School Influences on Adolescent Depression: A 6-Year Longitudinal Study Amongst Catholic, Government and Independent Schools, in Victoria, Australia

This study examined associations between school sector (Government, Catholic or Independent) and depressive symptomology over the secondary school years. Six waves of data collected annually from a representative Australian sample were examined. Multilevel piecewise linear and logistic regression controlling for a variety of demographic variables and protective factors was undertaken. In all sectors, depressive symptomology decreased between 10 and 13 years of age, but significantly increased for girls at age 13. Adolescents in Catholic schools reported significantly fewer symptoms of depression compared to those in Government and Independent schools. Adolescents in Catholic schools were less likely to report clinical levels of depressed mood compared to adolescents in Government schools.

Virtual reality and interactive 3D as effective tools for medical training

CAVE-like displays allow a user to walk in to a virtual environment, and use natural movement to change the viewpoint of virtual objects which they can manipulate with a hand held device. This maps well to many surgical procedures offering strong potential for training and planning. These devices may be networked together allowing geographically remote users to share the interactive experience. This maps to the strong need for distance training and planning of surgeons. Our paper shows how the properties of a CAVE-Like facility can be maximised in order to provide an ideal environment for medical training. The implementation of a large 3D-eye is described. The resulting application is that of an eye that can be manipulated and examined by trainee medics under the guidance of a medical expert. The progression and effects of different ailments can be illustrated and corrective procedures, demonstrated.

Improving outcomes for patients hospitalized with CHF

Congestive Heart Failure is a costly debilitating medical condition that affects millions of elderly people. This Clinical Practice Improvement study was under taken to determine how variation in patient characteristics and clinical processes impact patient outcomes including length of stay, total charges, and increased severity of illness during hospitalization. The AHCPR Guideline for Heart Failure was used to evaluate clinical care. Data on patient characteristics including severity of illness and process of care were analyzed to determine which variables had the greatest impact on outcomes of care. Results showed that patient characteristics including comorbidities, severity of illness, and noncompliance with diet were significantly related to longer lengths of stay, higher charges, and/or increased severity (all covariates, p < .05). In addition, process of care variables including medication use and patient education significantly (p < .05) impacted outcomes of care. Findings have implications for the development of practice guidelines designed to improve patient outcomes associated with CHF hospitalizations.

Treatment of depression in older primary care patients in health maintenance organizations

OBJECTIVE

To examine whether older HMO patients with depression are treated differently than younger patients in terms of diagnosis, treatment by specialty provider, and pharmacotherapy.

DESIGN

Chart-review, Cross sectional study.

SETTING AND PARTICIPANTS

Patients were selected from six HMOs in the United States who had one or more of five medical diagnoses: arthritis, asthma, otitis media, epigastric pain/ulcer, and hypertension, (n = 9143). From this group, chart diagnoses and pharmacy records were used to identify patients who also had a diagnosis of depression (n = 416) or who had a diagnosis of depression and/or treatment with antidepressant medication (n = 1286).

MEASUREMENT

Medical records and computerized service and pharmacy records were reviewed to obtain diagnoses, office visits by provider type, and psychiatric medication prescription counts.

RESULTS

Significant differences were found in treatment of depression for older versus younger patients. Although depression was identified at a similar rate for both groups, older patients received fewer mental health specialty visits and fewer prescriptions for SSRI antidepressants. Older patients with a diagnosis of depression were more likely to be treated with benzodiazepines (49.2% of older vs. 33.2% of younger) though they were less likely to receive long half-life benzodiazepines.

CONCLUSIONS

Psychotropic medication management is an important target for improving quality of care for older patients with depression in HMOs. Decreasing inefficient minor tranquilizer use and increasing use of newer antidepressant medications may lead to improved outcomes for older depressed adults.

