Holmium YAG laser treatment of superficial bladder carcinoma

Holmium YAG laser is one of the new modalities of treatment of urinary bladder tumor. Thirty patients of superficial bladder carcinoma were selected from the Urology out patient department of Dhaka Medical College Hospital from January 2004 to July 2004. Among thirty cases, 18 were recurrent and 12 were primary superficial bladder carcinoma. Out of thirty patients, 24 were male and six were female. Patients were treated with Holmium YAG laser under spinal anesthesia. Before resection, cold cup biopsy were taken from the apex and after resection of the tumor, another cold cup biopsy were taken from the base of the tumor. Holmium YAG laser therapy was given with a 550 micron end firing quartz laser fiber through the working element of resectoscope. Small tumors (< 1 cm) were ablated and large tumors (1-4 cm) were resected. The initial laser setting was 0.5 to 0.8 J and 10 Hz. For resection of the tumor, a slightly higher energy of 1 to 1.2 J was used at 10 to 12 Hz. After resection, bleeding vessels were coagulated. The resected tumor was evacuated by Elik's evacuator. All cases were followed for 6 to 12 months by history, physical examination, urine analysis, sonogram and cystoscopy three monthly. Bleeding was minimum during the procedure and no transfusion was required. Complications like obturator jerk, clot retention or perforation were not developed. No recurrence was found during the 6 to 12 months follow up period. The procedure was found safe, effective, and acceptable. The study was conducted to evaluate the initial result of Holmium YAG laser for the treatment of superficial bladder carcinoma. We warrants further studies in this regard.

Holmium laser urethrotomy for urethral stricture

A prospective cross-sectional study was carried-out in the department of urology, Dhaka Medical College Hospital (DMCH) to evaluate the outcome of Laser urethrotomy for the treatment of urethral stricture. For this purpose, 30 male patients aged 15 to 60 years with short segment anterior urethral stricture (>2cm) were treated by HO:YAG Laser. The energy used for this purpose was 0.8 to 1.5 joules by LISA 80 Watt Holmium Laser machine. All patients were catheterized for less than 24 hours and were followed up for 6 to 12 months postoperatively by uroflowmetry and by retrograde with voiding cystourethrogram 3 monthly. The study revealed that out of 30 patients, 27(90%) showed good flow of urine (Qave>16.0 ml/sec) and adequate caliber urethra in retrograde urethrogram (RGU). Only 3(10%) patients showed narrow stream of urine (Qave<8.0 ml/sec) and recurrent stricture in RGU which were managed by optical internal urethrotomy (OIU) and clean intermittent self catheterization (CISC). The study showed satisfactory results in 90% cases with short term follow up. The study concludes that HO:YAG Laser urethrotomy for the treatment of short segment urethral stricture is highly effective. The study further reveals that the method is simple, safe and thus, it can be considered favorably as a new therapeutic option for the treatment of urethral stricture. However, long term follow up is necessary for making a final comment on this issue.

Neurophysiology in clinical practice

Clinical neurophysiology is concerned with the recording of generation and propagation of electrical potentials of nerve and muscle cells. It can provide important information about brain and neuromuscular disorders. Electro encephalogram (EEG), Evoked potentials (EP), Nerve conduction study (NCS) and electromyogram (EMG) are the four main techniques used in clinical neurophysiology. EEG reflects the electrical activity arising from the cerebral cortex. Evoked Potentials are measurements of classic stimulus response. VEP, SSEP and BSAEP are most useful in diagnosing Multiple Sclerosis, Plexus lesions and 8(th) cranial nerve tumor, CP angle tumor respectively. Nerve conduction studies are the measurement of velocity of nerve impulse. It gives information about the lesion of a myelinated nerve. Electromyogram gives information about the integrity of innervations, condition of neuromuscular junctions and also condition of the muscle fiber itself.

Evidence for Pauli exchange leading to excited-state enhancement in electron transfer

Single- and double-electron transfer to autoionizing 1s2l2l(') configurations in fluorine ions have been investigated for 1.1 MeV/u collisions of F7+ and F8+ with He and Ne. The resulting Auger electron emission spectra show anomolously large intensities for the formation of the metastable 1s(2s2p 3P) 4P state compared to the similarly configured 1s(2s2p 3P) 2P- and 1s(2s2p 1P) 2P+ states. The large 4P intensity, which cannot be explained on the basis of spin statistics, is attributed instead to the Pauli exchange of similarly aligned electrons.

