Anatomical description of anaesthetic spread after deep erector spinae block at L-4

INTRODUCTION

Thoracic erector spinae plane (ESP) block is now used for postoperative analgesia. However, although reports of lumbar ESP have been published, the anesthetic spread and mechanism of action of this technique remains unclear. We describe the lumbar ESP block technique and evaluate the spread of 20ml of solution administered at the level of the transverse process of L4 in a cadaver model.

METHODS

Observational study after 12 lumbar ESP blocks at L4 on a fresh cadaver model (6 bilaterally). The spread of 20ml of injected contrast solution was assessed by computed tomography in all 6 samples. Four of the samples were evaluated by anatomical study, 2 by plane dissection, and 2 others were frozen and cut into 2-2.5cm axial slices.

RESULTS

The injected solution spread from L2 to L5 in a cranio-caudal direction in the erector spinae muscle, reaching the facet joints medially and the thoracolumbar fascia laterally. In 33% of cases the solution did not spread anterior to the transverse process; in 51%, spread was minimal and did not affect the corresponding spinal nerves, and in 2 samples (16%), spread was extensive and reached the corresponding spinal nerves.

CONCLUSIONS

Lumbar ESP at L4 always acts on the posterior branches of the spinal nerves, but seldom spreads to the paravertebral space to block the spinal nerve.

Cross-sectional area of the median nerve after intraneural vs perineural low volume administration

INTRODUCTION

To recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage. However, signs of intraneural injection are not clearly established. The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1ml of solution.

MATERIAL AND METHODS

Ultrasound guided median nerve blocks were performed in the forearm of 10 fresh cadavers on 60 occasions (3 per forearm). They were randomised into the intraneural (n=30) or perineural (n=30) location of the needle tip, after the consensus of location by 7 specialists. After 1ml of solution was injected an evaluation was made of the changes in the cross-sectional area of the nerve, as well as the displacement along the nerve.

RESULTS

The cross-sectional area of the median nerve was increased in both groups, however, the increase was significantly higher in the intraneural group (perineural 0.007±0.013cm2 vs. intraneural 0.032±0.021cm2, P<.0001). An increase of more than 27% of the area ensures an intraneural injection in the median nerve according to the ROC curve analysis. Both proximal and distal diffusion were observed more frequently in the intraneural group (proximal: 86% vs 14%, P<.0001, Distal: 43% vs 4%, P<.0001).

CONCLUSIONS

Based on this experimental study, it is concluded that the injection of a small volume (1ml) allows to discriminate the disposition of the intraneural vs perineural needle in a high percentage of cases. Therefore, it is suggested that this "dose test" should be considered in the safety algorithms if it is required to reduce the incidence of intraneural injection.

Spin dependent interactions catalyse the oxygen electrochemistry

The technological interest of oxygen reduction and evolution reactions, ORR and OER, for the clean use and storage of energy has resulted in the discovery of multiple catalysts; and the physical and catalytic properties of the most active compositions are only comprehensible with the consideration of magnetic interactions.

Effect of maceration time and the addition of enzymes on the amino acid composition of musts and wines and its influence on wine aroma Influencia del tiempo de maceración y de la adición de enzimas sobre la composición de los aminoácidos de mostos y vinos y su relación con el aroma

The purpose of this work is to study the effect of maceration time (with and without pectolitic en zyme addition) on the concentrations of 18 amino acids found in must and wines of the Macabeo grape variety. The presence of enzymes had a significant effect on the relative composition of the amino acids. The maceration process, with or without enzymes, led to a decrease in amino acid con tent after 2 h of maceration. After 2 h the solid parts of the grape released amino acids into the must, with the maximum concentration reached after 6 h. A certain degree of correlation given by principal component analysis was observed between the concentration of valine, isoleucine and histidine present in the musts and the aromatic compounds in the wines related to the metabolism of the fatty acids (hexanoic acid, octanoic acid, ethyl octanoate, hexanoate and decanoate). For the wines, a high corre lation was found between valine and isobutanol and a lower value for valine with isoamyl alcohol and β-phenyl ethanol.