Pelvic lysis and polyethylene wear at 5-8 years in an uncemented total hip

The clinical and radiographic results of 160 primary, uncemented porous coated total hip replacements performed at 3 teaching hospitals were reviewed. Followup was obtained in 132 of 148 (89%) nondeceased patients. The acetabular component is a full hemisphere, fabricated of cobalt chrome with a sintered bead coating and was implanted with screws in all cases. A 32 mm cobalt chrome femoral head was used in all cases. At 2 to 4 years the incidence of pelvic lysis was 0 and no acetabular revisions had been performed. At 5 to 8 years followup, 3 of 132 (2%) femoral stems had been revised, while on the acetabulum side discrete expansile pelvic lytic lesions occurred in 15 cases (11%) with 8 cases (5%) requiring revision. Abrasion of the screwhead against the backside of the polyethylene liner was seen in all retrieved cases and may have contributed to the development of the lytic lesions seen. Use of this uncemented press fit hemispheric acetabular components, using adjunctive screw fixation resulted in an unacceptably high rate of polyethylene wear and aggressive pelvic lysis. While the results on the femoral side were good, the results with this uncemented acetabular system did not represent an improvement over previous cemented or uncemented acetabular components.

Rush immunotherapy: experience with a one-day schedule

INTRODUCTION

Rush immunotherapy is a method for rapidly desensitizing patients to inhalant allergens. The frequency of systemic reactions during rush immunotherapy is similar to conventional immunotherapy when premedication is used. The most rapid protocol for rush immunotherapy reported to date requires one and one-half days which is inconvenient to patients and clinic schedules. To improve this situation and decrease the cost of giving rush immunotherapy, we have developed a 1-day protocol.

METHODS

for this ongoing study, 22 allergic patients received rush immunotherapy consisting of eight injections over six hours followed by two hours of observation in an outpatient clinic. Five had rhinitis and the rest has asthma, seven of whom were steroid-dependent. All were premedicated with astemizole, ranitidine, and prednisone for three days including the day of rush immunotherapy, and peak expiratory low rates were monitored.

RESULTS

Systemic reactions were seen in five of 22 (23%). They occurred following the sixth injection (1), seventh injection (2), or the final one (2) and consisted primarily of rhinitis or pulmonary symptoms with one episode of mild anaphylaxis. A systemic reaction was seen in only one steroid-dependent asthmatic patient. A local reaction preceded a systemic reaction in only one patient. All but three reached a maintenance dose in one day. All systemic reactions responded to epinephrine and all patients could go home after rush immunotherapy. Only one patient had a systemic reaction during the three months after rush immunotherapy.

CONCLUSION

One day rush immunotherapy is tolerated by most patients with a systemic reaction rate comparable to conventional immunotherapy. All patients were able to reach a maintenance dose months sooner than weekly schedules. With refinement of this procedure, rush immunotherapy may become a widely used method for desensitizing patients with inhalant allergens, and could make immunotherapy less expensive and more convenient.

Cataract surgery in one eye or both. A billion dollar per year issue

PURPOSE

To measure the relative effect of cataract surgery in the second eye compared with the first eye on functional impairment, satisfaction, and vision problems.

METHODS

Seventy-five randomly selected ophthalmologists in three cities in the United States were enrolled in a National Study of Cataract Outcomes. They, in turn, referred eligible, sequential patients scheduled for first-eye cataract surgery. Interviews were conducted at enrollment, 4 months after first-eye surgery, and 12 months after first-eye surgery. An attempt was made to conduct a special, preoperative interview of those patients scheduled to undergo second-eye surgery before the 4-month interview. Each interview included administration of the VF-14 (a 14-item questionnaire that assessed visual function), as well as questions about symptoms possibly related to cataract, "trouble with vision," and satisfaction with vision.

RESULTS

Seven hundred seventy-two patients were enrolled in the study, and interview data to 12 months were obtained from 669 (86%) patients. Of these patients, 243 (36%) underwent cataract extraction in the second eye during the 12-month period of observation. Overall, subjects who underwent cataract surgery in both eyes during the 12-month period had 61% greater improvement in VF-14 score (P < 0.001), 27% more decline in trouble with vision (P < 0.001), and 24% greater improvement in satisfaction with vision (P < 0.001) compared with those who underwent surgery in only one eye.

CONCLUSIONS

Cataract surgery in the second eye of patients with bilateral cataract is associated with clinical and statistically significant improvement in functional impairment, trouble with vision, and satisfaction with vision.

Preoperative functional expectations and postoperative outcomes among patients undergoing first eye cataract surgery

OBJECTIVE

To describe the relationship between patients' preoperative expectations regarding the outcome of cataract surgery and actual postoperative experience.