Acceptance of long-term contraceptive methods and its related factors among the eligible couples in a selected union

This study focuses on the acceptance of long-term contraceptive methods and its related factors among the eligible couples in the rural area of Bangladesh. Among the respondents sixty were acceptors and one hundred seventy were non-acceptors of long-term contraceptive methods. Socio-demographic characteristics of the both acceptors and non-acceptors of long-term contraceptive methods were same except their age. Acceptors of long-term contraceptive method were older than the non-acceptors. Regarding the reproductive characteristics acceptors were married for longer time than non-acceptors. There was significant association between acceptance of long-term method and number of male children and desired additional children. Acceptors had more living male children and desired less additional children than non-acceptors. Regarding reasons for acceptance 35% accepted the method because the methods are long-term and safe while 30% accepted because the methods well suited them and 18% because accepted don't need to take daily like pills. Main cause for not accepting long-term methods fear of side-effects (22%) lack of proper knowledge about the methods (21%) followed by husbands objection (12%), desire for more children (10%) and health reasons (8%).

A clinical review of large cerebello pontile angle tumors

The study was designed as retro-prospective and the study period was 3.5 years. A total of 66 (42 prospective and 24 retrospective) consecutive patients were included in the study. The commonest tumor in CPA is the Schwannoma (76%) followed by Meningioma (13.3%) and Epidermoid (4.44%). Unusual forms are Ependymoma and Hemangiopericytoma. Amongst the troublesome clinical features headache, hearing loss, vertigo and imbalance, vomiting and tinnitus were more important besides visual failure and features of lower cranial nerve involvement. The objective of the study is to "Review the Large Cerebello Pontile Angle tumors clinically". In this study 66 large CPA tumors were included and analyzed. Analysis of variance (ANOVA) was implied for the test of significance. On the whole, n=66 Schwannoma represents 76.70% and Meningioma 15.38%. Of these there are 45 cases with histological verification. The most common presenting (average duration is 1.3 years) symptoms were Headache (94.54%) and Hearing loss of varying grade (85.45%). Vertigo or imbalance was present in 67.27% cases. Vomiting was found in 54.54% of the times and difficulties in deglutition or voice change were complained of in 29.09% cases. Tinnitus was found only in 27.27% cases and it was the complaint mostly in lower diameter tumors. By maximum diameter, there were 24 cases measuring 3-4 cm, 15 more than 4 cm and only one case <3 cm sized tumors. Volume-wise tumors with volume <10 cc were 5 cases, 10-20 cc were 10, 20-30 cc were 13, 30-40 cc were 6 and >40 cc were 6. Similarly tumor volume and posterior fossa volume ratio was as follows: <10% were 6 cases, 10-20% were 15 cases, 20-30% were 7 cases and >30% were 6 cases. Amongst the schwannomas, the consistency of the tumor has been shown to be important factor for LCN involvement. The softer variety involved LCN more often than the harder (p<0.05). The involvement of the different groups of lower cranial nerve ranged from 7% to 92%.

Shoulder and elbow function following Marchetti-Vicenzi humeral nail fixation

Humeral nailing has been associated with reduction of shoulder and elbow function. We present the results of fixation of 15 diaphyseal humeral fractures with Marchetti-Vicenzi nails (B Braun Medical Aesculap). Shoulder and elbow functions were assessed by the Constant shoulder and Mayo elbow scoring systems. The average Constant Shoulder score was good (82.5/100) and the average Mayo Elbow Score was excellent (95.4/100). The indications for surgery included nonunion, pathological fractures and poor fracture position. The mean follow-up was 67 weeks with an average interval to surgery of 19 weeks. The mean time to union was 19 weeks. All the fractures united without any patient requiring any further procedure. There were two postoperative radial nerve palsies and one median nerve palsy, however two patients had complete recovery and one had partial recovery of the radial nerve. There was one deep infection requiring removal of the implant. There were no implant failures. Based on our experience, the Marchetti-Vicenzi humeral nail appears as a relatively safe implant and its use has been associated with preservation of good shoulder and elbow functions.

Comparison of non-invasive blood pressure measurements on the arm and calf during cesarean delivery

OBJECTIVE

Shivering may occur in 75% of women undergoing spinal anesthesia for cesarean delivery and may render an automated noninvasive blood pressure (ANIBP) device incapable of determining blood pressurc (BP). When patients shiver under spinal anesthesia, the lower extremities do not exhibit the same involuntary muscle movements as do the upper extremities. This study was undertaken to determine if a correlation exists between ANIBP measurements in the arm and calf of women undergoing cesarean delivery under spinal anesthesia.