Efficiency of pragmatic search strategies to update clinical guidelines recommendations

Background

A major challenge in updating clinical guidelines is to efficiently identify new, relevant evidence. We evaluated the efficiency and feasibility of two new approaches: the development of restrictive search strategies using PubMed Clinical Queries for MEDLINE and the use of the PLUS (McMaster Premium Literature Service) database.

Methods

We evaluated a random sample of recommendations from a national guideline development program and identified the references that would potentially trigger an update (key references) using an exhaustive approach.

We designed restrictive search strategies using the minimum number of Medical Subject Headings (MeSH) terms and text words required from the original exhaustive search strategies and applying broad and narrow filters. We developed PLUS search strategies, matching Medical Subject Headings (MeSH) and Systematized Nomenclature of Medicine (SNOMED) terms with guideline topics. We compared the number of key references retrieved by these approaches with those retrieved by the exhaustive approach.

Results

The restrictive approach retrieved 68.1 % fewer references than the exhaustive approach (12,486 versus 39,136), and identified 89.9 % (62/69) of key references and 88 % (22/25) of recommendation updates. The use of PLUS retrieved 88.5 % fewer references than the exhaustive approach (4,486 versus 39,136) and identified substantially fewer key references (18/69, 26.1 %) and fewer recommendation updates (10/25, 40 %).

Conclusions

The proposed restrictive approach is a highly efficient and feasible method to identify new evidence that triggers a recommendation update. Searching only in the PLUS database proved to be a suboptimal approach and suggests the need for topic-specific tailoring.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-015-0058-2) contains supplementary material, which is available to authorized users.

Facile production of stable silicon nanoparticles: laser chemistry coupled to in situ stabilization via room temperature hydrosilylation

Stable, alkyl-terminated, light-emitting silicon nanoparticles have been synthesized in a continuous process by laser pyrolysis of a liquid trialkyl-silane precursor selected as a safer alternative to gas silane (SiH4). Stabilization was achieved by in situ reaction using a liquid collection system instead of the usual solid state filtration. The alkene contained in the collection liquid (1-dodecene) reacted with the newly formed silicon nanoparticles in an unusual room-temperature hydrosilylation process. It was achieved by the presence of fluoride species, also produced during laser pyrolysis from the decomposition of sulfur hexafluoride (SF6) selected as a laser sensitizer. This process directly rendered alkyl-passivated silicon nanoparticles with consistent morphology and size (<3 nm), avoiding the use of costly post-synthetic treatments.

Multilead measurement system for the time-domain analysis of bioimpedance magnitude

Bioimpedance measurement applications range from the characterization of organic matter to the monitoring of biological signals and physiological parameters. Occasionally, multiple bioimpedances measured in different locations are combined in order to solve complex problems or produce enhanced physiological measures. The present multilead bioimpedance measurement methods are mainly focused on electrical impedance tomography. Systems designed to suit other multilead applications are lacking. In this study, a novel multilead bioimpedance measurement system was designed. This was particularly aimed at the time-domain analysis of bioimpedance magnitude. Frequency division multiplexing was used to avoid overlapping between excitation signals; undersampling, to reduce the hardware requirements; and power isolated active current sources, to reduce the electrical interactions between leads. These theoretical concepts were implemented on a prototype device. The prototype was tested on equivalent circuits and a saline tank in order to assess excitation signal interferences and electrical interactions between leads. The results showed that the proposed techniques are functional and the system's validity was demonstrated on a real application, multilead impedance pneumography. Potential applications and further improvements were discussed. It was concluded that the novel approach potentially enables accurate and relatively low-power multilead bioimpedance measurements systems.

Recombinant activated factor VII as treatment for uncontrolled mucosal haemorrhage

We report the use of a haemostatic drug (recombinant activated factor VII (rFVIIa)) in a patient who presented a slow but constant bleed in oesophageal mucosa (which required frequent red blood cell transfusion) due to ingestion of caustic products. The administration of rFVIIa ceased bleeding and allowed mucosal cicatrisation and patient haemodynamic stabilisation and clinical recovery.

