A model intervention for elder abuse and dementia

This article describes a 2-year collaborative project in Cleveland, OH, that improved the reporting and management of potential and suspected elder abuse situations involving persons with dementia. Educational curricula for cross-training, screening tools, and referral protocols were developed and tested for staff and volunteers in adult protective services and dementia care. A handbook for caregivers of persons with dementia was produced that enables caregivers to self-identify elder abuse risk and seek appropriate interventions to prevent abuse. Project organization, implementation, and evaluation are discussed along with strategies for replication in other communities.

Monitoring osteoporosis therapy with bone densitometry: misleading changes and regression to the mean. Fracture Intervention Trial Research Group

CONTEXT

The principle of "regression to the mean" predicts that patients with unusual responses to treatment might represent outliers who are likely to have more typical responses if treatment is continued without change.

OBJECTIVE

To test whether women who lose bone mineral density (BMD) during the first year of treatment for osteoporosis continue to lose BMD if the same treatment is continued beyond 1 year.

DESIGN AND SETTING

Two randomized, double-blind, placebo-controlled trials in 11 US clinical research centers for the Fracture Intervention Trial and 180 centers in the United States and other countries for the Multiple Outcomes of Raloxifene Evaluation Trial.

PARTICIPANTS AND INTERVENTIONS

Postmenopausal women with low BMD assigned to treatment with 5 mg/d of alendronate sodium in the Fracture intervention Trial who completed 2 years of BMD monitoring and adhered to study medication (n = 2634), and postmenopausal women with osteoporosis assigned to treatment with 60 or 120 mg/d of raloxifene hydrochloride in the Multiple Outcomes of Raloxifene Evaluation trial who similarly completed 2 years of monitoring while adhering to study medication (n = 3954).

MAIN OUTCOME MEASURES

Baseline, 12-, and 24-month hip and spine BMD.

RESULTS

Women with the greatest loss of BMD during the first year of treatment were the most likely to gain BMD during continued treatment. Specifically, among women taking alendronate whose hip BMD decreased by more than 4% during the first year, 83% (95% confidence interval [CI], 82%-84%)had increases in hip BMD during the second year, with an overall mean increase of 4.7%. In contrast, those who seemed to gain at least 8% during the first year lost an average of 1% (95% CI, 0.1%-1.9%) during the next year. Similar results were observed among women taking raloxifene for 2 years.

CONCLUSIONS

Our data suggest that most women who lose BMD during the first year of treatment with alendronate or raloxifene will gain BMD if the same treatment is continued for a second year. These results illustrate the principle of regression to the mean and suggest that effective treatments for osteoporosis should not be changed because of loss of BMD during the first year of use.

Effects of lovastatin on progression of non-dilated and dilated coronary segments and on restenosis in patients after PTCA. The cholesterol lowering atherosclerosis PTCA trial (CLAPT)

OBJECTIVES

The Cholesterol Lowering Atherosclerosis PTCA Trial (CLAPT) is a prospective, randomized trial with blinded angiographic end-points to assess the effect of 2-year's treatment with lovastatin initiated 4 weeks prior to PTCA, compared to usual care on non-dilated coronary segments and on dilated coronary lesions in male patients with total cholesterol between 200 and 300 mg. dl(-1)who underwent elective PTCA.

METHODS AND RESULTS

Two hundred and twenty six patients were randomized 4 weeks prior to PTCA to special care (diet plus lovastatin n=112) or usual care (diet; n=114). One hundred and ninety-nine patients underwent PTCA at baseline and were finally included in the study. Quantitative coronary angiographic assessment was performed on blinded cinefilms at baseline (PTCA) and repeated after 4 and 24 months in 91% and 81% of the patients. The primary end-point was a change in the mean segment diameter of non-dilated segments. The mean lovastatin dose was 33 mg. day(-1). Total- and LDL-cholesterol decreased by 21% and 29% in the special care group and by 7% and 11% in the usual care patients. After 2 years, the mean segment diameter of non-dilated segments decreased by 0.03 mm in the usual care group and 0.004 mm in the special care group (P=0.27). The decrease in the mean segment diameter of dilated lesions was 0.17 mm (usual care) and 0.06 mm (special care) (P=0.04) after 4 months; 0.16 mm (usual care) and 0. 002 mm (special care) after 24 months, respectively (P=0.05). In both groups, the mean segment diameter of dilated lesions increased between 4 and 24 months after PTCA compared to a decrease in mean segment diameter of non-dilated segments (P<0.05). Restenosis (>50% diameter stenosis at follow-up) occurred in 28.4% of usual care and 22.2% of special care patients (P=0.17).