METHODS

We enrolled 73 women in this blinded, prospective study. Simultaneous arm and calf BP were measured with an ANIBP and differences between the two were determined.

RESULTS

We found significant differences between the average difference in systolic and in diastolic BP, no significant difference between the average mean BP, and a tendency for the systolic BP to be higher and the diastolic BP to be lower in the calf than in the arm; however, there was a large degree of variability among patients.

CONCLUSION

We conclude that there is a poor correlation between the BP measured by an ANIBP on the calf and one on the arm. In the parturient undergoing cesarean section, lower extremity BP as measured by an ANIBP does not correlate with the arm ANIBP and should not be used to assure fetal well being.

Correction of hammer toe with an extended release of the metatarsophalangeal joint

Between March 1995 and January 2000 we reviewed retrospectively 84 patients with hammer-toe deformity (99 feet; 179 toes) who had undergone metatarsophalangeal soft-tissue release and proximal interphalangeal arthroplasty. The median follow-up was 28 months. Patients were assessed by the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and reviewed by independent assessors. The median AOFAS score was 83, with 87% of patients having a score of more than 60 points; 83% were satisfied and 17% were dissatisfied with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction, with 14% having moderate or severe pain. Only 2.5% had instability and 9% had formation of callus. There was no statistical difference for the age and gender of the patients, the number of toes operated on, associated surgery for hallux valgus or length of follow-up. Our study was based on an anatomical model and shows good results with no recurrence of deformity.

Correction of hammer toe with an extended release of the metatarsophalangeal joint

Between March 1995 and January 2000 we reviewed retrospectively 84 patients with hammer-toe deformity (99 feet; 179 toes) who had undergone metatarsophalangeal soft-tissue release and proximal interphalangeal arthroplasty. The median follow-up was 28 months. Patients were assessed by the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and reviewed by independent assessors.

The median AOFAS score was 83, with 87% of patients having a score of more than 60 points; 83% were satisfied and 17% were dissatisfied with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction, with 14% having moderate or severe pain. Only 2.5% had instability and 9% had formation of callus.

There was no statistical difference for the age and gender of the patients, the number of toes operated on, associated surgery for hallux valgus or length of follow-up. Our study was based on an anatomical model and shows good results with no recurrence of deformity.

The visual analog scale for pain: clinical significance in postoperative patients

BACKGROUND

The visual analog scale is widely used in research studies, but its connection with clinical experience outside the research setting and the best way to administer the VAS forms are not well established. This study defines changes in dosing of intravenous patient-controlled analgesia as a clinically relevant outcome and compares it with VAS measures of postoperative pain.

METHODS

Visual analog scale measurements were obtained from 150 patients on the morning after intraabdominal surgery. On the same afternoon, 50 of the patients provided a VAS score on the same form used in the morning, 50 on a new form, and 50 were not asked for a second VAS measurement.

RESULTS

Visual analog scale values and changes in value were similar for patients who were given a new VAS form in the afternoon and those who used the form that showed the morning value. The proportions of patients requesting additional analgesia were 4, 43, and 80%, corresponding to afternoon VAS scores of 30 or less, 31-70, and greater than 70, respectively. Change from morning VAS score had no apparent influence on patient-controlled analgesic dosing for patients with afternoon values of 30 or less or greater than 70, but changes in VAS scores of at least 10 did discriminate among patients whose afternoon values were between 31 and 70.

CONCLUSIONS

When pain is an outcome measure in research studies, grouping final VAS scores into a small number of categories provides greater clinical relevance for comparisons than using the full spectrum of measured values or changes in value. Seeing an earlier VAS form has no apparent influence on later values.

Phylogeny of Cryptocercus species (Blattodea: Cryptocercidae) inferred from nuclear ribosomal DNA

The wood-feeding cockroaches of the genus Cryptocercus occur in temperate forests. Of the seven known species, five occur in the United States and two in Eurasia. Until 1997, all populations in the United States were considered a single species. Populations in the western United States were elevated to a species status based on variation in DNA sequence and morphology. In 1999, three new species were described from the eastern United States based on variation in chromosome number and mitochondrial DNA, bringing the number of species in the United States to five. The objective of this study was to determine if the DNA sequence of nuclear rRNA also signals the existence of four species in the eastern United States and to compare the inferred relationships with those proposed based on mitochondrial sequences. We obtained the DNA sequence from a portion of the 5.8S and 28S rRNA genes and the entire ITS2 region from 38 individuals and 30 additional clones to assess intraindividual, intraspecific, and interspecific variation. We found extensive sequence variation among the various species and little or no intraindividual and intraspecific variation. Phylogenetic analysis indicated the existence of monophyletic lineages among the eastern United States samples, which largely corresponded to the four species previously described. The inferred relationships were well-supported by bootstrap analysis and decay indices. Although the nuclear rRNA sequences resulted in a coherent phylogenetic tree, the ITS2 region contained many insertions and deletions, which may introduce homoplasy and ambiguity in alignment as more taxa are added to the data set.