A strategy for patient involvement in clinical practice guidelines: methodological approaches

BACKGROUND An increasing number of initiatives involve patients in the development of Clinical Practice Guidelines (CPGs). However, the method used for patient involvement is fundamental to achieving a quality patient-oriented CPG. The objective is to present a strategy for patient involvement that includes both robust patient consultation and participation. This strategy is based on the authors' experience in the development of four CPGs included in the Spanish National CPG Development Program, which deemed it a valuable nation-wide patient involvement initiative. METHODS Patient consultation in the CPG preparation phase combines quantitative and qualitative primary research techniques as well as a systematic review of patient-perspective studies. Participation relies on patients and patient representatives as members of the guideline development groups in all development phases at the same level as professionals. NVivo 8 software was used to analyse discourses of qualitative data. RESULTS Patients and patient representatives provided relevant information on their perspectives, experiences with the illness, social circumstances, habits, values and preferences. They collaborated in different CPG development phases, including setting the scope and objectives, defining key research questions, writing and reviewing recommendations, developing patients' versions and the dissemination of CPGs. CONCLUSIONS The authors' strategy allows for patient-oriented CPG development, but it requires appropriate training and knowledge of qualitative research techniques (primary research and systematic review of qualitative evidence) for developers. It is also crucial to have specific support for patients, previously selected with eligibility criteria, to facilitate an effective engagement, providing clear guidance on their roles and ensuring opportunities to attend training events.

Visna/maedi virus serology in sheep: survey, risk factors and implementation of a successful control programme in Aragón (Spain)

A serological survey of Visna/maedi virus (VMV) infection involving 274,048 sheep from 554 flocks was undertaken during 2002-2007 in Aragón, North-East Spain. One hundred and two of these flocks enrolled in a VMV control programme to reduce seroprevalence by selecting replacement lambs from seronegative dams and gradual culling of seropositive sheep. Twenty-five flocks were also visited to collect flock management and housing data. All study flocks had seropositive animals and 52.8% of animals tested were seropositive. Among flocks that joined the control programme 66 adopted the proposed measures and reduced seroprevalence significantly by between 26.1% and 76.9% whereas the remaining 36 flocks did not apply the measures and seroprevalence significantly increased. Seroprevalence increased with flock size and the number of days the sheep were housed, and decreased with increasing weaning age and shed open area, suggesting a reduced risk of VMV infection in sheep associated with better ventilation. At the end of the period, 24 flocks were certified as VMV-controlled with a seroprevalence <5%, and seven as VMV-free with 0% seroprevalence. These are the first officially recognised VMV-free flocks in Spain and represent a nucleus of VMV-free replacement animals for other flocks. Moreover, they are evidence of the possibility of eliminating VMV infection without resorting to whole-flock segregation or culling of seropositive sheep.

Novel pyrazolopyrimidopyridazinones with potent and selective phosphodiesterase 5 (PDE5) inhibitory activity as potential agents for treatment of erectile dysfunction

Pyrazolo[1',5':1,6]pyrimido[4,5-d]pyridazin-4(3H)-ones and their analogues, potentially useful for the treatment of erectile dysfunction, were synthesized and evaluated as inhibitors of phosphodiesterase 5 (PDE5). Several compounds showed IC50 values in the low nanomolar range, and in particular, compound 5r, displaying high potency toward PDE5 (IC50 = 8.3 nM) and high selectivity versus PDE6 (240-fold) appeared to be a very promising new lead both in comparison with the potent but not selective sildenafil and in comparison with some analogues previously reported by us. SAR studies in this triheterocyclic scaffold led us to conclude that the best arranged groups are a methyl in position 1, a benzyl in position 3, a phenyl in position 9, and a linear four-carbon chain in position 6.

[Esophageal atresia type I. Is impossible possible?]

INTRODUCTION

Treatment of esophageal atresia with "long gap" remains difficult and controversial. According to the idea that esophageal anastomosis is imposible in most cases, several esophageal substitution methods have been proposed, as esophagocoloplasty, gastric transposition or reversed gastric tube. Nevertheless reconstruction of native esophagus is accepted as the best option if posible. "Long gap" definition is imprecise, expressed by variability in percent of these cases in total esophageal atresias reported in different series in literature. We report our experience in seven cases type I esophageal atresia with long gap and the different therapeutic options used, with attention to delayed or early esophageal anastomosis feasibility and outcome.