CONCLUSIONS

Lovastatin reduced the progression of dilated lesions in men with elective PTCA. Independent of treatment allocation, the dilated lesions regressed and the non-dilated segments progressed during the study follow-up. Four weeks of pre-treatment with lovastatin did not influence the rate of restenosis. Lovastatin had no statistically significant effect on non-dilated segments.

Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators

CONTEXT

Raloxifene hydrochloride, a selective estrogen receptor modulator, prevents bone loss in postmenopausal women, but whether it reduces fracture risk in these women is not known.

OBJECTIVE

To determine the effect of raloxifene therapy on risk of vertebral and nonvertebral fractures.

DESIGN

The Multiple Outcomes of Raloxifene Evaluation (MORE) study, a multicenter, randomized, blinded, placebo-controlled trial.

SETTING AND PARTICIPANTS

A total of 7705 women aged 31 to 80 years in 25 countries who had been postmenopausal for at least 2 years and who met World Health Organization criteria for having osteoporosis. The study began in 1994 and had up to 36 months of follow-up for primary efficacy measurements and nonserious adverse events and up to 40 months of follow-up for serious adverse events.

INTERVENTIONS

Participants were randomized to 60 mg/d or 120 mg/d of raloxifene or to identically appearing placebo pills; in addition, all women received supplemental calcium and cholecalciferol.

MAIN OUTCOME MEASURES

Incident vertebral fracture was determined radiographically at baseline and at scheduled 24- and 36-month visits. Nonvertebral fracture was ascertained by interview at 6-month-interim visits. Bone mineral density was determined annually by dual-energy x-ray absorptiometry.

RESULTS

At 36 months of the evaluable radiographs in 6828 women, 503 (7.4%) had at least 1 new vertebral fracture, including 10.1% of women receiving placebo, 6.6% of those receiving 60 mg/d of raloxifene, and 5.4% of those receiving 120 mg/d of raloxifene. Risk of vertebral fracture was reduced in both study groups receiving raloxifene (for 60-mg/d group: relative risk [RR], 0.7; 95% confidence interval [CI], 0.5-0.8; for 120-mg/d group: RR, 0.5; 95% CI, 0.4-0.7). Frequency of vertebral fracture was reduced both in women who did and did not have prevalent fracture. Risk of nonvertebral fracture for raloxifene vs placebo did not differ significantly (RR, 0.9; 95% CI, 0.8-1.1 for both raloxifene groups combined). Compared with placebo, raloxifene increased bone mineral density in the femoral neck by 2.1 % (60 mg) and 2.4% (120 mg) and in the spine by 2.6% (60 mg) and 2.7% (120 mg) P<0.001 for all comparisons). Women receiving raloxifene had increased risk of venous thromboembolus vs placebo (RR, 3.1; 95% CI, 1.5-6.2). Raloxifene did not cause vaginal bleeding or breast pain and was associated with a lower incidence of breast cancer.

CONCLUSIONS

In postmenopausal women with osteoporosis, raloxifene increases bone mineral density in the spine and femoral neck and reduces risk of vertebral fracture.