METHODS

A longitudinal study of 772 patients undergoing first eye cataract surgery recruited from 75 ophthalmology practices in three metropolitan areas was conducted. Prior to surgery and approximately 4 months after surgery, a detailed interview was conducted that included general and vision-specific health status measures (including the Visual Function 12-Item Scale [VF-12]), patient-reported level of trouble and satisfaction with vision, and questions addressing patients' preoperative expectations regarding the outcomes of surgery. In addition, detailed clinical data were collected preoperatively and postoperatively. A total of 552 patients had only single eye cataract surgery by 4 months postoperatively and are included in this analysis.

RESULTS

Patients' preoperative expectations regarding the impact of cataract surgery were very high and were unrelated to their demographic or ocular characteristics. The preoperative VF-12 score, however, was positively correlated with expected postoperative VF-12 score (Spearman correlation, .45, P < .001). Only 61% of patients achieved or surpassed their expected level of postoperative functioning. The difference between expected and actual postoperative VF-12 scores was not associated with patients' demographic characteristics or provider-related variables. Older patients (> 75 years) and patients with ocular comorbidity had a larger difference between expected and actual postoperative functioning than younger patients and those without ocular comorbidity.

CONCLUSION

Expectations regarding visual functioning after cataract surgery are very high, and in most cases such expectations are fulfilled. In selected cases, more comprehensive counseling may reduce the discrepancy between expectations and actual outcomes of cataract surgery.

Cataract surgical techniques. Preferences and underlying beliefs

To characterize the intraoperative procedures employed by cataract surgeons in the United States and the beliefs underlying the practices, a standardized questionnaire was sent to a systematic random sample of members of the American Academy of Ophthalmology in 1992. Of 667 surveyed ophthalmologists, 550 completed the questionnaire (response rate, 82.5%). Phacoemulsification was used for more than 75% of routine cataract surgery by 46% of respondents, whereas standard extracapsular surgery was used for more than 75% of routine cataract surgery by 41% of respondents. Preferential use of phacoemulsification was independently associated with more recent graduation from medical school and higher reported annual surgical volume. Continuous tear capsulotomy was employed by 52% of ophthalmologists. Preference for this technique was independently associated with both the use of phacoemulsification and higher annual surgical volume. Seventy-one percent of respondents used retrobulbar anesthesia, whereas 28% used peribulbar anesthesia. Use of peribulbar anesthesia was independently associated with both greater surgical volume and performance of surgery in an ambulatory surgical center. Beliefs regarding comparative safety and effectiveness were reported to influence surgeons' preferences strongly among all of the competing techniques studied. Those performing phacoemulsification, in comparison with those performing extracapsular cataract extraction, reported that the expectation of reduced astigmatism and shorter recovery time strongly influenced their choice of procedure. Variation in preferred intraoperative techniques is substantial for cataract surgery and the beliefs that underlie the preferences. Such variation highlights the need to determine which techniques maximize patient outcomes and are most cost-effective.

Variation in ophthalmic testing prior to cataract surgery. Results of a national survey of optometrists. Cataract Patient Outcome Research Team

OBJECTIVE

To assess variation in optometrists' use of ophthalmic tests in the evaluation of patients being considered for cataract surgery who have no history of other eye disease.

DESIGN/PARTICIPANTS

National survey of a systematic sample of practicing members of the American Optometric Association (St Louis, Mo), who had referred at least one patient to an ophthalmologist for consideration of cataract surgery in 1991.

RESULTS

Ninety-two of 130 eligible responding optometrists reported that they routinely performed preoperative testing on patients being considered for cataract surgery. Of these 92 optometrists, 91 (99%) frequently or always performed refraction, and 82 (89%) frequently or always performed a dilated fundus examination in their evaluation of patients being considered for cataract surgery who had no history of other eye disease. None of these 92 optometrists reported using B-scan ultrasonography or electroretinograms frequently or always, and few used A-scan ultrasonography or visual evoked responses frequently or always. A substantial percentage frequently or always used formal visual field testing (47%), formal color vision testing (40%), fundus photography (24%), potential acuity measurement (25%), glare testing (23%), contrast sensitivity testing (19%), and specular microscopy (14%), while 11% to 81% of optometrists never performed these tests on such patients. More recent graduation from optometry school was associated with a decreased frequency of use of potential acuity measurement and contrast sensitivity testing and with an increased use of dilated fundus examinations.