MATERIAL AND METHODS

We have treated 121 patients with esophageal atresia from whom we analized 7 cases with pure esophageal atresia with "long gap" (5.8%). Six patients underwent gastrostomy and two gastrostomy and esophagostomy. Five patient underwent primary repair with esophageal anastomosis, delayed between 14 days and 4 months in 4 cases. One patient underwent esophageal anastomosis in the first day without gastrostomy. Retroesternal esophagocoloplasty was performed in 2 patients about their first year of life. Esophagogram was done in first month after surgery and pH monitoring of gastroesophageal reflux. Follow-up ranged from 6 months to 28 years.

RESULTS

Esophageal anastomosis was feasible in all 5 patients in whom it was tried. Stricture occurred in two patients, one patient underwent anastomotic resection and new esophageal anastomosis. Esophageal reflux was present in two patients, one of them required funduplication. One patient was dead by complications of cardiac malformation. Remaining patients have normal swallowing and are in normal growth curves. Patients with esophagocoloplasty had not relevant early or late complications.

CONCLUSIONS

In most pure esophageal atresia, delayed or even early esophageal anastomosis is feasible, making use of surgical and anesthesic sources that favour it. Esophageal substitution techniques can be reserved if this approach fails.

¿Existe agrupación en las epistaxis no traumáticas?

OBJECTIVE

Non traumatic epistaxis seems to be clustering in different periods. This paper tries to find out if there is any relationship between incidence of epistaxis and the year season, month, week, day, hour and/or lunar phase.

METHODS

We have retrospectively studied 754 episodes seen between May 2001 and April 2002 in our Hospital. The following parameters were registered in each patient: age, sex, number of episodes, season, month, week, day, hour and lunar phase.

RESULTS

Epistaxis represented 12.1% of the total otolaryngological emergencies. That means an incidence of 0.1% of non traumatic epistaxis which needed hospital specialized attention. We found statistical differences (p = 0.003) in the number of epistaxis per day and the different months (greater in june and november). No differences were found in the remaining periods studied.

CONCLUSIONS

This paper shows monthly clustering of epistaxis episodes.

An outbreak of Legionnaires' disease in an inner city district: importance of the first 24 hours in the investigation

OBJECTIVE

To present the main results of the investigation of an outbreak of Legionnaire's disease that occurred in an inner city district of Barcelona between 15 October and 15 November 2000.

METHODS

Epidemiological surveys of patients and environmental investigations were initiated on the day the first five cases were notified. Water samples and smears from cooling tower trays were taken for microbiological analysis. Maps of the distribution of cases and possible contamination foci were elaborated. Incidences were calculated for each census tract.

RESULTS

A total of 54 patients related to the outbreak were identified, with a case fatality rate of 5.5%. Incidence rate in the area closest to the cooling tower (6.40/1000) was significantly higher than that of the rest of the neighbourhood (2.23/1.000, RR 2.87, 95%CI 1.37-6.12, P = 0.0035). Cultures positive for Legionella pneumophila serogroup 1, subtypes Pontiac, Philadelphia or Allentown, were obtained from eight patients. On the 39th day of the investigation it was found that the strain isolated in one of the cooling towers coincided with the serogroup, subtype and molecular profiles identified in clinical samples.

CONCLUSIONS

Rapid coordination of clinicians, microbiologists, epidemiologists and environmentalists permitted the source of infection and the affected cases to be correlated within a few days.

Fatal amniotic fluid embolism diagnosed histologically

Although the mortality of amniotic fluid embolism remains very high, there are more and more reports of patients surviving after prompt and aggressive therapy. However its pathogenesis is controversial, and, in some cases, an anaphylactic reaction to the amniotic fluid rather than the hemodynamic changes following mechanical obstruction by an embolus has been proposed as the underlying pathophysiological mechanism. In this paper we describe a case of amniotic fluid embolism with florid clinical features and a difficult and delayed diagnosis. On autopsy, clear-cut histological changes of amniotic fluid embolism were found.

