Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

P–687 Impact of medroxyprogesterone acetate (MPA) as pituitary suppression on oocyte quality and clinical outcomes in egg donation recipients

Study question

To compare the impact on oocyte quality and reproductive outcomes in patients who received oocytes from donors stimulated with MPA versus GnRH antagonist protocol.

Summary answer

Compared to GnRH antagonist, MPA does not exert a major effect on oocyte quality and yields similar reproductive outcomes in egg donation recipients.

What is known already

Conventional ovarian stimulation (OS) protocols have classically used GnRH analogues, both agonists and antagonists, to avoid premature follicular luteinization. The oral administration of MPA or micronized progesterone during the follicular phase of OS has emerged as an attractive alternative to conventional protocols in the prevention of early luteinization. Compared to progesterone, MPA is characterized by a moderate-strong progestanic action, lower androgenic properties and does not interfere with the measurement of endogenous progesterone. In our group, administration of MPA during the follicular phase of OS has been included in the routine clinical practice of our donor program since late 2019.

Study design, size, duration

Multicentre, retrospective, observational, cohort study carried out in eleven private university-affiliated IVF centers. The present study included a total of 14,282 fresh ovum donation cycles performed from October 2017 to March 2020. Oocyte donors were recruited and stimulated under either MPA (n = 4,665) or GnRHa (n = 9,617) to suppress the pituitary during the follicular phase of OS, and GnRH agonist was administered to trigger final oocyte maturation in all the participants.

Participants/materials, setting, methods

Recipients were divided according to the protocol used for premature luteinization prevention during the follicular phase of the ovum donation matched-cycle: Group 1, recipients who received oocytes from donors treated with 10 mg/day of MPA (ProgeveraÒ); Group 2, recipients who received oocytes from GnRH antagonist (FyremadelÒ) down-regulated donor cycles. All the procedures were approved by an Institutional Review Board (1910-VLC–091-JG) and complied with Spanish law on assisted reproductive technologies (14/2006).

Main results and the role of chance

Regarding donoŕs baseline characteristics, age and antral follicle count were significantly different between groups, but not clinical differences. The length of ovarian stimulation was similar in both groups (10.7 days [95% Confidence Interval (CI) 10.5–10–8] vs 10.5 days [95% CI 10.0–11.00]). Despite slightly higher mean total dose of FSH administered in Group 1 compared to Group 2 (1.841 IU [95% CI 1.813–1.868] vs 1.739 IU [95% CI 1.723–1.754]), there were no differences in the total dose of hMG administered between both groups (967 IU [95% CI 901–1.034] vs 971 IU [95% CI 944–998]). With regard to IVF data, both the number of retrieved oocytes (22.9 [95% CI 22.4–23.4] vs 24.1 [95% CI 23.8–24.3]), and mature oocytes (18.7 [95% CI 18.3–19.1] vs 19.3 [95% CI 19.1–19.6]), were slightly lower in Group 1 compared to Group 2, whereas fertilization rate was significantly higher in Group 1 compared to Group 2 (82.1% [95% CI 81.7–82.6] vs 80.8% [95% CI 80.6–81.2]),. Regarding the clinical outcomes, no differences were observed in either implantation rate (58.7% [95% CI 56.7–60.7] vs 59.3% [95% CI 57.3–61.3]) or clinical pregnancy rate (59.5% vs 59.8%, P = 0.04) between both groups.

Limitations, reasons for caution

As a consequence of being a retrospective study, only association, and not causation, can be inferred from the results. A further limitation is that donors are healthy young women and do not perfectly match other populations, as infertile patients who may be older, low or high responders to OS.

Wider implications of the findings: MPA emerges as an effective oral alternative to GnRH analogues for preventing premature luteinizing hormone surges in donors undergoing OS in ovum donation program. Compared with GnRH antagonists, MPA has advantages of being an oral administration route and providing easy access, yielding similar clinical results.

Trial registration number

1910-VLC–091-JG

Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor?

OBJECTIVE

To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors.

METHODS

This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions.

RESULTS

In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068).

