External dacryocystorhinostomy in consultants and fellows - a comparison of the causes of failure

PURPOSE

Failure of primary dacryocystorhinostomy (DCR) often requires revision surgery to inspect the cause of failure and re-establish anatomic patency. This study aims to specifcally compare the anatomical causes of failure noted during revision DCR of primary external DCR (EX-DCR) and compare the difference between consultants and fellows.

METHODS

A retrospective review of 37 patients who underwent revision of a primary external approach DCR over a 7-year-period in a University Hospital. All primary surgery was performed by either a consultant surgeon or senior oculoplastic fellow. Details of the initial pathology prior to primary DCR and grade of operating surgeon were collected along with perioperative surgical findings. The cause of failure of the initial surgery was classified according to perioperative findings. Failure was classified as either inappropriately sized/located ostium or fibrous/membranous soft tissue obstruction of the newly created ostium.

RESULTS

The cause of failure of the initial surgery was soft tissue obstruction in 43.3% and an inappropriately sized/located ostium in 56.7%. In those patients whose primary surgery was performed by a consultant, 73.3% were found to have a soft tissue obstruction and 26.7% were found to have an inappropriately sized/ located ostium. In contrast, if initial surgery was performed by a fellow, 22.7% were found to have a soft tissue obstruction and 77.3% an inappropriately sized/ located ostium (p =0.002).

CONCLUSIONS

Where the primary surgeon has been a trainee there is a trend toward inadequately sized or located ostium being the most likely causative factor in failure of primary EX-DCR.  Hippokratia 2015; 19 (3): 216-218.

Patients' perceptions of health-related quality of life during and after adjuvant radiotherapy for T1N0M0 breast cancer

AIMS

The effects of radiotherapy on health-related quality of life (HRQOL) may influence decisions about adjuvant radiotherapy after breast-conserving surgery. We sought women's ratings of HRQOL during and after radiotherapy.

MATERIALS AND METHODS

Women completed HRQOL measures before, during and after adjuvant radiotherapy for node-negative, hormone receptor-positive breast cancers that were less than 2 cm in size. Acute and late toxicities were rated by clinicians.

RESULTS

There were 161 participants with a median age of 58 years (range 34-82). Mean scores for most aspects of HRQOL worsened only slightly during radiotherapy and improved to baseline levels or better within a few months. The symptoms rated as most distressing were: difficulty sleeping (29%), fatigue (23%), breast discolouration (21%), uncertainty about the future (18%), feeling sad or depressed (18%), feeling anxious or worried (19%). Most rated their experience as better (39%) or much better (28%) than expected. Grade 3 toxicities were rare (5% acute, 1% late) with no grade 4 toxicities.

CONCLUSIONS

Radiotherapy was associated with transient and generally mild impairments in a few aspects of HRQOL. Concerns about adverse effects on HRQOL should not weigh heavily on decisions about adjuvant breast radiotherapy.

Intravitreal bevacizumab injection in unrecognised early pregnancy

PURPOSE

The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age.

PATIENTS AND METHODS

We present our experiences following intravitreal injection of bevacizumab during the first trimester of unrecognised pregnancies in four women.

RESULTS

All our patients were inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place. There were three cases of pregnancy without complication and one case of complicated pregnancy in which there was a significant past obstetric history.

CONCLUSION

This case series provides further insights into intravitreal injection of bevacizumab in early pregnancy. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections. Should a woman become pregnant, counselling is needed to explain the potential risks and benefits, and the limited available data relating to the use of these agents in early pregnancy.

A Year of Fractures: a snapshot analysis of the logistics, problems and outcomes of a hospital-based fracture liaison service

SUMMARY

Our fracture liaison service identifies patients with low trauma fractures, determines the need for osteoporosis therapy and instigates therapy if necessary. We describe the tracking and outcome of 768 patients attending our emergency department over 1 year and discuss the problems we encountered and potential solutions.