Rhodium/iridium-titanium azaheterometallocubanes

Treatment of [[Ti(eta5-C5Me5)(mu-NH)]3(mu3-N)] (1) with the diolefin complexes [[MCl(cod)]2] (M = Rh, Ir; cod = 1,5-cyclooctadiene) in toluene afforded the ionic complexes [M-(cod)(mu3-NH)3Ti3(eta5-C5Me5)3(mu3-N)]Cl [M = Rh (2), Ir (3)]. Reaction of complexes 2 and 3 with [Ag(BPh4)] in dichloromethane leads to anion metathesis and formation of the analogous ionic derivatives [M(cod)(mu3-NH)3Ti3-(eta5-C5Me5)3(mu3-N)][BPh4] [M = Rh (4), Ir (5)]. An X-ray crystal structure determination for 5 reveals a cube-type core [IrTi3N4] for the cationic fragment, in which 1 coordinates in a tripodal fashion to the iridium atom. Reaction of the diolefin complexes [[MCl(cod))2] (M = Rh, Ir) and [[RhCl(C2H4)2]2] with the lithium derivative [[Li(mu3-NH)2(mu3-N)-Ti3(eta5-C5Me5)3(mu3-N)]2] x C7H8 (6 C7H8) in toluene gave the neutral cube-type complexes [M(cod)(mu-NH)2(mu3-N)Ti3-(eta5-C5Me5)3(mu3-N)] [M = Rh (7), Ir (8)] and [Rh(C2H4)2(mu3-NH)2(mu3-N)Ti3(eta5-C5Me5)3(mu3-N)] (9), respectively. Density functional theory calculations have been carried out on the ionic and neutral azaheterometallocubane complexes to understand their electronic structures.

The histone acetyltransferase, hGCN5, interacts with and acetylates the HIV transactivator, Tat

Factor acetyltransferase activity associated with several histone acetyltransferases plays a key role in the control of transcription. Here we report that hGCN5, a well known histone acetyltransferase, specifically interacts with and acetylates the human immunodeficiency virus type 1 (HIV-1) transactivator protein, Tat. The interaction between Tat and hGCN5 is direct and involves the acetyltransferase and the bromodomain regions of hGCN5, as well as a limited region of Tat encompassing the cysteine-rich domain of the protein. Tat lysines 50 and 51, target of acetylation by p300/CBP, were also found to be acetylated by hGCN5. The acetylation of these two lysines by p300/CBP has been recently shown to stimulate Tat transcriptional activity and accordingly, we have found that hGCN5 can considerably enhance Tat-dependent transcription of the HIV-1 long terminal repeat. These data highlight the importance of the acetylation of lysines 50 and 51 in the function of Tat, since different histone acetyltransferases involved in distinct signaling pathways, GCN5 and p300/CBP, converge to acetylate Tat on the same site.

A small outbreak of Legionnaires' disease in a cargo ship under repair

It was reported that two mechanics working on a cargo ship under repair in the port of Barcelona had died after having fever. An investigation was made into the possibility of any additional cases and the presence of Legionella pneumophila in the ship they were repairing and in their hotel. The contaminated water system was treated with sodium hypochlorite. Both patients died after having been repeatedly diagnosed as having influenza. The two cases occurred among those who had been working with the pump of the ship's water system, while no cases were observed among the other workers (p = 0.02). Various serogroups of L. pneumophila were isolated from the ship's water pump and distribution system. However, organism of serogroup 1, subgroup Pontiac (Knoxville) were identified with identical deoxyribonucleic acid (DNA) patterns in the lung tissue of one patient and in the cooling water circuit valve of the ship's water pump. The first postintervention control water samples showed no further growth of legionella, but serogroups 4 and 8 were identified 8 months later. This legionellosis outbreak, although small, was highly lethal, probably due to the high levels of bacteria to which the patients were exposed and also because of the failure of correct diagnosis. International recommendations on prevention and control of legionellosis, which include ships under repair, are required.