CONCLUSION

When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Atmospheric implications of large C2-C5 alkane emissions from the U.S. oil and gas industry

Emissions of C₂-C₅ alkanes from the U.S. oil and gas sector have changed rapidly over the last decade. We use a nested GEOS-Chem simulation driven by updated 2011NEI emissions with aircraft, surface and column observations to 1) examine spatial patterns in the emissions and observed atmospheric abundances of C₂-C₅ alkanes over the U.S., and 2) estimate the contribution of emissions from the U.S. oil and gas industry to these patterns. The oil and gas sector in the updated 2011NEI contributes over 80% of the total U.S. emissions of ethane (C₂H₆) and propane (C₃H₈), and emissions of these species are largest in the central U.S. Observed mixing ratios of C₂-C₅ alkanes show enhancements over the central U.S. below 2 km. A nested GEOS-Chem simulation underpredicts observed C₃H₈ mixing ratios in the boundary layer over several U.S. regions and the relative underprediction is not consistent, suggesting C₃H₈ emissions should receive more attention moving forward. Our decision to consider only C₄-C₅ alkane emissions as a single lumped species produces a geographic distribution similar to observations. Due to the increasing importance of oil and gas emissions in the U.S., we recommend continued support of existing long-term measurements of C₂-C₅ alkanes. We suggest additional monitoring of C₂-C₅ alkanes downwind of northeastern Colorado, Wyoming and western North Dakota to capture changes in these regions. The atmospheric chemistry modeling community should also evaluate whether chemical mechanisms that lump larger alkanes are sufficient to understand air quality issues in regions with large emissions of these species.

Emergence of spatiotemporal dislocation chains in drifting patterns

One-dimensional patterns subjected to counter-propagative flows or speed jumps exhibit a rich and complex spatiotemporal dynamics, which is characterized by the perpetual emergence of spatiotemporal dislocation chains. Using a universal amplitude equation of drifting patterns, we show that this behavior is a result of a combination of a phase instability and an advection process caused by an inhomogeneous drift force. The emergence of spatiotemporal dislocation chains is verified in numerical simulations on an optical feedback system with a non-uniform intensity pump. Experimentally this phenomenon is also observed in a tilted quasi-one-dimensional fluidized shallow granular bed mechanically driven by a harmonic vertical vibration.

Symmetry-induced pinning-depinning transition of a subharmonic wave pattern

The stationary to drifting transition of a subharmonic wave pattern is studied in the presence of inhomogeneities and drift forces as the pattern wavelength is comparable with the system size. We consider a pinning-depinning transition of stationary subharmonic waves in a tilted quasi-one-dimensional fluidized shallow granular bed driven by a periodic air flow in a small cell. The transition is mediated by the competition of the inherent periodicity of the subharmonic pattern, the asymmetry of the system, and the finite size of the cell. Measurements of the mean phase velocity of the subharmonic pattern are in good agreement with those inferred from an amplitude equation, which takes into account asymmetry and finite-size effects of the system, emphasizing the main ingredients and mechanism of the transition.

The cadherin-catenin complex in laryngeal squamous cell carcinoma

Abnormal Wnt signaling and impaired cell–cell adhesion due to abnormal E-cadherin and β-catenin function have been implicated in many cancers, but have not been fully explored in laryngeal squamous cell carcinoma. In this study, β-catenin cellular location and E-cadherin expression levels were analyzed in 16 laryngeal squamous cell carcinomas (LSCCs) (9 glottic and 7 supraglottic) and 11 samples of non-tumoral inflammatory larynx tissue, using immunohistochemical methods. All non-tumoral tissues showed equally strong membranous expression of β-catenin, while cytoplasmic expression was found in only 3 of the 11 samples. By contrast, whereas 8/9 glottic LSCCs exhibited only membranous expression of β-catenin, 6/7 supraglottic LSCCs displayed both membranous and cytoplasmic expression (p = 0.003). Strong E-cadherin staining was observed in 9/11 non-tumoral tissues and 7/9 glottic LSCCs, whereas 4/7 supraglottic LSCCs exhibited weak expression. Reduced membrane expression of E-cadherin and cytoplasmic retention of β-catenin in supraglottic LSCC seems to be related with more aggressive biological behavior which has been described in clinical studies. Further research is required to clarify the involvement of β-catenin in the mechanism associated with malignant transformation in laryngeal tissues.

