsenic exposure predicted by the U.S. Environmental Protection Agency

The EPA uses an exposure assessment model to estimate daily intake to chemicals of potential concern. At the Anaconda Superfund site in Montana, the EPA exposure assessment model was used to predict total and speciated urinary arsenic concentrations. Predicted concentrations were then compared to concentrations measured in children living near the site. When site-specific information on concentrations of arsenic in soil, interior dust, and diet, site-specific ingestion rates, and arsenic absorption rates were used, measured and predicted urinary arsenic concentrations were in reasonable agreement. The central tendency exposure assessment model successfully described the measured urinary arsenic concentration for the majority of children at the site. The reasonable maximum exposure assessment model successfully identified the uppermost exposed population. While the agreement between measured and predicted urinary arsenic is good, it is not exact. The variables that were identified which influenced agreement included soil and dust sample collection methodology, daily urinary volume, soil ingestion rate, and the ability to define the exposure unit. The concentration of arsenic in food affected agreement between measured and predicted total urinary arsenic, but was not considered when comparing measured and predicted speciated urinary arsenic. Speciated urinary arsenic is the recommended biomarker for recent inorganic arsenic exposure. By using site-specific data in the exposure assessment model, predicted risks from exposure to arsenic were less than predicted risks would have been if the EPA's default values had been used in the exposure assessment model. This difference resulted in reduced magnitude and cost of remediation while still protecting human health.