INTRODUCTION

Osteoporotic fractures result in substantial morbidity, mortality and economic cost, and patients sustaining a first fracture are known to be at higher risk of sustaining future fracture. Treatment of at-risk patients has been shown to assist in prevention of future fracture including hip fracture. We established a "First Fracture Project" to identify and treat these patients in 2003.

METHODS

We assessed "A Year of Fractures": the logistics, outcome and problems in tracking patients presenting to our emergency department with a low trauma fracture by our fracture liaison service, over 1 year from July 2008 to June 2009. Patients were tracked by our osteoporosis nurse and offered assessment, and treatment where necessary.

RESULTS

In 1 year, 768 patients aged 50 or over were identified from emergency department records as attending with a low trauma fracture. About 84 % of patients eventually received assessment. Of the162 patients progressing through the entire process, 74 % had osteoporosis treatment planned and/or commenced.

CONCLUSIONS

Our fracture liaison service was effective at identifying most low trauma fracture patients at risk of further fracture and providing access to osteoporosis assessment. There were many difficulties: we outline logistic and practical issues in delivering our service and suggest potential improvements.

Intravenous zoledronic acid and oral alendronate in patients with a low trauma fracture: experience from an osteoporosis clinic

BACKGROUND/AIMS

Oral bisphosphonates have been shown to be effective in treating osteoporosis. However, there has been a significant problem with compliance. Newer intravenous bisphosphonates are available for osteoporosis management, but have not been compared with oral bisphosphonates in a clinical setting. The aim of this study was to compare the safety and effectiveness of intravenous zoledronic acid (ZOL) and oral alendronate (ALN) in osteoporotic patients following a low trauma fracture.

METHODS

A non-randomized, retrospective cohort study was conducted of 169 patients with a low trauma fracture and reduced bone mineral density (BMD). Patients were treated with either an infusion of 4 mg ZOL or ALN 70 mg weekly. The outcomes measured were change in BMD after 12 months of treatment with either bisphosphonate, and new osteoporotic fractures. All adverse events were documented.

RESULTS

Lumbar spine BMD (L2-L4) improved 5.6% in the ZOL group (P < 0.001) and 5.5% in the ALN group (P < 0.001). Total hip BMD improved 2% in the ZOL group (P < 0.01) and 2.5% in the ALN group (P < 0.001). There was no significant difference in BMD change between the groups. There were significantly more new fractures (P < 0.001) in the ZOL group (7.2%) than the ALN group (1%). The ZOL group were significantly older (P < 0.01) and had a significantly higher proportion of males (P < 0.05) at baseline. There were no serious adverse reactions in either group.

CONCLUSION

ZOL and ALN both produce a significant increase in BMD and are well tolerated in patients with osteoporotic, low trauma fractures. Yearly ZOL provides a safe, convenient alternative to weekly oral bisphosphonates.

Clinical correlates of sex steroids and gonadotropins in men over the late adulthood: the Framingham Heart Study

Low serum concentrations of sex steroids and gonadotropins in men have been associated with increased cardiometabolic risk and mortality, but the clinical correlates of these hormones in men over late adulthood are less clearly understood. We analysed up to five serial measurements of total testosterone (TT), dehydroepiandrosterone sulphate (DHEAS), follicle stimulating hormone (FSH), luteinizing hormone (LH) and total estradiol (EST) in older men in the original cohort of the Framingham Heart Study to determine the short- (2-years; 1,165 person-observations in 528 individuals) and long-term (up to 10-years follow-up; 2520 person-observations in 835 individuals with mean baseline age: 71.2 years) clinical correlates of these sex steroids and gonadotropins using multilevel modelling and Generalized Estimating Equations. Age, body mass index and pre-existing type 2 diabetes were inversely related to long-term TT concentrations, whereas higher systolic blood pressure showed a positive association. Furthermore, age and pre-existing cardiovascular disease (CVD) were inversely associated and HDL cholesterol concentrations positively associated with long-term DHEAS concentrations respectively. Analyses of short-term changes revealed age was inversely related to DHEAS, but positively related to FSH and LH concentrations. Our community-based study identified modifiable correlates of decreasing TT and DHEAS concentrations in elderly men, suggesting that maintenance of a low CVD risk factor burden may mitigate the age-related decline of these hormones over the late adulthood.

Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial

OBJECTIVES

Women with a sonographic short cervix in the mid-trimester are at increased risk for preterm delivery. This study was undertaken to determine the efficacy and safety of using micronized vaginal progesterone gel to reduce the risk of preterm birth and associated neonatal complications in women with a sonographic short cervix.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled trial that enrolled asymptomatic women with a singleton pregnancy and a sonographic short cervix (10-20 mm) at 19 + 0 to 23 + 6 weeks of gestation. Women were allocated randomly to receive vaginal progesterone gel or placebo daily starting from 20 to 23 + 6 weeks until 36 + 6 weeks, rupture of membranes or delivery, whichever occurred first. Randomization sequence was stratified by center and history of a previous preterm birth. The primary endpoint was preterm birth before 33 weeks of gestation. Analysis was by intention to treat.

RESULTS

Of 465 women randomized, seven were lost to follow-up and 458 (vaginal progesterone gel, n=235; placebo, n=223) were included in the analysis. Women allocated to receive vaginal progesterone had a lower rate of preterm birth before 33 weeks than did those allocated to placebo (8.9% (n=21) vs 16.1% (n=36); relative risk (RR), 0.55; 95% CI, 0.33-0.92; P=0.02). The effect remained significant after adjustment for covariables (adjusted RR, 0.52; 95% CI, 0.31-0.91; P=0.02). Vaginal progesterone was also associated with a significant reduction in the rate of preterm birth before 28 weeks (5.1% vs 10.3%; RR, 0.50; 95% CI, 0.25-0.97; P=0.04) and 35 weeks (14.5% vs 23.3%; RR, 0.62; 95% CI, 0.42-0.92; P=0.02), respiratory distress syndrome (3.0% vs 7.6%; RR, 0.39; 95% CI, 0.17-0.92; P=0.03), any neonatal morbidity or mortality event (7.7% vs 13.5%; RR, 0.57; 95% CI, 0.33-0.99; P=0.04) and birth weight < 1500 g (6.4% (15/234) vs 13.6% (30/220); RR, 0.47; 95% CI, 0.26-0.85; P=0.01). There were no differences in the incidence of treatment-related adverse events between the groups.

CONCLUSIONS

The administration of vaginal progesterone gel to women with a sonographic short cervix in the mid-trimester is associated with a 45% reduction in the rate of preterm birth before 33 weeks of gestation and with improved neonatal outcome.

The effect of acute and chronic exercise on thyroid hormones in obesity

Thyroid hormones were measured before, during and after acute exercise (60 min) or physical training (3 months) in obese women. Thyroid stimulating hormone concentration increased during acute work and decreased immediately after. No changes were seen during the two following days. An increase was seen after ten days as well as after three months of physical training. Thyroxine concentrations showed no changes. 3,5,3'-Triiodothyronine decreased slightly immediately after acute exercise, and after three months of physical training, 3,3',5'-triiodothyronine (reverse triiodothyronine) increased slowly during and after acute exercise. A negative correlation was found between changes in fasting insulin and thyroxine and a positive correlation between changes in blood pressure and triiodothyronine after training. Lack of agreement in previous reports is probably due to methodological differences such as methods more or less susceptible to fatty acid interference, and thyroid hormones changing differently during acute work and before and after physical training. The duration of the study may also be of importance, even 3 months possibly being too short for attaining equilibrium in thyroid homeostasis.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to March 2007. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data from included studies, assessed quality and confirmed decisions by consulting with all other reviewers.