Use of intraoperative transesophageal echocardiography to predict atrial fibrillation after coronary artery bypass grafting

BACKGROUND

Postoperative atrial fibrillation in coronary artery bypass graft surgery occurs in 10-40% of patients. It is associated with a significant degree of morbidity and results in prolonged lengths of stay in both the intensive care unit and hospital.

METHODS

The authors prospectively evaluated patients undergoing coronary artery bypass with detailed transesophageal echocardiography examinations conducted before and after cardiopulmonary bypass to study whether risk factors for atrial fibrillation could be identified. Demographic and surgical parameters were also included in the analysis. Selected variables were subjected to univariate and subsequent multivariate analyses to test for their independent or joint influence on atrial fibrillation.

RESULTS

Seventy-nine patients had assessable transesophageal echocardiography examinations. Significant univariate predictors of atrial fibrillation included advanced age (P = 0.002), pre-cardiopulmonary bypass left atrial appendage area (P = 0.04), and post-cardiopulmonary bypass left upper pulmonary vein systole/diastole velocity ratio (P = 0.03). When these three factors were considered together in a multiple logistic regression analysis, left upper pulmonary vein systole/diastole velocity ratio was a significant predictor (P < 0.05), as was the joint effect of age plus pre-cardiopulmonary bypass left atrial appendage area (P = 0.005). The probability of developing atrial fibrillation for the combination of age = 75 yr, post-cardiopulmonary bypass left upper pulmonary vein systole/diastole velocity ratio = 0.5, and left atrial appendage area = 4.0 cm was 0.83 (95% confidence interval, 0.51-0.96).

CONCLUSIONS

Early identification of patients at risk for postoperative atrial fibrillation may be feasible using the parameters identified in this study.

Clinicopathological correlation of acute appendicitis

Acute appendicitis is the most common acute surgical condition of the abdomen and appendicectomy is the most frequently performed urgent abdominal operation. Delay in treatment of acute appendicitis causes lot of complications. On the other hand, to reduce complications prompt diagnosis and treatment results lot of negative laparotomy (as high as 25%). The prime aim of this study was to reduce the incidence of negative laparotomy.

Negative knee arthroscopy: Is it really negative?

PURPOSE

To evaluate the outcome of patients in whom knee arthroscopy proved to be normal.

TYPE OF STUDY

Retrospective study.

METHODS

Knee arthroscopy is probably the most common procedure performed in orthopaedic practice. A number of patients who undergo this procedure do not have any abnormality detected. Is negative arthroscopy really such an unnecessary procedure? Hospital records of patients who had undergone knee arthroscopy were retrospectively studied and all patients with a normal knee arthroscopy were selected. Fifty-three patients (55 knees) with a normal arthroscopy were included into the study. Patients were then interviewed either by telephone or questionnaire to ascertain current symptoms, job changes, and patient perception of the procedure.

RESULTS

The mean follow-up was 43 months. Fifty percent of the patients had a history of injury, and the preoperative diagnosis was thought to be a meniscal lesion or a rupture of the anterior cruciate ligament in 38% of patients. Sixty-eight percent of the patients felt that they were better and there were no complications. The incidence of all symptoms were significantly reduced after arthroscopy.

CONCLUSIONS

A significant number of patients felt that they were better after the knee arthroscopy. The reason for this is not entirely clear. It may well be attributable to a placebo effect, the fact that patients now know that there is no abnormality and learn to live with the symptoms, or there may be an additional benefit of the procedure itself.

Retrograde cerebral perfusion during thoracic aortic surgery and late neuropsychological dysfunction

OBJECTIVE

Retrograde cerebral perfusion (RCP) is commonly used in thoracic aortic surgery, ostensibly to provide metabolic support, maintain cerebral hypothermia and/or wash out particulate emboli. We tested the hypothesis that RCP would affect neuropsychological outcome in a clinical cohort.