CONCLUSION

There is a substantial variation in optometrists self-reported use of a number of ophthalmic tests in the preoperative evaluation of patients being considered for cataract surgery who have no history of other eye disease.

Variation in ophthalmic testing before cataract surgery. Results of a national survey of ophthalmologists

Little information is available either for the clinical value of many ophthalmic tests performed preoperatively in the evaluation of patients for cataract surgery or for variation in ophthalmologists' use of such tests. To assess variation in ophthalmologists' use of ophthalmic tests, we conducted a national survey of American Academy of Ophthalmology members. Thirty-three percent, 17%, 37%, and 19% of the respondents reported that they "frequently" or "always" perform glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy, respectively, in patients being considered for cataract surgery who have no history of eye disease other than cataract. In contrast, 27%, 54%, 24%, and 48% of respondents reported that they never perform each of these four tests in such patients. Two ophthalmologist characteristics--a surgical volume of greater than 200 cataract extractions per year and performance of surgery in an ambulatory surgical center or private office (as opposed to a hospital)--were independently associated with an increased probability of performing each of these four tests frequently or always. Ten percent or less of the respondents reported that they frequently or always perform electroretinography, visual evoked response testing, photography of fundus or anterior segment, B-scan ultrasonography, formal color vision testing, and formal visual field testing in such patients. Thus, there is considerable variation in ophthalmologists' use of glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy. A small percentage of ophthalmologists may be overusing several other tests in the evaluation of patients being considered for cataract surgery.

National study of cataract surgery outcomes. Variation in 4-month postoperative outcomes as reflected in multiple outcome measures

BACKGROUND

Although ophthalmologists have long recognized that visual acuity alone is an inadequate measure of visual impairment, the need for and outcomes of cataract surgery historically have been assessed in terms of visual acuity.

PURPOSE

To examine the relation among different cataract surgery outcome measures, including a 14-item instrument designed to measure functional impairment caused by cataract (the VF-14), at 4 months after cataract surgery.

METHODS

The authors performed a longitudinal study of 552 patients undergoing first eye cataract surgery by 1 of 75 ophthalmologists practicing in Columbus, Ohio, St. Louis, Missouri, or Houston, Texas. Patients were interviewed, and clinical data were obtained preoperatively (July 15, 1991-March 14, 1992) and 4 months postoperatively.

RESULTS

The percentage of patients judged to be improved at 4 months after cataract surgery varied by the outcome measure used: Snellen visual acuity (96%); VF-14 score (89%); satisfaction with vision (85%); self-reported trouble with vision (80%); and Sickness Impact Profile score (67%). The change in patients' ratings of their trouble with vision and their satisfaction with vision were correlated more strongly with the change in VF-14 score than with the change in visual acuity (operated eye or better eye). The average change in VF-14 score was unrelated to the preoperative visual acuity in the eye undergoing surgery.

CONCLUSION

Estimates of the proportion of patients benefiting from cataract surgery vary with the outcome measure used to measure benefit. Change in VF-14 score, a measure of functional impairment related to vision, may be a better measure of the benefit of cataract surgery than change in visual acuity.

The VF-14. An index of functional impairment in patients with cataract

OBJECTIVE

To describe the development and the performance of a brief questionnaire designed to measure functional impairment caused by cataract (the VF-14).

DESIGN

Observational cross-sectional study. Patients were recruited between July 15 and December 15, 1991.

SETTING

Patients were recruited from the practices of 70 ophthalmologists, located in Columbus, Ohio (N = 21), St Louis, Mo (N = 26), and Houston, Tex (N = 23).

PATIENTS

Seven hundred sixty-six patients undergoing cataract surgery for the first time.

MAIN OUTCOME MEASURES

Preoperative best corrected visual acuity in each eye; scores on the VF-14, a new index of functional impairment in patients with cataract; patient reports of overall trouble and satisfaction with their vision; and scores on the Sickness Impact Profile, a measure of general health status.

RESULTS

The VF-14 has high internal consistency (Cronbach's alpha = .85) and correlates more strongly with the overall self-rating of the amount of trouble and satisfaction patients have with their vision than do several measures of visual acuity or the Sickness Impact Profile score. The VF-14 score is moderately correlated with visual acuity in the better eye.