MAIN RESULTS

Thirty-three studies, involving 10,400 participants, were included. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Long-term adjustment of early-stage ovarian cancer survivors

The objectives of this study were to describe the quality of life (QOL), consequences of treatment, complementary therapy use, and factors correlating with psychologic state in 58 survivors of early-stage ovarian cancer since little is known about the QOL of early-stage ovarian cancer survivors. Survivors were interviewed using standardized measures to assess physical, psychologic, social, and sexual functioning; impact of cancer on socioeconomic status; and complementary therapy use. Survivors reported good physical QOL scores and few unmet needs. However, menopausal symptoms and negative impact on sexuality were reported. Less than 10% of survivors reported either an interest in sex or were sexually active. Psychologic assessment yielded a subset of 26% of patients with scores suggestive of posttraumatic stress disorder (PTSD) and 40% of survivors scored below the norm on the Mental Health Inventory-17 Survey. One third of patients required treatment for family/personal problems and took antianxiety medications. About 56% of survivors reported fear of cancer recurrence and 59% reported anxiety when their CA125 is tested. Better mental health was significantly related to less fatigue (Functional Assessment of Cancer Therapy [FACT]-fatigue, r = 0.61, P < 0.0001), less pain (European Organisation for Research and Treatment of Cancer [EORTC], r =-0.54, P < 0.0001), fewer stressful life events (Life Event Scale, r =-0.44, P > 0.001), and greater social support (MOS Social Support Survey, r = 0.41, P < 0.01). Early-stage ovarian cancer survivors had few physical complaints and unmet needs, but psychologic distress was evident in a subset of survivors; the majority of survivors reported sexual dysfunction. These results indicate the need for intervention and improved distress screening in the early-stage ovarian cancer population.

First Fracture Project: addressing the osteoporosis care gap

Patients sustaining a low-trauma fracture are at greater risk of subsequent fracture, but as a group are poorly managed. We report the development of our 'First Fracture Project', in which we attempt to assess all patients over 50 years of age with a low-trauma fracture attending orthopaedic fracture clinics and treat osteopenia and osteoporosis. We found that the First Fracture Project has greatly increased our success in improving delivery of osteoporosis care to appropriate at-risk patients.

Long-term impact of chemotherapy on early stage ovarian cancer patients

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Background: Quality of life (QOL) assessments in early stage (stage I and II) ovarian cancer survivors (CS) are limited and have to date not focused on CS who have received adjuvant platinum- and taxane-based chemotherapy (CT). Methods: 55 early stage ovarian patients (pts) were identified from patient logs from the Dana-Farber Cancer Institute and Massachusetts General Hospital. 54 pts. received CT. QOL and long-term medical sequelae were measured in pts who were > 3 years from diagnosis and had no evidence of recurrent cancer. Pts were interviewed by phone, and the following surveys were administered: EORTC QLQ-C30 (EORTC) and QLQ-OV28 (OV-28), MHI-17, CALGB sexual functioning, GOG Neuropathy, FACT Fatigue, Beck’s Hopelessness, Fear of Recurrence (FOR), Dyadic Adjustment Scale (DAS), PCL-C post-traumatic stress disorder (PTSD), Unmet Needs, FACT-Spirituality (FACT-Sp), complementary therapy use, and MOS Social Support (MOS). Results: 55 pts were interviewed (mean age 58 yrs, range 34 to 77 yrs). Mean time between diagnosis and interview was 5.6 yrs. CS reported significantly higher MHI-17 scores than the population norm, and higher MHI-17 scores were associated with better overall QOL (EORTC, r = 0.57, p < 0.0001), increased social support (MOS, r = 0.54, p < 0.0001), and better marital relationships (DAS, r = 0.42, p < 0.001). Sexual problems (1.57 out of 6) and unmet needs (1.5 out of 14) were minimal. FOR was correlated with lowered overall QOL (EORTC, r = −0.63, p < 0.0001), increased abdominal symptoms (OV-28 abdominal scale, r = 0.48, p < 0.0002), increased hopelessness (Beck’s, r = 0.46, p < 0.0005), and increased spirituality (FACT-Sp, r = −0.57, p < 0.0001). CS were using 5.4 complementary therapies for QOL purposes and 5.8 for cancer treatment. Minimal negative socioeconomic impact was observed in CS (0.16 out of 4). However, 12.5% of pts had scores indicative of a diagnosis of PTSD. Conclusions: Long-term QOL follow-up of early stage ovarian cancer survivors demonstrated minimal long-term symptoms, excellent mental health, minimal unmet needs, and minimal socioeconomic impact.