Direct laser writing of 3D scaffolds for neural tissue engineering applications

This study reports on the production of high-resolution 3D structures of polylactide-based materials via multi-photon polymerization and explores their use as neural tissue engineering scaffolds. To achieve this, a liquid polylactide resin was synthesized in house and rendered photocurable via attaching methacrylate groups to the hydroxyl end groups of the small molecular weight prepolymer. This resin cures easily under UV irradiation, using a mercury lamp, and under femtosecond IR irradiation. The results showed that the photocurable polylactide (PLA) resin can be readily structured via direct laser write (DLW) with a femtosecond Ti:sapphire laser and submicrometer structures can be produced. The maximum resolution achieved is 800 nm. Neuroblastoma cells were grown on thin films of the cured PLA material, and cell viability and proliferation assays revealed good biocompatibility of the material. Additionally, PC12 and NG108-15 neuroblastoma growth on bespoke scaffolds was studied in more detail to assess potential applications for neuronal implants of this material.

Subharmonic wave transition in a quasi-one-dimensional noisy fluidized shallow granular bed

We present an experimental and theoretical study of the pattern formation process of standing subharmonic waves in a fluidized quasi-one-dimensional shallow granular bed. The fluidization process is driven by means of a time-periodic air flow, analogous to a tapping type of forcing. Measurements of the amplitude of the critical mode close to the transition are in quite good agreement with those inferred from a universal stochastic amplitude equation. This allows us to determine both the bifurcation point of the deterministic system and the corresponding noise intensity. We also show that the probability density distribution is well described by a generalized Rayleigh distribution, which is the stationary solution of the corresponding Fokker-Planck equation of the universal stochastic amplitude equation that describes our system.

Effect of P-glycoprotein inhibition on methadone analgesia and brain distribution in the rat

Methadone is an opiate drug that has been identified as an in-vitro substrate of the efflux pump P-glycoprotein (P-gp), active in the intestinal epithelium and in the blood–brain barrier (BBB), among other sites. The objective of this study was to test in vivo, in the rat model, the role of P-gp modulation on the analgesic effect and brain uptake of methadone, as well as identify the most relevant site via dual oral and intravenous (i.v.) experiments. The P-gp specific inhibitor (valspodar or PSC833) was preadministered (10 mg kg−1 i.v.) to test groups. Analgesia was measured using the tailflick test. The ED50 for oral methadone (2, 3, 6 and 8 mg kg−1) decreased three-fold in valspodar groups compared with controls (2.23 + 0.002 mg kg−1 and 6.07 + 0.07 mg kg−1; P &lt; 0.0001). The overall analgesic effect (% antinociception) was elevated 3.1 times in pretreated compared with control rats (90.65% + 0.22 vs 29.23% + 14.0; P &lt; 0.01) after 6 mg kg−1 oral methadone and 2.8 times after i.v. (0.35 mg kg−1) administration (91.75% + 4.27 vs 32.45% + 9.0; P &lt; 0.01). The brain:plasma distribution ratio was higher in pretreated animals and AUCbrain (overall brain concentration) was 6 times higher after oral methadone and 4 times higher after i.v. compared with controls, disproportionally increased relative to plasma, implying an active process at the BBB. P-gp, and hence substrate comedication, plays a critical role in the evolution of the methadone analgesic effect and in its brain uptake, independent of the administration route.

Modeling the effectiveness of paliperidone ER and olanzapine in schizophrenia: meta-analysis of 3 randomized, controlled clinical trials

The time course of Positive and Negative Syndrome Scale (PANSS) scores in adult schizophrenia patients was modeled, and the effectiveness of paliperidone extended-release tablets (paliperidone ER) and olanzapine was quantified. Data from 3 randomized, double-blind phase III studies were used. Patients received paliperidone ER (3, 6, 9, 12, or 15 mg), olanzapine 10 mg, or matched placebo once daily for 6 consecutive weeks. An indirect response model implemented using a nonlinear mixed effects approach described the time course of the PANSS. Deterioration rate was modeled as a function of baseline PANSS score, placebo, and drug effects, and the dropout effect. An exponential decrease of the placebo response was also implemented. Paliperidone ER and olanzapine treatment were characterized by a long-lasting drug effect (13%), with a larger but short-lasting placebo effect (40%) and a notable dropout rate. The covariate exploration failed to identify any clinically relevant factors. The nonparametric bootstrap analysis confirmed the acceptable precision of parameter estimates. The visual predictive check supported the model's adequacy to reproduce observed PANSS time courses. The population model describes the time course of PANSS scores in schizophrenia patients and is appropriate for use in clinical trial simulation activities.