CONCLUSIONS

The VF-14 is a reliable and valid measure of functional impairment caused by cataract and provides information not conveyed by visual acuity or a general measure of health status.

The effect of early surgical intervention on mortality and cost-effectiveness in burn care, 1978-91

A 14-year (1978-91) single centre analysis was performed involving 3561 patients. Several variables thought to influence burn outcome were included in the analysis, as was length of stay, interval between surgical interventions on each patient, and cost of care. Mortality rate declined by over 2 per cent (from 9.8 per cent during the first 7 years to 7.3 per cent in the second 7 years, P < 0.001). Multiple regression showed that percentage burn, presence of inhalation injury, and age had a significant effect on mortality. These variables, as well as the DRG distribution, were statistically evenly distributed over the 14-year study. There was a statistically significant decrease in length of stay (23 days in 1979 to 14.2 days in 1990), which significantly correlated with a decrease in interval between surgical interventions (14.76 days in 1979 to 6.12 days in 1990). The average annual increase of hospital charges for burn care grew at 9.6 per cent annually, higher than the consumer price index during the same time (5.8 per cent) but substantially lower than the hospital market as a whole (10.8 per cent). Mortality rate of major burns has decreased significantly in this study, while burn severity indices remained constant. Increase in cost of care was substantially lower than that of general hospital care. This apparent cost efficiency is driven by a decreased length of stay closely correlated with aggressive surgical intervention for closure of the burn wound.

In vitro translation of RNA from the German cockroach Blattella germanica

The translation of mRNA within total RNA of German (Blattella germanica) cockroaches was performed using a rabbit reticulocyte lysate system. Analysis of the translation products by SDS-PAGE and combined autoradiography revealed several synthesized proteins with apparent molecular weights ranging from 20 kD to 110 kD. SDS-PAGE/Western blotting of non-radiolabeled translation products and incubation with human serum with IgE to cockroach allergens showed the presence of a 36 kD and 50 kD allergen. The confirmation of the translation of the cockroach allergens from total RNA is an important first step in the cloning of cockroach allergens.

The importance of severity of illness in assessing hospital mortality

Each year, the Health Care Financing Administration (HCFA) releases a report comparing hospital mortality rates with predicted rates. Some argue that the HCFA's prediction model does not adequately account for patient severity. We tested this hypothesis by comparing the HCFA's model (replicated as closely as we could) to a second that added a severity measure (the Stage of Principal Diagnosis at Admission, a subscale of the Severity of Illness Index). In our simulation, the HCFA's model had very limited capacity to predict mortality (average R2, 2.5%). Patients grouped according to admission severity had markedly different mortality rates, which the HCFA's model's predictions could not differentiate. The HCFA model also failed to predict large differences in mortality between hospitals with low- and high-severity admissions. Adding severity to the HCFA's model yielded more than an eightfold increase in the R2, to 21.5%, and reduced instances of higher than expected hospital mortality to chance levels. These findings suggest that the HCFA's mortality release needs to be made much more sensitive to admission severity before it can be used to make valid inferences about the quality or effectiveness of hospital care.

Oral fluconazole therapy for patients with acquired immunodeficiency syndrome and cryptococcosis: experience with 22 patients

PURPOSE

Cryptococcus neoformans causes infections in up to 10 percent of patients with the acquired immunodeficiency syndrome (AIDS). Nearly 50 percent of AIDS patients with previously treated cryptococcal meningitis will experience a relapse within six months. To reduce the likelihood of relapse, a maintenance regimen of amphotericin B is often administered weekly. However, the drug's intravenous route of administration and considerable toxicity have led to a search for alternative antifungal agents. In this report, we document our experience with fluconazole, a new oral triazole antifungal agent.

PATIENTS AND METHODS

Twenty-two patients with AIDS and various forms of cryptococcosis were treated in an open-label study with 50 to 400 mg/day of fluconazole. The following laboratory studies were done on a monthly basis: complete blood cell count, liver function tests, serum creatinine level, serum cryptococcal antigen level, and serum fluconazole level. Lumbar puncture was performed in patients with meningitis every four to eight weeks to evaluate cerebrospinal fluid cryptococcal antigen, India ink preparation findings, fungal culture, fluconazole level, and protein, glucose, and cell count.