The aroC gene of Aspergillus nidulans codes for a monofunctional, allosterically regulated chorismate mutase

The cDNA and the chromosomal locus of the aroC gene of Aspergillus nidulans were cloned and is the first representative of a filamentous fungal gene encoding chorismate mutase (EC 5.4.99.5), the enzyme at the first branch point of aromatic amino acid biosynthesis. The aroC gene complements the Saccharomyces cerevisiae aro7Delta as well as the A. nidulans aroC mutation. The gene consists of three exons interrupted by two short intron sequences. The expressed mRNA is 0.96 kilobases in length and aroC expression is not regulated on the transcriptional level under amino acid starvation conditions. aroC encodes a monofunctional polypeptide of 268 amino acids. Purification of this 30-kDa enzyme allowed determination of its kinetic parameters (k(cat) = 82 s(-1), n(H) = 1. 56, [S](0.5) = 2.3 mM), varying pH dependence of catalytic activity in different regulatory states, and an acidic pI value of 4.7. Tryptophan acts as heterotropic activator and tyrosine as negative acting, heterotropic feedback-inhibitor with a K(i) of 2.8 microM. Immunological data, homology modeling, as well as electron microscopy studies, indicate that this chorismate mutase has a dimeric structure like the S. cerevisiae enzyme. Site-directed mutagenesis of a crucial residue in loop220s (Asp(233)) revealed differences concerning the intramolecular signal transduction for allosteric regulation of enzymatic activity.

The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple Outcomes of Raloxifene Evaluation

CONTEXT

Raloxifene hydrochloride is a selective estrogen receptor modulator that has antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipid metabolism, and blood clotting.

OBJECTIVE

To determine whether women taking raloxifene have a lower risk of invasive breast cancer.

DESIGN AND SETTING

The Multiple Outcomes of Raloxifene Evaluation (MORE), a multicenter, randomized, double-blind trial, in which women taking raloxifene or placebo were followed up for a median of 40 months (SD, 3 years), from 1994 through 1998, at 180 clinical centers composed of community settings and medical practices in 25 countries, mainly in the United States and Europe.

PARTICIPANTS

A total of 7705 postmenopausal women, younger than 81 (mean age, 66.5) years, with osteoporosis, defined by the presence of vertebral fractures or a femoral neck or spine T-score of at least 2.5 SDs below the mean for young healthy women. Almost all participants (96%) were white. Women who had a history of breast cancer or who were taking estrogen were excluded.

INTERVENTION

Raloxifene, 60 mg, 2 tablets daily; or raloxifene, 60 mg, 1 tablet daily and 1 placebo tablet; or 2 placebo tablets.

MAIN OUTCOME MEASURES

New cases of breast cancer, confirmed by histopathology. Transvaginal ultrasonography was used to assess the endometrial effects of raloxifene in 1781 women. Deep vein thrombosis or pulmonary embolism were determined by chart review.

RESULTS

Thirteen cases of breast cancer were confirmed among the 5129 women assigned to raloxifene vs 27 among the 2576 women assigned to placebo (relative risk [RR], 0.24; 95% confidence interval [CI], 0.13-0.44; P<.001). To prevent 1 case of breast cancer, 126 women would need to be treated. Raloxifene decreased the risk of estrogen receptor-positive breast cancer by 90% (RR, 0.10; 95% CI, 0.04-0.24), but not estrogen receptor-negative invasive breast cancer (RR, 0.88; 95% CI, 0.26-3.0). Raloxifene increased the risk of venous thromboembolic disease (RR, 3.1; 95% CI, 1.5-6.2), but did not increase the risk of endometrial cancer (RR, 0.8; 95% CI, 0.2-2.7).

CONCLUSION

Among postmenopausal women with osteoporosis, the risk of invasive breast cancer was decreased by 76% during 3 years of treatment with raloxifene.

Validation of the Omron F3 blood pressure measuring device for use in the finger through simultaneous invasive comparative measurements according to the German Institute for Validation (DIN) 58130 protocol

OBJECTIVES AND DESIGN

Simultaneous invasive comparative measurements in order to validate the blood pressure measuring device Omron F3 for use in the finger, in accordance with the German Institute for Validation (DIN) 58130 protocol.

METHODS

A total of five consecutive simultaneous blood pressure comparative measurements were carried out in each of 15 patients (n = 75). Blood pressure was measured in the left index finger using the blood pressure measuring device Omron F3, and at the same time invasively using a pigtail catheter situated in the aortic arch. The measuring arrangements, validation of the unit of invasive measurement and evaluation were all carried out in accordance with the DIN 58130 protocol.