[Uveitis and idiopathic juvenile arthritis in Spain. Epidemiological and therapeutic aspects]

PURPOSE

The purpose of this paper is to describe the frequency and characteristics of uveitis associated with juvenile idiopathic arthritis at a tertiary referral centre in Spain.

METHODS

Review of clinical records. 205 children diagnosed with chronic juvenile arthritis over the last 15 years, of whom 26 presented anterior uveitis. Patients were classified according to their pattern of evolution, the time the uveitis was diagnosed with respect to the onset of arthritis, and the severity of uveitis at diagnosis.

RESULTS

The prevalence of uveitis was 12.7%. Of the patients affected with uveitis 71% were girls. The average age at which the arthritis was diagnosed was significantly earlier in the group of patients who developed uveitis (4.06 years). No differences were observed in the incidence of uveitis in girls and boys, nor in pauci/polyarticular affectation. ANA positivity was found in 84.6% of the uveitis-affected patients, this being significantly different to the ANA- group. The average age at which uveitis was diagnosed is 5.87 years. 48.1% of uveitis patients develop uveitis within 12 months of the onset of arthritis. This group presented more complications during the evolution of the condition. A total of 84.7% of the uveitis-affected patients presented with a final visual acuity of >0.5 during the observation period.

CONCLUSIONS

In our study, the development of uveitis was significantly associated with an earlier age of diagnosis of the arthritis and with the presence of ANA positivity. No differences were observed between boys and girls, or between pauci and polyarticular groups. A greater prevalence of complications was observed in cases presenting with a shorter time interval between the diagnosis of arthritis and uveitis and in those that presented with complications on diagnosis.

[Evolution of breastfeeding in the population attending the Mendillorri Health Centre]

The aim of this study is to estimate the prevalence and duration of breastfeeding, and how this has varied in the population attending the Mendillorri health centre between the years 2002 and 2006. We studied two cohorts of neonates (born in 2002 and 2006, respectively), who attended our centre, through a revision of their computerised clinical history. The prevalence figures of the different lactation categories were compared, with a monthly periodicity from the time of maternity discharge until the first year of life. Home visits by nurses were also registered where these occurred. The conclusion drawn from the results is that the panorama of maternal lactation has changed substantially in this area following hospital discharge; the results show that the prevalence figures over the first year of life are significantly higher in 2006 compared with 2002.

Modeling methadone pharmacokinetics in rats in presence of P-glycoprotein inhibitor valspodar

PURPOSE

To quantify the in vivo role of P-glycoprotein (P-gp) in the pharmacokinetics of methadone after intravenous and oral administration, using valspodar as a P-gp inhibitor.

MATERIALS AND METHODS

Methadone plasma concentrations after intravenous (0.35 mg/kg) and oral (6 mg/kg) administration were analyzed, in absence and presence of valspodar, using nonlinear mixed effects modeling (NONMEM V). Non-parametric bootstrap analysis and posterior predictive check were employed as model evaluation techniques.

RESULTS

The pharmacokinetics of methadone in the rat was successfully modeled using a two-compartmental model with a linear elimination from the central compartment and a first-order absorption process with lag time. Valspodar increased methadone F by 122% (95%CI: 34-269%) and decreased the V ( c ) and V ( p ) by 35% (95%CI: 16-49%) and 81% (95%CI: 63-93%), respectively. No effect of valspodar on other pharmacokinetic parameters was discernible. The non-parametric bootstrap analysis confirmed the absence of bias on the parameter estimates, and visual predictive check evidence the adequacy of the model to reproduce the observed time course of methadone plasma concentrations.

CONCLUSION

Valspodar increased methadone's bioavailability as consequence of P-gp inhibition, which resulted in an increased analgesic effect of methadone.