RESULTS

Of seven patients with active culture-positive infections, four showed clinical and microbiologic responses (three of four with meningitis, one of three with extraneural cryptococcosis). Fifteen patients who had already undergone successful amphotericin B therapy for either meningitis (n = 14) or pneumonia (n = 1) received fluconazole as prophylaxis against relapse. Fourteen patients remained free of infection during 11 to 64 weeks of suppressive therapy; one patient with meningitis experienced relapse after 26 weeks of treatment. Reverse reactions were limited to increases in hepatic enzyme levels in four patients.

CONCLUSION

These results appear sufficiently encouraging to warrant further trials of this oral agent in the suppression of chronic cryptococcosis and perhaps in the treatment of acute infection.

Calcaneal fracture with compartment syndrome of the foot

We report the unusual case of a compartment syndrome of the foot that developed after a calcaneal fracture in a 68-year-old man. The diagnosis was suspected clinically because of pain in excess of his injury and was confirmed with direct tissue pressure measurements. Surgical decompression of all the compartments was required with evacuation of a plantar hematoma.

Hypokalemia after cardioversion from ventricular tachycardia induced in the electrophysiology laboratory

Serum potassium is often low after resuscitation from out-of-hospital ventricular fibrillation. We hypothesized that hypokalemia develops after ventricular tachycardia induced by programmed electrical stimulation. We measured serum potassium in 10 patients before induction of ventricular tachycardia and 15 minutes, 45 minutes, and 3 hours following cardioversion from ventricular tachycardia. Ventricular tachycardia rate was 243 +/- 71 bpm and duration was 57 +/- 87 seconds. Mean serum potassium (mEq/L) decreased from 4.1 +/- 0.3 at baseline to 3.8 +/- 0.5 at 15 minutes (p less than 0.01 vs baseline) and 3.7 +/- 0.6 at 45 minutes (p less than 0.005 vs baseline), but returned to 4.1 +/- 0.5 at 3 hours. Although no patients were hypokalemic (potassium less than 3.5 mEq/L) at baseline, 33% were hypokalemic at 15 minutes and 40% were hypokalemic at 45 minutes (p = 0.06 vs baseline). A low serum potassium was found in several of these patients immediately after the clinical arrhythmia that led to electrophysiologic study, and rapid resolution of the hypokalemia was observed. Thus, serum potassium decreases rapidly in man after resuscitation from brief but hemodynamically significant ventricular tachycardia. This suggests that patients with hypokalemia after resuscitation from out-of-hospital ventricular fibrillation have hypokalemia secondary to the event. The electrophysiologic effects of post-cardioversion hypokalemia are unknown.

Pharmacodynamics and side effects of flecainide acetate

We compared side effects with flecainide trough levels and ECG intervals among 43 patients who received flecainide for up to 34 months. Flecainide plasma levels were higher when associated with cardiovascular side effects (mean 1063 ng/ml; range 296 to 2050 ng/ml) than when no side effects occurred (mean 609 ng/ml; range 89 to 1508 ng/ml; P less than 0.001). The PR interval (P less than 0.001), QRS interval (P less than 0.001), and the rate-corrected QT interval (P less than 0.001) were greater at the time of cardiovascular side effects, but the rate-corrected JT interval was not. The therapeutic-toxic window for flecainide plasma level was 381 ng/ml (at least 50% probability of efficacy) to 710 ng/ml (less than 10% probability of cardiovascular side effects). The risk of cardiovascular side effects increases at higher plasma levels of flecainide and is associated with greater increases in the PR and QRS intervals from baseline than are routinely observed during flecainide dosing.