RESULTS

The blood pressure measuring device Omron F3 for use in the finger fulfils the criteria of the European Standard prEn 1060-3. Systolic blood pressure decreased by 2.9+/- 6.6 mmHg and diastolic blood pressure decreased by 2.6+/- 5.9 mmHg.

CONCLUSION

The blood pressure measuring device Omron F3 measures blood pressure reliably and accurately if used correctly in appropriate patients. Before using the device for the first time, comparative blood pressure measurements in the upper arm, using the standard auscultatory blood pressure measurement technique according to Riva-Rocci and Korotkoff, should be carried out, in order to check the accuracy of measurement.

Surgical-prosthodontic reconstruction of advanced maxillary bone compromise with autogenous onlay block bone grafts and osseointegrated endosseous implants: a 12-year study of 32 consecutive patients

During a 12-year period (1984 to 1997), 32 consecutive patients with advanced maxillary bone compromise received surgical-prosthodontic rehabilitation. The most frequent procedure used was maxillary augmentation with a free nonvascularized autogenous onlay block bone graft, and the average time of prosthesis function was 67 months. Twenty-eight patients underwent a 1-stage procedure, in which endosseous implants were placed simultaneously for internal rigid skeletal fixation of the onlay bone graft, and 4 patients underwent a 2-stage procedure, in which endosseous implants were placed secondarily 6 months after complete healing of the previously placed onlay bone graft, which initially was stabilized by titanium miniplates and lag screws. Treatment success was evaluated separately for the first 7 consecutively treated patients (developmental group) and for the next 25 consecutive patients (routine group). Assessment was made of implant survival relative to etiology of bone loss, implant type and length, type of prosthesis, type of opposing occlusion, type of surgical procedure, and presence of discontinuity. The implant survival rate was 91% in the 25 routine patients and 65% in the 7 developmental patients. Implant type and length, prosthesis type, opposing occlusion, and the presence or absence of discontinuity significantly impacted treatment outcome. Onlay block bone graft success (96%) in all 32 treated patients and prosthetic success (96%) in the last 25 patients was recorded.

Endosseous implant and autogenous bone graft reconstruction of mandibular discontinuity: a 12-year longitudinal study of 31 patients

Surgical, medical, and prosthodontic records of 61 consecutively treated patients with mandibular discontinuity were reviewed retrospectively. All 61 patients had undergone discontinuity reconstruction with autogenous bone grafts; 31 of 61 had also received endosseous dental implants and a dental osseoprosthesis. Of these 31 implant-reconstructed patients, 23 had free autogenous nonvascularized and 8 had vascularized bone grafts. The surgical-prosthetic protocol consisted primarily of secondary, free autogenous nonvascularized bone graft reconstruction and secondary root-form endosseous implant and fixed prosthesis dental reconstruction. Vascularized bone (8 patients) or soft tissue (4 patients) grafts were utilized selectively for severely compromised patients after extensive oncologic resection, avulsive trauma, or after previous radiation treatment. Endosseous implant survival (95.5% in 31 patients), autogenous bone graft success (98.4% in 61 patients), and dental osseoprosthesis success (100% in 31 patients) were favorable. A high incidence (9.1%) of nonfunctioning (sleeping) implants was recorded for this patient population. The need to remove the titanium mesh tray for various reasons (17.6%) and the need to reconstruct soft tissue in the irradiated patient (12%) were noteworthy.

Geographic differences in bone turnover: data from a multinational study in healthy postmenopausal women