[Treatment of two cases of diffuse retinal pigment epitheliopathy with photodynamic therapy]

CASE REPORT

We present two patients with Diffuse Retinal Pigment Epitheliopathy (DRPE) treated with verteporfin photodynamic therapy (PDT). The first patient was treated with PDT because there was foveal involvement. The second patient received PDT because he had multiple recurrences of DRPE with poor resolution following previous argon-laser photocoagulation. Resolution of the lesions occurred in both cases with improvement in visual acuity. No recurrences have been documented at eleven months of follow-up.

DISCUSSION

The outcomes in our patients were satisfactory. We consider PDT is a safe and effective option, but further randomized studies are necessary to confirm this.

Double-balloon enteroscopy: a descriptive study of 50 explorations

AIM

To evaluate the utility of double-balloon enteroscopy for small-bowel disease.

DESIGN

A prospective study of 50 consecutive enteroscopies performed from December 2004 to July 2005 to analyze diagnoses and treatments.

PATIENTS

44 patients (33 had undergone a previous capsule endoscopy) with indications for obscure digestive hemorrhage, angiodysplasia, Peutz-Jeghers syndrome, ulcer, suspected Crohn's disease, tumors, and refractory celiac disease.

RESULTS

We carried out enteroscopy studies in 44 patients by the oral route and, in 6 additional patients, by both the oral and anal routes. We reached the ileon with the oral route in all cases but one (jejunal stenosis), and in 4 cases out of 7 with the anal route, with an average duration of 73 minutes. We found angiodysplasia in 19 cases, as well as NSAID-related enteropathy, Crohn's disease, diverticulosis, and Waldenström's disease. We performed biopsies in 31% of cases with diagnoses of adenocarcinoma, lymphangiectasia secondary to tumor in celiac disease, and Whipple's disease. We treated 19 patients with angiodysplasia (1 to 20 synchronous lesions) with argon, and 4 patients with polyps using polipectomy (sporadic polyps or Peutz-Jeghers syndrome). A retained capsule in one patient with stenosis was removed.

CONCLUSIONS

Double-balloon enteroscopy is a useful and effective technique in the diagnosis and treatment of small intestine diseases, thus complementing capsule endoscopy. More studies are needed to analyze its impact on the management of this condition.

Alpha‐1‐acid glycoprotein directly affects the pharmacokinetics and the analgesic effect of methadone in the rat beyond protein binding

Methadone is a basic drug highly bound to alpha1-acid glycoprotein (AGP), a plasma protein that increases in several pathological situations. Our aims were to evaluate the processes (pharmacokinetics-PK and/or pharmacodynamics-PD) associated with changes of methadone analgesia under conditions of increased AGP, and whether these changes are dependent on binding, secondary to a pathology, or directly attributable to AGP. AGP levels, in rats, were increased by two different methods: (a) experimental inflammation with turpentine oil (TP), and (b) by directly infusing the protein (exo-AGP). Both had a corresponding control group. Tail-flick analgesia and PK were evaluated after methadone dose (0.35 mg/kg i.v.). Bicompartmental PK parameters as well as interanimal and assay variabilities were estimated using NONMEM. The relationship between Cp and analgesic effect (PD) was analyzed with WINNONLIN. AGP levels in both pretreated groups (TP and exo-AGP) were significantly increased, and the unbound fraction (fu) was decreased, compared to controls. All PK parameters were lower in the pretreated groups, but in exo-AGP the difference was maintained even when corrected by fu. Paradoxically, also in exo-AGP the analgesic effect was practically nonexistent, although the unbound Cp remained high, possibly associated to a change in the PD. AGP appears responsible for alterations in both PK and PD, beyond protein binding and inflammatory processes.

Sex specificity in methadone analgesia in the rat: a population pharmacokinetic and pharmacodynamic approach

PURPOSE

To quantify the extent to which a sex-specific dichotomy in the temporal evolution of the analgesic effect, after intravenous (i.v.) methadone injection in the rat, relates to the pharmacokinetics (PK) and pharmacodynamics (PD) that mediate the dose-to-effect pathway.