No significant financial relationships to disclose.

Utility of osteopontin as a biomarker in recurrent epithelial ovarian cancer

OBJECTIVE

Osteopontin (OPN) is overexpressed in tumors and serum of ovarian cancer patients and may serve as a biomarker. To evaluate the utility of serum osteopontin in monitoring disease status, we evaluated 234 serum samples from post-oophorectomy patients with ovarian cancer and 38 samples from healthy controls.

METHODS

Serum samples were collected from 203 women with recurrent ovarian cancer and 31 newly diagnosed women participating in an experimental chemotherapeutic clinical trial. Controls included 11 young healthy women and 27 peri- or postmenopausal women without ovarian cancer. Samples were assayed for osteopontin using an enzyme-linked immunosorbent assay (ELISA) kit. Statistical analyses for group comparisons of biomarker distribution used the nonparametric Wilcoxon's rank sum test for two-group comparisons and the Kruskal-Wallis test for three-group comparisons.

RESULTS

Osteopontin values ranged from 25 to 1463 ng/ml for patients and 25 to 617 ng/ml for controls. Mean patient levels were lower than mean control levels (74 ng/ml vs. 147 ng/ml, respectively, P = 0.0006). Serum osteopontin levels correlated with recurrent disease versus remission (68 ng/ml vs. 34 ng/ml, P = 0.0034), presence of ascites versus absence (71 ng/ml vs. 53 ng/ml, P = 0.0002), and bulky disease vs. nonbulky disease (75 ng/ml vs. 38 ng/ml, P = 0.0005). CA-125 values yielded the same trends with greater statistical difference.

CONCLUSIONS

These results demonstrate that serum osteopontin concentrations in post-oophorectomy patients with recurrent ovarian cancer are not greater than in healthy controls. Nevertheless, within this heterogeneous patient population, the values do correlate with bulk of disease. The potential utility of this assay in monitoring women with CA-125 negative disease is worthy of exploration.

An adaptation of the Framingham coronary heart disease risk function to European Mediterranean areas

AIM

To determine whether the Framingham function accurately predicts the 10 year risk of coronary disease and to adapt this predictive method to the characteristics of a Spanish population.

METHOD AND RESULTS

A Framingham function for predicting 10 year coronary deaths and non-fatal myocardial infarction was applied to the population of the province of Gerona, Spain, where the cumulated incidence rate of myocardial infarction has been determined since 1988 by a specific registry. The prevalence of cardiovascular risk factors in this region of Spain was established in 1995 by a cross sectional study on a representative sample of 1748 people. The number of cases estimated by the Framingham function for 10 year coronary deaths and non-fatal myocardial infarction was compared with that observed. The Framingham function estimated 2425 coronary heart disease cases in women and 1181 were observed. In men, 9919 were estimated and 3706 were observed. Recalibrating the Framingham equations to the event rate and the prevalence of the risk factors in Gerona led to estimates very close to the number of cases observed in Gerona men and women.

CONCLUSIONS

The Framingham function estimates more than doubled the actual risk of coronary disease observed in north east Spain. After calibration, the Framingham function became an effective method of estimating the risk in this region with low coronary heart disease incidence.

Identifying bipolar disorders in individuals with intellectual disability

OBJECTIVE

The aim of the present study was to characterize adults with intellectual disability (ID) and concomitant clinical diagnoses of bipolar disorder (BPD), and determine whether DSM-IV criteria would distinguish individuals with BPD from patients with other psychiatric diagnoses.

METHODS

A retrospective chart review was done of a convenience sample of adult patients seen over a 3-year period in a specialty clinic for adults with ID and psychiatric disorders. The DSM-IV criteria were used to differentiate individuals with clinical symptoms of BPD from groups of patients with other mood or thought disorders with behavioural symptoms which frequently overlap those of BPD. Behavioural symptoms were also catalogued and used to distinguish the diagnostic groups.