Pulmonary microvascular fluid flux in a large animal model of sepsis: evidence for increased pulmonary endothelial permeability accompanying surgically induced peritonitis in sheep

To characterize some of the remote effects of systemic sepsis on the lung, we evaluated changes in pulmonary microvascular fluid flux before and during sepsis secondary to a peritoneal focus of inflammation in sheep. We induced peritonitis by cecal ligation, perforation, and devascularization. During a subsequent 72-hour study period, both the mean blood pressure and the pulmonary capillary wedge pressure were unchanged, while the cardiac index increased slightly. The PaO2 fell by 48 hours (98 +/- 8 to 84 +/- 10 mm Hg; p less than 0.05) (mean +/- SD) and subsequently remained low throughout the experiment. Simultaneously, pulmonary lymph flow increased by 24 hours (11.5 +/- 4.9 to 26.7 +/- 13 ml/hr; p less than 0.05) and remained elevated throughout the experiment while [L/P] total protein ratios remained unchanged at 24 hours (baseline: 0.59 +/- 0.15 at 24 hours: 0.65 +/- 0.16). Morphologic examination of the lung showed that this model of peritonitis was characterized by neutrophil emigration into the pulmonary interstitium by 24 hours and interstitial edema by 48 hours. Therefore this model of bacterial peritonitis in sheep demonstrates that one of the remote effects of surgically induced systemic sepsis is an increase in permeability of the pulmonary microvascular membrane.

Microsurgical selective procedures in peripheral nerves and the posterior root-spinal cord junction for spasticity

This review deals with the long-term results of selective peripheral neurotomy (SPN) of the tibial nerve and selective posterior rhizotomy (SPR) in 123 cases of severe spastic syndromes in the limbs. The microtechniques and preoperative electrostimulation for identification of the nervous structures responsible for the spastic components give to these methods an advantage of a substantial reduction of the harmful spasticity, without suppressing the useful muscle tone and impairing the residual motor and sensory functions. The results were effective, with a 1- to 13-year follow-up, in 89% of 47 SPN of the tibial nerve for spastic foot, in 92% of 53 SPR for paraplegia and in 87% of 23 SPR for hemiplegia.

A controlled trial of propafenone for treatment of frequent and repetitive ventricular premature complexes

The effectiveness of oral propafenone was evaluated for the treatment of ventricular premature complexes (VPCs) in 12 patients, using a single-blind, dose-ranging trial followed by a double-blind comparison with placebo, and then an open-label, long-term protocol. During dose ranging, 8 of 12 patients achieved greater than or equal to 80% suppression of total VPCs (mean 83%) (p less than 0.01 vs single-blind placebo). Paired VPCs were suppressed greater than or equal to 90% and ventricular tachycardia was eliminated in 11 of the 12 patients (p less than 0.01). The effectiveness of propafenone for treatment of VPCs was confirmed during the double-blind trial (p less than 0.05 vs double-blind placebo) and during treatment for 6 months (p less than 0.05 vs initial single-blind placebo). Propafenone prolonged the PR interval by 16% (p less than 0.01 vs single-blind placebo) and the QRS interval by 18% (p less than 0.001). Left ventricular systolic performance decreased as assessed by 2-dimensional echocardiography (p less than 0.01 vs single-blind placebo). Propafenone increased serum digoxin levels in 5 of 5 patients (mean increase of 83%). Side effects included exacerbation of congestive heart failure (1 patient) and conduction abnormalities (2 patients). Thus, propafenone is effective for treatment of total and repetitive VPCs. Although generally well tolerated, the drug reduces left ventricular systolic function and atrioventricular conduction and increases serum digoxin levels.

Comparison of flecainide with quinidine for suppression of chronic stable ventricular ectopic depolarizations. A double-blind randomized study in ambulatory outpatients

In a randomized placebo-controlled double-blind trial, we compared flecainide to quinidine for treatment of ventricular ectopic depolarizations in 19 patients. The mean percent suppression of total ventricular ectopic depolarizations was 95% for flecainide and 56% for quinidine (p less than 0.05). A greater than 80% reduction of total ventricular ectopic depolarizations was obtained in eight of nine patients given flecainide and in five of ten patients given quinidine (p = 0.09). After the randomized protocol, the patients who had received quinidine were given flecainide; 9 of the 10 patients had greater than 80% reduction of total ventricular ectopic depolarizations. Flecainide produced 100% suppression of nonsustained ventricular tachycardia and 99.5% suppression of paired ventricular depolarizations. Flecainide prolonged the PR and QRS intervals; quinidine prolonged the PR and JTC intervals. Side effects were commoner with quinidine than flecainide (p = 0.06). Three other patients failed to complete the protocol because of serious adverse experiences.