METHODS

Tail-flick analgesia was measured after i.v. methadone injection (0.35 mg/kg) in female (n = 16) and male (n = 16) Sprague-Dawley rats. The PK were evaluated in separate female (n = 56) and male (n = 56) rats after they had received the same dose of methadone i.v. (0.35 mg/kg). A bicompartmental model described the kinetics and a sigmoid Emax model-related drug effect vs. simulated concentrations (pharmacodynamics) at the times of effect measurement. All model parameters as well as interanimal and assay variabilities were estimated with a mixed-effects population method using the program NONMEM.

RESULTS

The area under the effect-time curve (AUCE0-120) was (mean +/- interanimal SD) 1859+/-346 min in the females, which was significantly lower than the 4871+/-393 min in the males (P < 0.0001). On the contrary, the profiles of concentration vs. time were higher in females and, therefore, corresponded inversely to the effect vs. time-relative magnitudes. The central volume of distribution, V1, was 1.94+/-0.37 l/kg for female rats and 3.01+/-0.33 l/kg for male rats. Also, the central clearance was 0.077+/-0.006 l/min/kg and 0.102+/-0.005 l/min/ kg, respectively, for female and male rats. Both parameters differed significantly between sexes (P < 0.0001). The pharmacodynamic maximum observed effect parameter (Emax) was 37%+/-29% in female rats and 85%+/-16% in male rats, and these values were significantly different (P < 0.0001). The parameter for the concentration eliciting half of Emax (EC50) was 24.1+/-7.5 microg/l in female rats and 20.3+/-2.9 microg/l in male rats, and the Hill-related exponent, gamma, was 6.3+/-3.9 in female rats and 5.5+/-4.1 in male rats. These parameters did not differ significantly (at the P < 0.05 level).

CONCLUSIONS

A sex-specific dichotomy in the methadone antinociceptive effect, in the rat, was not proportionally related to plasma concentrations. Each sex corresponded to a distinct subpopulation of the PK parameters and one of the pharmacodynamic parameters (Emax). When the course of a drug involves PK or PD subpopulations, PK/PD modeling can afford the safest prediction of the effect-time evolution for a particular dose.

Influence of the route of administration and the chemical form (MnCl2, MnO2) on the absorption and cerebral distribution of manganese in rats

The absorption and cerebral distribution of manganese (Mn) have been studied with respect to the route of administration and the chemical form of the Mn compound. Different groups of adult male rats received either MnCl2, 4H2O or MnO2 once a week for 4 weeks at a dose of 24.3 mg Mn/kg body wt. (b.w.) by oral gavage (g.) or 1.22 mg Mn/kg b.w. by intraperitoneal injection (i.p.) or intratracheal instillation (i.t.). Control rats were treated with 0.9% saline. Four days after the last administration the rats were killed and the concentration of Mn measured in blood, hepatic and cerebral tissues (cortex, cerebellum, and striatum). The liver Mn concentration was not affected by the treatments whatever the chemical form or the route of administration of the Mn compound. Administration of MnCl2 by g., i.p., and i.t. routes produced equivalent steady-state blood Mn concentrations (about 1000 ng Mn/100 ml), representing increases of 68, 59, and 68% compared with controls, respectively. Mn concentrations were significantly increased in the cortex but to a lesser extent (g., 22%; i.p., 36%; i.t., 48%) and were higher in the cerebellum after i.p. and i.t. administrations than after oral gavage. Rats treated i.t. with MnCl2 showed an elective increase of the striatal Mn concentration (205%). In contrast, MnO2 given orally did not significantly increase blood and cerebral tissue Mn concentrations; the low bioavailability is most likely due to the lack of intestinal resorption. Administration of MnO2 i.p. and i.t., however, led to significant increases of Mn concentrations in blood and cerebral tissues. These increments were not significantly different from those measured after MnCl2 administration, except for striatal Mn after i.t. which was markedly less (48%) after MnO2 administration. A comparison of the blood Mn kinetics immediately after g. and i.t. treatment with MnCl2 or MnO2 indicated that the higher elevation of blood Mn concentration (> 2000 ng Mn/100 ml) after i.t. administration of MnCl2 could account for the elective uptake of Mn in the striatum observed in repeated dosing experiments. It is concluded that the modulation of Mn distribution in brain regions according to the route of administration and the chemical form of the Mn compound may be explained on the basis of different blood Mn kinetics and regional anatomic specificities of the striatal region.