Biochemical markers of bone metabolism (bone markers) are used increasingly to monitor response to therapy and may be predictors of bone loss and fractures. The relationship between fracture rates, which differ between countries, and the rate of bone turnover has not been examined. Therefore, we explored the geographic variability of bone turnover in a selected, healthy study population of 619 postmenopausal women, ages 40-61, participating in a clinical trial of raloxifene hydrochloride for osteoporosis prevention. The subjects were distributed among 38 investigative sites in 10 countries (9-211 subjects/country) on four continents (North America, n = 277, Europe, n = 168, Australia, n = 125, and Africa, n = 49). Specimens for serum osteocalcin (OC), bone-specific alkaline phosphatase (BSAP), and urine type I collagen fragment/urinary creatinine ratio (CTX) were handled in a uniform fashion and assayed in a central laboratory. Mean levels of OC (P < 0.001), BSAP (P = 0. 006), and CTX (P < 0.001) varied significantly by country (ANOVA), with the lowest values typically in German and Spanish subjects and the highest in American and Canadian subjects. The consistent pattern and wide ranges of mean bone marker values (OC 1.6-fold, BSAP 1.7-fold, CTX 3.1-fold) between countries suggest clinically significant differences in bone turnover. Geographic differences in bone markers were not explained by the determined potential confounders of age, years posthysterectomy, total serum cholesterol, and serum follicle stimulating hormone (FSH). We conclude that bone marker values vary substantially by country in this selected study population, suggesting systematic geographic differences in bone metabolism that potentially relate to osteoporotic fracture rates.

TGF-beta isoforms and fibroblast growth factor exhibit analogous indirect antioncogenic activity through triggering of intercellular induction of apoptosis

TGF-beta-1 has recently been shown to trigger nontransformed effector cells to induce apoptosis specifically in transformed cells. This intercellular induction of apoptosis has been discussed as a potential control step in oncogenesis. Here we show that triggering of intercellular induction of apoptosis is not a non-specific growth factor effect, but is restricted to the TGF-beta and FGF family of growth factors. Within the TGF-beta family, all isoforms triggered the intercellular induction of apoptosis with the same efficiency. This finding illustrates that these effects observed have been conserved throughout evolution, which thus points to their potential biological significance. The parallel action of TGF-beta and FGF in the intercellular induction of apoptosis correlates with the role of both families of factors in the establishment and maintenance of the transformed state. Autocrine loops of either growth factor seem to be recognized by the surrounding nontransformed cells and to evoke an apoptosis- inducing effect which thus prevents the survival and outgrowth of potential tumor cells.

[Value of intravascular ultrasound in angiographically underestimated coronary findings: exemplified by 2 case reports]

Coronary angiography is considered to be the most important component in the diagnosis of coronary artery disease. Only the lumen may be visualized using contrast radiography of the coronary arteries, however. With intravascular ultrasound, on the other hand, pathological changes in the vascular wall can be recorded. Despite typical symptoms, an angiographical image of the coronary arteries is sometimes unable to show unambiguous stenotic lesions of the coronary arteries. In such cases, intravascular ultrasound provides a new complementary diagnostic tool for detecting even early forms of arteriosclerosis or angiographically underestimated coronary findings. Two cases are used to illustrate this. In those, angiographic visualization of the coronary arteries was unable to produce an unambiguous finding despite typical clinical symptoms, yet intravascular ultrasound could detect considerable arteriosclerotic wall changes.

[Single-dose spinal anesthesia with a mixture of isobaric bupivacaine 0.5% and hyperbaric mepivacaine 4%]

BACKGROUND

Single-dose spinal anaesthesia with hyperbaric local anaesthetic provides profound analgesia and motor blockade and allows exact assessment of the analgesic level. The present prospective, randomised study compares a mixture of plain 0.5% bupivacaine and hyperbaric 4% mepivacaine with hyperbaric 0.5% bupivacaine with regard to onset time of analgesia and duration of the sensory and motor blockade.

METHODS

One hundred and twenty-two orthopaedic patients (69 m/53 f, aged 20-91 years) scheduled for elective lower limb surgery under spinal anaesthesia were randomly allocated to one of two groups. In group 1, 67 patients received a 1:1 mixture of plain 0.5% bupivacaine and hyperbaric 4% mepivacaine (density: 1,015 kg/m3, 37 degrees C). In group 2, 55 patients received hyperbaric 0.5% bupivacaine (density: 1,021). The lumbar puncture was performed between L3 and L5 using a 26 G Quincke needle through a 20 G introducer with the patients either in the sitting or lateral position. The local anaesthetic was administered with an injection speed of 1 ml per 5 s. Patients with a body height < 160 cm received 2.0 ml, those 160-180 cm 3.0 ml, and those > 180 cm 4.0 ml. The level of analgesia was registered every minute by pin-prick until the maximal analgesic level was reached. The time of regression of analgesia to the level of T 12 and regression of the motor block to Bromage scale 3 was registered. The data were analysed using Student's t-test with P < 0.05 considered as significant.