METHODS

Ninety-four patients undergoing elective thoracic aortic repairs requiring deep hypothermic circulatory arrest consented to participate in this study. These patients underwent preoperative neuropsychological evaluation and comprise the reference group. Fifty-six of these patients also underwent neuropsychological evaluation several weeks postoperatively, 12 of whom (21%) had RCP. The neuropsychological domains tested were attention, processing speed, memory, executive function, and fine motor function. A global assessment of impairment, negative neuropsychological outcome (NNO), was defined as a postoperative decrease in function in two or more neuropsychological domains for patients with at least three domains tested both pre- and postoperatively (n=48). The relationship of three potential predictors (RCP, cerebral ischemia time and patient age) to negative outcomes was analyzed using Wilcoxon two-sample tests, chi(2) tests, Mantel-Haenszel tests and multiple logistic regression. P<0.05 was considered significant.

RESULTS

Memory dysfunction and NNO had strong associations with RCP. This effect remained significant when controlling separately for age and cerebral ischemia time.

CONCLUSIONS

The effects of RCP are difficult to distinguish from those of age and prolonged cerebral ischemia time, because complex thoracic aortic repairs are associated with advanced age, prolonged cerebral ischemia and use of RCP. Despite this limitation, these preliminary data indicated that RCP had no beneficial effect (and most likely a negative effect) upon cognitive outcome.

Chronic administration of docosahexaenoic acid improves the performance of radial arm maze task in aged rats

1. In the present study, we investigated the effect of docosahexaenoic acid (DHA) on spatial memory related learning ability in aged (100 weeks) male Wistar rats. 2. Rats were fed a fish oil-deficient diet through three generations and were then randomly divided into two groups. Over 10 weeks, one group was per orally administered 300 mg/kg per day DHA dissolved in 5% gum Arabic solution and the other group was administered the vehicle alone. Five weeks after the start of the administration, rats were tested with the partially baited eight-arm radial maze to estimate two types of spatial memory related learning ability displayed by reference memory error and working memory error. 3. Chronic administration of DHA significantly decreased the number of reference memory errors and working memory errors. 4. The level of lipid peroxide (LPO) in the hippocampus tended to decrease with chronic DHA administration and demonstrated a positive correlation with the number of reference memory errors. 5. These results suggest that the accumulation of hippocampal LPO reduces spatial memory related learning ability in aged rats. Moreover, chronic administration of DHA was effective in decreasing the level of hippocampal LPO, then improving learning ability.

Prevalence of home deliveries and antenatal care coverage in some selected villages

A cross sectional study was conducted in 14 selected villages of Gazipur Thana with the aim to find the prevalence of home deliveries and ante natal care coverage. All those females who delivered in the recent past (within last three months) from the selected villages were the study population Data were collected by two trained interviewers with a semi-structured interview schedule. Study result shows that 83% of the respondents received ante natal check-up throughout their last pregnancy. Most of this group (88.5%) received this care from "Health Assistant or 'Family Welfare visitor's while only 3.1% received care from graduate doctors. Out of 505 respondents 91.3% of the respondents was found to have delivered at home while only 8.7% at institutions. Study findings also suggested that there was association of place of delivery with level of education and family income of the respondents. Also there was associations of utilisation of antenatal care with level of education and family income of the respondents.

Nicorandil--induced ATP release in endothelial cells of rat caudal artery is associated with increase in intracellular Ca(2+)

The effect of nicorandil, an ATP-sensitive K(+) channel opener, on the level of intracellular Ca(2+) ([Ca(2+)](i)) and on ATP release in endothelial cells of the rat caudal artery was examined using a fluorescent confocal microscopic imaging system and high-performance liquid chromatography (HPLC) with fluorescent detection, respectively. Nicorandil significantly increased [Ca(2+)](i) and the overflow of ATP and its metabolites. The former reaction was abolished in the absence of extracellular Ca(2+), but it did not change in the presence of thapsigargin or cyclopiazonic acid. The increase in the overflow of ATP and [Ca(2+)](i) induced by nicorandil was markedly suppressed by glibenclamide, an ATP-sensitive K(+) channel blocker. The increase of [Ca(2+)](i) induced by nicorandil was significantly and inversely correlated with the level of intracellular ATP in the endothelial cells, suggesting that activation of ATP-sensitive K(+) channels by nicorandil increases Ca(2+) influx in endothelial cells. The increase of [Ca(2+)](i) might be associated with ATP release.