The Pelosi Simplified Technique to Repair Inguinal Hernias During Gynecologic Laparoscopy

Inguinal and incisional hernias are frequently discovered during gynecologic laparoscopy. Current laparoscopic techniques to repair hernias are time consuming and require expensive procedure-specific instrumentation. The Pelosi simplified method of hernia repair, which uses an operative laparoscope, Carter-Thomason needle carriers, and standard suturing material, was performed successfully in eight women to repair inguinal hernias at the time of gynecologic laparoscopy. No intraoperative or postoperative complications occurred. None of the patients developed recurrent hernias.

The Carter-Thomason Needle Suture Passer to Correct Cannula-Induced Defects and Vascular Injuries in the Abdominal Wall During Laparoscopy

Postoperative omental and bowel entrapment secondary to incisional hernias and life-threatening hemorrhage secondary to anterior abdominal wall bleeding may occur during cannula placement. The Carter-Thomason needle suture passer was used to correct 20 fascial and peritoneal cannula defects and 7 severe anterior abdominal wall bleeders. The procedure was performed quickly and successfully in all instances. The instrument provides a safe, rapid, easy, and cost-effective way to correct complications secondary to the creation of surgical ports during laparoscopic surgery.

[Self application of preventive measures and opinion about applying them to the population at the health centers of Cantabria]

OBJECTIVE

To establish the degree of fulfillment of preventive measures and health promotion recommended by the Spanish Society of Family and Community Medicine for medical staff; to determine the opinion for medical staff about the application to these preventive measures in the general population and to analyse the relationship between the self application and the recommendation to the population.

DESIGN

Cross-sectional observational through questionnaire.

SETTING

Health Centers in Cantabria.

PARTICIPANTS

Medical staff of Health Centers.

MEASUREMENTS AND MAIN RESULTS

A response of 67.9% (146 out of 215) was obtained. The results of the self application had been: smokers, 35.6%; know their TA, 89.5%; know their weight, 99.3%; know their cholesterol, 81.5%; tetanus vaccinated, 41.4%; influence vaccinated, 33.6%; hepatitis B vaccinated, 38.6%; consume alcohol in excess, 5.6%; make breasts annual exploration, 44.4%; mammography, 33.0%; cervical cytology, 73.1% protected against german measles, 87.2%. The opinion of the medical staff about the application of the preventive measures in the general population of was positive in more of 90% the respondent. We found a significant relation (p < 0.01) between self application and recommendations to the population; and the population recommendation also showed an inverse relationship with the number of years of experience in First Aid (p < 0.01). However, the statistical was low for these variables (0.2).

CONCLUSION

The self application of the preventive measures in the Health Centers of Cantabria is in general better than in other Spanish regions and although, we found relations between self application and recommendation to the population the statistics potency was low for this variable.

Stereotactic retransplantation in Parkinson's disease: clinical, imaging and electrophysiological evidence of adrenal brain graft viability

In March 1993, a patient with idiopathic Parkinson disease who had received an adrenal brain autograft 6 years before underwent bilateral stereotactic transplantation of a mesencephalic cell suspension into the striatum, in order to prevent further deterioration in his neurological condition. During the CT-guided surgical planning and the transplantation procedures, electrophysiological evidence of the adrenal graft viability was assessed. Based on these findings, we drew the preliminary conclusion that the chromaffin tissue implanted in April 1987 is still functional, which explains the clinical evolution of this patient during the postoperative long-term follow-up.

[Minimally invasive laparoscopic hysterectomy: Pelosi's single puncture technique]

The purposes of this paper were to determine the indications, feasibility, outcome, complications and costs of laparoscopic hysterectomy utilizing the Pelosi single umbilical puncture technique and to introduce in Latinoamérica this minimally invasive and inexpensive alternative of laparoscopic hysterectomy. Ours results suggest that laparoscopic hysterectomy using a single umbilical puncture approach is a safe, inexpensive and effective alternative when compared with other techniques of laparoscopic hysterectomy.