Clinical, physical, sperm and hormonal data in 251 adults operated on for cryptorchidism in childhood

OBJECTIVE

To determine the clinical, physical, sperm and hormonal status during adulthood in cryptorchid patients operated on during childhood, and to assess these variables according to the age at surgery and preoperative testicular position.

PATIENTS AND METHODS

A letter was sent to all 890 patients > 18 years old who underwent surgery for cryptorchidism during childhood; 274 responded and were assessed using a sexual history, physical examination, pituitary axis study and sperm analysis. Data were complete for 251 patients (mean age 21 years, range 18-30); 196 had unilateral (25 anorchic) and 55 had bilateral cryptorchidism. Clinical, surgical and anatomopathological records at surgery during childhood were also reviewed.

RESULTS

The mean (SD) age at orchidopexy was 6.4 (3.3) years and the mean age at assessment 21.1 (2.7) years. Semen samples generally showed abnormalities; 10 patients (4%) with bilateral and 57 (23%) with unilateral cryptorchidism had semen values within the normal range. There was no correlation between the sperm count and age at surgery for unilateral or bilateral cases (Spearman test). There was a significant correlation (r = - 0.41) between the sperm count and level of follicle-stimulating hormone (FSH). There were no significant differences in the sperm count for patients with different testicular locations (ANOVA) or in those treated or untreated with human chorionic gonadotrophin (Student's t-test). The only significant relationship (P < 0.001) was between the sperm count and unilateral or bilateral cryptorchidism.

CONCLUSIONS

The sperm quality of adults operated on for cryptorchidism during childhood is independent of the age at surgery or testicular location, but is influenced by whether the cryptorchidism was unilateral or bilateral. FSH levels were negatively correlated with sperm density.

Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution

Epidural anaesthesia using the loss of resistance to saline technique, without air, was successfully performed in a 65-year-old man scheduled for elective vascular surgery of the right leg. Epidural catheterisation was uneventful. Fifteen minutes after the initial dose of plain 0.5% bupivacaine, the patient experienced severe pain in his lower abdomen and legs which coincided with a supplementary injection of 2 ml bupivacaine and 50 microgram fentanyl, and a change from the lateral to the supine position. General anaesthesia was induced and CT and MRI scans were performed showing trapped air in the epidural space at the L4 level causing compression of the thecal sac. After excluding other causes, the spontaneous entry of air through the Tuohy needle was thought to be the most likely explanation for this complication. The patient recovered uneventfully.

What is the relationship between spermatozoa per milliliter at adulthood and the tubular fertility index at surgical age for patients with cryptorchidism?

PURPOSE

The aim of this study was to find out the relationship in the patient with cryptorchidism between the number of spermatogonia at surgical age and spermiogram data at adulthood.

METHODS

Between 1971 and 1996 the authors surgically treated 1,550 children for 2,249 undescended testis. In 21 unilateral and 41 bilateral cryptorchidism patients, both testis were biopsied at surgical procedure during childhood. We currently have spermiogram data for a patient at adulthood.

RESULTS

By using the best Tubular Fertility Index (TFI) figures of both testis, the Sperman correlation index between the two parameters is r = 0.22, statistically nonsignificant. The TFI test sensitivity is 0.68 and the specificity is 0.60. The likehood ratio for a positive test result is 0.84 and the likehood ratio for a negative test result is 0.37.

CONCLUSION

Although the authors have only one spermiogram, and there are few cases, they suspect the TFI is not a good index to predict the potential fertility in cryptorchidism patients.

Spontaneous ascent of the testis

OBJECTIVE

To report confirmed cases of spontaneous testicular ascent in patients with a cryptorchid testis which had been previously placed in the scrotum.

PATIENTS AND METHODS

Between 1972 and 1992, 46 cryptorchid testes (36 patients), which were previously verified to be in the scrotum by staff paediatricians or paediatric surgeons, were treated surgically. The clinical, surgical and anatomicopathological records were reviewed to determine testicular position and associated conditions, and biopsies were taken from 35 testes.