RESULTS

Subjects with clinical symptoms of BPD had significantly more DSM-IV mood-related and non-mood-related symptoms, as well as functional impairments, compared to individuals with major depression, depression with psychosis or schizophrenia/psychosis NOS (not otherwise specified). Likewise, behavioural profiles of the BPD group of patients differed significantly from patients in the other three groups.

CONCLUSIONS

Bipolar disorder can be readily recognized and distinguished from other behavioural and psychiatric diagnoses in individuals with ID, and DSM-IV criteria can be useful in the diagnosis of BPD.

Single vs weekly courses of antenatal corticosteroids for women at risk of preterm delivery: A randomized controlled trial

CONTEXT

The practice of administering weekly courses of antenatal corticosteroids to pregnant women at risk of preterm delivery is widespread, but no randomized trial has established the efficacy or safety of this practice.

OBJECTIVES

To evaluate the efficacy of weekly administration of antenatal corticosteroids compared with a single course in reducing the incidence of neonatal morbidity and to evaluate potential complications of weekly treatment.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled intention-to-treat trial conducted in 13 academic centers in the United States from February 1996 through April 2000.

PARTICIPANTS

A total of 502 pregnant women between 24 and 32 completed weeks' gestation who were at high risk of preterm delivery.

INTERVENTION

All patients received a complete single course of antenatal corticosteroids (either betamethasone, 12 mg intramuscularly repeated once in 24 hours for 2 doses, or dexamethasone, 6 mg intramuscularly repeated every 12 hours for 4 doses). Participants who had not delivered 1 week after receipt of the single course were randomly assigned to receive either betamethasone, 12 mg intramuscularly repeated once in 24 hours for 2 doses every week until 34 weeks' gestation or delivery, whichever came first (n = 256), or a similarly administered placebo (n = 246).

MAIN OUTCOME MEASURE

Composite neonatal morbidity (including severe respiratory distress syndrome, bronchopulmonary dysplasia, severe intraventricular hemorrhage, periventricular leukomalacia, proven sepsis, necrotizing enterocolitis, or perinatal death).

RESULTS

Composite morbidity occurred in 22.5% of the weekly-course group vs 28.0% of the single-course group (unadjusted relative risk, 0.80; 95% confidence interval, 0.59-1.10). Neither group assignment nor the number of treatment courses was associated with a reduction in composite morbidity.

CONCLUSIONS

Weekly courses of antenatal corticosteroids did not reduce composite neonatal morbidity compared with a single course of treatment. Weekly courses of antenatal corticosteroids should not be routinely prescribed for women at risk of preterm delivery.

The pharmacokinetics of epidural ropivacaine in infants and young children

The pharmacokinetic variables of ropivacaine were characterized after epidural bolus injection in pediatric patients. The subjects, 7 infants (aged 3-11 mo) and 11 young children (aged 12-48 mo), received 1.7 mg/kg of ropivacaine via a lumbar epidural catheter. Total plasma concentrations of ropivacaine measured over 24 h were assayed by high-pressure liquid chromatography, and pharmacokinetic modeling was performed by Nonlinear Mixed Effects Modeling analysis. The median peak venous plasma concentrations (C(max)) in infants and young children were 610 microg/L (interquartile range [IQR], 550-725 microg/L) and 640 microg/L (IQR, 540-750 microg/L), respectively. The median times to maximum plasma ropivacaine concentration (T(max)) were 60 min (IQR, 60-120 min) in infants and 60 min (IQR, 30-90 min) in young children. There were no statistical differences between median values of C(max) and T(max) between infants and young children. The calculated clearance (CL) in infants was 4.26 mL x min(-1) x kg(-1) (9% coefficient of variation), and in young children it was 6.15 mL x min(-1) x kg(-1) (11% coefficient of variation). The CL for infants was significantly less than the CL for young children (P < 0.01). The volume of distribution was estimated to be 2370 mL/kg (9% coefficient of variation) for both young children and infants. No systemic toxicity was observed in either group.

IMPLICATIONS

This study revealed that the pharmacokinetic variables of lumbar epidural bolus ropivacaine in pediatric patients aged 3 to 48 mo are similar to those of adults, except that drug clearance was less in infants compared with older children.