Computer-assisted CT-guided stereotactic biopsy and brachytherapy of brain tumors

From March 1991 to September 1993, 26 patients (aged 4-78 years) with brain tumors (4 glioblastoma multiforme, 10 nonglioblastoma multiforme, 1 mixed oligoastrocytoma, 2 carniopharyngiomas, 2 meningiomas and 7 metastases) were treated with stereotactic techniques at the Centro Internacional de Restauración Neurológica, La Habana, Cuba. A total of 28 stereotactic surgical procedures were performed with no operative mortality; they included biopsies in all cases, 1 stereotactic microsurgical resection and 12 permanent implants of 192Ir, followed by external beam fractionated radiation therapy (40-60 Gy). The present paper shows that the combined use of a stereotactic approach, a comprehensive and reliable stereotactic dosimetric planning system, stereotactic brachytherapy with 192Ir and complementary percutaneous radiation treatment constitutes a promising strategy for brain tumor management.

Neurotransplantation in Parkinson's disease: from open microsurgery to bilateral stereotactic approach: first clinical trial using microelectrode recording technique

This paper summarizes the results of three controlled clinical trials related to the transplantation of embryonic ventral mesencephalic tissue into the striatum of 46 idiopathic parkinsonian patients exhibiting motor complications on standard levodopa therapy. From January 1988 to April 1990, 30 subjects with fluctuating Parkinson's disease received fetal dopaminergic tissue implants by the open microsurgical technique. In March 1992 the stereotactic approach was adopted for successive fetal mesencephalic cell suspension transplants (7 unilateral and 9 bilateral) into the caudate and putamen of parkinsonian patients with levodopa-induced complex fluctuations and dyskinesias. The neurological assessment performed 12 months before and 3-18 months after transplantation demonstrated a reduction of both the daily time spent in the 'off' condition and the number of daily 'off' periods, and a significant improvement of the motor scale. The stereotactic selective thalamotomy with microelectrode recording was introduced in January 1993, in order to provide a further potential treatment strategy; i.e., the combination of the two surgical trends in Parkinson's disease, the restorative neurotransplantation technique, and the selective lesional approach. In addition to that, microelectrode recording is also used for implantation site selection and functional characterization.

CT-oriented microrecording guided selective thalamotomy

A further trial of CT-oriented microrecording guided stereotactic selective thalamotomy was conducted at the Centro Internacional de Restauración Neurológica, Havana City as treatment of resting tremor in 11 patients with idiopathic Parkinson's disease (PD), and in 3 other patients with intentional tremor associated with multisystemic atrophy and cerebral palsy. Three of the parkinsonian patients had undergone fetal mesencephalic tissue transplantation with significant improvement of the most debilitating symptoms of PD and stabilization of the motor state, but predominantly unilateral tremor had impaired them progressively despite increased levodopa doses. A Leksell frame was used with a novel surgical planning system and electrophysiological recordings to identify the optimal target point inside the ventralis intermedius. In all but 1 case, the tremor was totally arrested. No persistent complications were observed.

Computer assisted CT-guided stereotactic transplantation of foetal ventral mesencephalon to the caudate nucleus and putamen in Parkinson's disease

We report our preliminary results related to CT-guided stereotactic transplantation of foetal ventral mesencephalic cell suspension into the striatum of five patients with idiopathic Parkinson's disease. The mean age was 51 years, the evolution time of the disease ranged from 7 to 14 years, and all of them had motor complications associated with chronic L-dopa therapy. The patients were evaluated according to the Core Assessment Program for Intracerebral Transplantations (CAPIT) for one year before and three months after surgery. The postoperative clinical assessment demonstrated significant improvement of neurological symptoms and reduction of daily L-dopa dosage.

Effect of brodimoprim on Mycobacterium leprae in vitro and in mouse foot-pads

The new in vitro screening system reported earlier was adopted to determine anti-M. leprae activity of a dihydrofolate reductase inhibitor, brodimoprim, and the results were compared with those obtained using mouse foot-pad technique. Even though the MIC of brodimoprim against M. leprae was very high compared to other commonly used anti-leprosy drugs, in combination with dapsone it showed a remarkable synergistic activity in inhibiting the growth of M. leprae at concentrations much lower than the MICs of each of the drugs used singly. Similar effects were also demonstrated in mouse foot-pad experiments.