RESULTS

Demographic data did not differ between groups. In group 1, the onset time of analgesia was faster than in group 2 (8 +/- 3 vs. 14 +/- 5 min, P < 0.001). While in group 1 the onset time of analgesia was faster in patients injected sitting compared to those in the lateral position (p < 0.05), there was no position-related difference in group 2. The groups also did not differ with respect to the maximal level of analgesia and the duration of sensory and motor blockade.

CONCLUSIONS

The local anaesthetic mixture may be preferred to hyperbaric 0.5% bupivacaine in patients requiring a fast onset of analgesia associated with a 2-3 h duration of sensory and motor block.

The Aspergillus niger GCN4 homologue, cpcA, is transcriptionally regulated and encodes an unusual leucine zipper

The general control transcriptional regulator gene cpcA of Aspergillus niger was cloned by complementation of a Saccharomyces cerevisiae delta gcn4 mutant strain. The encoded protein conferred resistance to amino acid analogues when expressed in yeast. Disruption of cpcA in A. niger resulted in a strain which is sensitive towards 3-aminotriazole and fails to respond to amino acid starvation, cpcA encodes a transcript of approximately 2400 nucleotides in length that includes a 5' leader region of 900 nucleotides. The 5' leader region contains two small open reading frames, suggesting translational control of gene expression. Steady-state mRNA levels of cpcA increase by a factor of three upon amino acid starvation. The coding region of cpcA is interrupted by a 57 bp intron and the deduced amino acid sequence displays an approximately 30% overall identity to yeast GCN4p and Neurospora crassa cpc1p. Critical amino acid residues of the transcriptional activation domains of GCN4p are conserved in cpcAp. The basic DNA-binding domain shows up to 70% amino acid sequence identity to other basic zipper (bZIP)-type transcriptional activators. cpcAp binds specifically to a GCN4p recognition element in gel retardation experiments. The C-terminal dimerization domain encodes a leucine zipper with only a single leucine residue.

Postoperative complaints after spinal and thiopentone-isoflurane anaesthesia in patients undergoing orthopaedic surgery. Spinal versus general anaesthesia

BACKGROUND

The present prospective study investigates the impact of a standardized technique of spinal and general anaesthesia on the incidence and consequences of postanaesthetic complaints dependent on age and sex of patients.

METHODS

433 orthopaedic patients underwent lower limb surgery in spinal (group 1) or general (group 2) anaesthesia. Spinal anaesthesia was performed with 0.5% hyperbaric bupivacaine using a 26-gauge Quincke needle. General anaesthesia was induced with i.v. injection of thiopentone, fentanyl and atracurium and maintained with 65% nitrous oxide and 1-1.5 Vol% isoflurane in oxygen. On postoperative day 4, patients were interviewed for onset and duration of postoperative complaints.

RESULTS

The overall incidence of nausea/vomiting (P = 0.025) and sore throat (P = 0.0001) was higher in group 2. In addition, nausea/vomiting was higher in patients between 20 and 60 years in group 2 compared with group 1. While the incidence of urinary dysfunction was higher in men after spinal (P = 0.04), nausea/vomiting was more frequent in women after general anaesthesia (P = 0.008). Analgetic requirements (P = 0.013), time of postoperative surveillance (P = 0.042) and frequency of treatment of postoperative complaints (P = 0.0001) was higher in group 2.

CONCLUSION

Spinal anaesthesia was associated with a lower incidence of postoperative complaints and treatments and a shorter surveillance compared to general anaesthesia. Specific complications related to spinal anaesthesia did not depend on age or sex and may allow for recommendation of this technique even in younger and female patients undergoing orthopaedic surgery.