RESULTS

The mean time between the last "normal' exploration until the testes ascended was 4.5 years. Before ascent, the testes were confirmed to be in the scrotum by up to seven separate recorded examinations. During surgical treatment, an open processus vaginalis was found in 18 testes. The mean (SD) tubular fertility index was 40 (37)%.

CONCLUSIONS

This study confirms that a previously descended testis can ascend spontaneously. The clinical and anatomicopathological characteristics of these testes were similar to those of the cryptorchid testis.

Clinical and anatomopathological study of 2000 cryptorchid testes

OBJECTIVE

To establish whether age at the time of surgery and location of the testes help to determine the anatomopathological lesions.

PATIENTS AND METHODS

Between 1972 and 1992 surgery was performed on 2000 testes in 1342 children, 658 of whom had bilateral cryptorchidism. The clinical, surgical and anatomopathological records were reviewed.

RESULTS

Parametric and non-parametric tests failed to reveal any relation between the tubular fertility index or tubular diameter and the time of surgery or testicular location.

CONCLUSION

We cannot recommend a particular age at which surgery should be performed, in relation to the anatomopathological damage.

[The coordination of care for the spina bifida patient. 8 years of experience]

We have analyzed some factors which can show the special health care given to spina bifida patients in two periods, from 1971, when the set Hospital was set up, to 1985 and from 1985 to 1991. In 1985 the position of medical coordinator for spina bifida was created, and at the same time, a spina bifida consultancy was set up. This consultancy was created to improve this coordination and to analyze urological problems. In the first period, there were 54 affected in our Hospital. Now there are 68 patients. The most important goal achieved with this coordination is the improvement in the relationship between the patient, family and doctor, based on a personalized attention, even though this is a difficult subject to quantify. Since 1985 we have seen a lower number of visits to the consultancies in general, but mainly in neurosurgery, urology and orthopedics, a mean of 119 in first period and 45 in the second period. The number of consultancy visits has been the same since the consultancy was set up (46 per year). The number of patients admitted to in hospital was also decreasing. The spina bifida consultancy involves only an hours work a week, the urology ward has been integrated into this, and this avoids the handicapped having to attend other specialized wards so often. The consultancy structure lets us send urine analyses results by post or recover the test results on the same day they are done. Analysing the number of X-ray examinations performed on those patients, the coordinators value is evident: we got a lower number of X-ray examinations, especially invasive, e.g. cystographies and urographies, the latter because they have been replaced by echographies.

[Results of biofeedback on incontinence caused by anorectal atresia]

Eight patients with anorectal incontinence because of anorectal atresia, aged between seven and seventeen years, following surgical treatment with Romualdi-Soave procedure in seven cases and with PSARP in one case, have received biofeedback training to improve their continence. Clinical evaluation has been performed with a new numeric punctuation method that allows a quantitative and precise appraisal of incontinence (Incontinence Punctuation: IP). From a clinical point of view, biofeedback training has increased 4.16 points IP in patients in whom the method has been effective. It has prolonged the mean duration of voluntary contraction in 5.9 sec. and elevated in 13.6 mm. Hg. the maximal pressure contraction. In two patients, clinical evolution and manometry measurements indicated surgical treatment and PSARP was performed, improving IP in 5.5 points. We considered biofeedback training, when indicated, an adequate and innocuous technique to achieve an important clinical continence improvement in these patients.

Bait shyness: avoidance of the taste without escape from the illness in rats

Thirsty rats habituated to drinking .12 M sodium chloride accepted .12 M lithium chloride for 5 min on the first trial but stopped short of their sodium baseline. With repeated trials they reduced consumption of the toxin by either (a) detecting subtle oral (conditioned stimulus, CS) differences, thus avoiding toxicosis (unconditioned stimulus, US) or (b) detecting earlier signs of malaise (US), thus escaping further distress. When both solutions were masked with saccharin, the discrimination was more difficult but still possible. When both solutions were mixed in a solution masking all four taste qualities, the discrimination was severely disrupted. When oral sensors were bypassed with nasopharyngeal tubes, intragastric pumping rats were unable to use postingestional cues to escape, even though such cues were proximal to the ultimate malaise. Oral cues at the distal end of the consummatory chain were extremely effective.