An investigation of a new activated clotting time "MAX-ACT" in patients undergoing extracorporeal circulation

Activated clotting time (ACT) is a test used in the operating room for monitoring heparin effect. However, ACT does not correlate with heparin levels because of its lack of specificity for heparin and its variability during hypothermia and hemodilution on cardiopulmonary bypass (CPB). A modified ACT using maximal activation of Factor XII, MAX-ACT (Actalyke MAX-ACT; Array Medical, Somerville, NJ), may be less variable and more closely related to heparin levels. We compared MAX-ACT with ACT in 27 patients undergoing CPB. We measured ACT, MAX-ACT, temperature, and hematocrit at six time points: baseline; postheparin; on CPB 30, 60, and 90 min; and postprotamine. Additionally, we assessed anti-Factor Xa heparin activity and antithrombin III activity at four of these six time points. With institution of CPB and hemodilution, MAX-ACT and ACT did not change significantly but had a tendency to increase, whereas concomitant heparin levels decreased (P = 0.065). Neither test correlated with heparin levels. ACT and MAX-ACT did not differ during normothermia but did during hypothermia, and ACT was significantly longer than MAX-ACT (P = 0.009). At the postheparin time point, ACT-heparin sensitivity (defined as [ACT postheparin - ACT baseline]/[heparin concentration postheparin - heparin concentration baseline]) was greater than MAX-ACT-heparin sensitivity (analogous calculation for MAX-ACT; 520 [266 - 9366] s. U(-1). mL(-1) vs 468 [203 - 8833] s. U(-1). mL(-1); P = 0.022).

IMPLICATIONS

MAX-ACT (a new activated clotting time [ACT] test) uses more maximal clotting activation in vitro and, although it is less susceptible to increase because of hypothermia and hemodilution than ACT, lack of correlation with heparin levels remains a persistent limitation.

Coevolution between a cockroach and its bacterial endosymbiont: a biogeographical perspective

Cryptocercus are subsocial, xylophagous cockroaches that live in temperate forests. Like other cockroaches, Cryptocercus harbour endosymbiotic bacteria in their fat bodies. Two species of Cryptocercus occur in the palaearctic, one each in eastern Russia and south-central China. In the USA, there are five species: one in the north-west and four in the south-east. Little is known about the relationship between the Eurasian and North American Cryptocercus or the causes of the disjunct distribution. Here, a molecular phylogeny for six out of the seven Cryptocercus species and their endosymbionts is inferred in an attempt to understand the evolution and biogeography of the genus. Our analysis showed that the North American Cryptocercus are monophyletic, suggesting that a single colonization event was followed by vicariance. There was complete concordance between the host and endosymbiont phylogenetic trees. Divergence estimates based on endosymbiont DNA sequences suggested that the palaearctic and nearctic Cryptocercus diverged 70-115 million years (Myr) ago and the eastern- and western-USA species diverged 53-88 Myr ago. These divergence estimates were correlated with biogeographical events, and a hypothesis is presented to explain the current distribution of Cryptocercus. Our findings suggest that Cryptocercus has had a long evolutionary history, dating back to the Jurassic.

Dislocation of Insall-Burstein II modified total knee arthroplasty

Dislocation of total knee arthroplasty is a rare but serious complication. The experience with the Insall-Burstein II modified knee prosthesis, which was designed to address the issue of dislocation, has been favorable. We present a series of 3 dislocations in 1,500 total knee arthroplasties done with this prosthesis, accounting for about 0.2% of cases.

Improved epidural analgesia in the parturient in the 30 degree tilt position

PURPOSE

To compare the incidence of incomplete analgesia when epidural local anesthetic is administered with the parturient supine in a 30 degree leftward tilt or in the left lateral decubitus position.

METHODS

After placement of a multiorifice catheter 5 cm into the epidural space, 293 women in active labour were randomly positioned either to the left lateral decubitus position (lateral group) or supine with a 30 degree leftward tilt (tilt group) and then received 13 mL bupivacaine 0.25%. The success of the epidural block was determined by asking the patient if she required additional medication 15 min later. The incidence of complications (fetal heart rate decelerations, hypotension, and ephedrine usage) was noted.

RESULTS

In the lateral group, 38% required additional medication compared with 24% in the tilt group (P = 0.006). There were no differences between groups in the incidence of maternal hypotension or fetal heart rate decelerations, but more women (10%) received ephedrine in the lateral than in the tilt group (4%), P = 0.035.

CONCLUSIONS

Placing the parturient supine with a 30 degree leftward tilt is associated with a greater success rate of labour epidural analgesia without an increase in complications than in women in the left lateral decubitus position. This advantage should be considered when positioning the parturient after epidural catheter placement.