[The effect of puncture needle on the subarachnoid catheter position in continuous spinal ansthesia]

The subarachnoid position of the microcatheter has an impact on the outcome of continuous spinal anaesthesia (CSA). The present prospective, randomised study investigated the influence of two different spinal needles on the radiographically documented subarachnoid positions of microcatheters in CSA. In addition, the influence of the subarachnoid position of the microcatheter on onset time of analgesia, dose requirement of local anaesthetics, and level of analgesia was examined. METHODS. Forty orthopaedic patients received CSA using a 28-gauge spinal catheter inserted either through a non-directional 22-gauge Quincke needle (group 1) or a directional 22-gauge Sprotte needle (group 2). After initial injection of 2 ml to a maximum of 5 ml of supplemental doses of 0.5% plain bupivacaine, onset time of analgesia at the level of T 10, dose requirement of bupivacaine, and the achieved analgesic level were registered. After surgery, a dye-enhanced AP X-ray film of the lumbar spine was performed for radiological control of the subarachnoid catheter position. RESULTS. There was a higher number of cranial catheter positions in group 2 (60%) compared with group 1 (40%, P = 0.037). In contrast to group 1, with 35% caudally directed catheters, no catheter was seen in a caudal position in group 2. Onset time of analgesia (P = 0.0002) and anaesthetic dose requirement (P = 0.037) were lower in patients with cranially directed catheters compared to patients with the catheters situated at the level of the puncture site or in a caudal position. Maximal analgesic levels were higher in cranially directed catheters compared with other localisations (P = 0.022). CONCLUSIONS. Sprotte needles provide a higher number of cranially directed microcatheters, which are associated with faster onset of analgesia, lower dose requirement of local anaesthetics, and higher analgesic levels in CSA. The results suggest more effectiveness and probably more safety in microcatheter CSA using Sprotte needles for catheter insertion.

A directional needle improves effectiveness and reduces complications of microcatheter continuous spinal anaesthesia

The present prospective randomized study compares the impact of two different spinal needle designs--non-directional versus directional--on the effectiveness of continuous spinal anaesthesia provided via a microcatheter in orthopaedic patients. Using the midline approach, a 28-gauge spinal catheter was inserted either through a 22-gauge Quincke needle (non-directional, Group 1, n = 21) or a 22-gauge Sprotte needle (directional, Group 2, n = 21) under standardized conditions. The incidence of technical difficulties and postoperative complaints, onset time of analgesia at the level of T10 and dose requirement of plain bupivacaine 0.5% were recorded. Postoperatively, the subarachnoid position of the catheters was radiographically evaluated. There was a higher incidence of technical problems during catheter insertion in Group 1 compared with Group 2 (71% vs 19%, P < 0.05). Onset time of analgesia was shorter (P < 0.05) and anaesthetic dose requirement was lower in patients in Group 2 than in Group 1. While 40% of the catheters were found in a caudal position in Group 1, all catheters were in a cranial position or at the level of the puncture site in Group 2 (P < 0.05). There was no difference in the incidence of postoperative complaints between the groups. The faster onset of analgesia and lower dose requirement of local anaesthetics associated with a lower incidence of technical problems suggest that there is greater effectiveness and safety when microcatheters are inserted using directional needles rather than non-directional needles.

Microcatheter continuous spinal anaesthesia in the post-operative period: a prospective study of its effectiveness and complications

One hundred patients (aged 22-86 years, mean 62.5), undergoing lower limb orthopaedic surgery, received continuous spinal anaesthesia using a 28 s.w.g. catheter inserted through a 22 s.w.g. Quincke needle. Post-operative pain relief was provided by bolus injections of 1-2.5 mL 4 h-1 of plain 0.25% bupivacaine. The mean dose of bupivacaine required for sufficient pain relief in 93% of patients was 1.6 +/- 0.2 (1.3-1.9) mL 4 h-1. The highest dose was needed between 4 and 8 h post-operatively. No dependence of dose on age or type of operation was found. Technical problems with the microcatheter occurred in 12%. The most frequent complaint was post-operative backache (12%). Only one patient suffered from post-dural puncture headache on the day after surgery. There was no microbiological contamination of the catheter tips after removal. In the post-operative interview, 89% of the patients were completely satisfied with CSA; 91% would prefer this technique to general anaesthesia.