Effects of perioperative analgesic technique on rate of recovery after colon surgery

BACKGROUND

Choice of perioperative analgesia may affect the rate of recovery of gastrointestinal function and thus duration and cost of hospitalization after colonic surgery.

METHODS

Fifty-four patients undergoing partial colectomy surgery were randomized into four groups. All groups received a standardized general anesthetic. Group MB received a preoperative bolus of epidural bupivacaine and morphine followed by an infusion of morphine and bupivacaine. Group M received a preoperative bolus of epidural morphine followed by an infusion of morphine. Group B received a preoperative bolus of bupivacaine followed by an infusion of bupivacaine. Group P received a preoperative bolus of intravenous morphine followed by intravenous patient-controlled morphine postoperatively. All patients participated in a standardized recovery program to minimize the influence of nonanalgesic factors on recovery of gastrointestinal function. All epidural groups were double-blinded. All patients were deemed ready for discharge according to prospectively defined criteria.

RESULTS

Groups B and MB reported superior analgesia with activity (P < 0.01). Group M had a greater incidence of pruritus (P < 0.05). Group B had a greater incidence of orthostatic hypotension (P = 0.04). Groups B and MB recovered gastrointestinal function and fulfilled discharge criteria approximately 1.5 days earlier than groups M and P (P < 0.005).

CONCLUSIONS

Epidural analgesia with bupivacaine and morphine provided the best balance of analgesia and side effects while accelerating postoperative recovery of gastrointestinal function and time to fulfillment of discharge criteria after colon surgery in relatively healthy patients within the context of a multimodal recovery program.

Spatial orientation during locomotion [correction of locomation] following space flight

To investigate changes in spatial orientation ability and walking performance following space flight, 7 astronaut subjects were asked pre- and post-flight to perform a goal directed locomotion paradigm which consisted of walking a triangular path with and without vision. This new paradigm, involving inputs from different sensory systems, allows quantification of several critical parameters, like orientation performance, walking velocities and postural stability, in a natural walking task. The paper presented here mainly focuses on spatial orientation performance quantified by the errors in walking the previously seen path without vision. Errors in length and reaching the corners did not change significantly from pre- to post-flight, while absolute angular errors slightly increased post-flight. The significant decrease in walking velocity and a change in head-trunk coordination while walking around the corners of the path observed post-flight may suggest that during re-adaptation to gravity the mechanisms which are necessary to perform the task have to be re-accomplished.

Quality at the hub of HMO Blue

Since the mid-1980s, quality management has infused the healthcare industry with a newborn commitment to improving the quality and efficiency of its service delivery processes. Increasing industry competition has served to sharpen the focus on quality. For health services companies such as Blue Cross and Blue Shield of Massachusetts, a relative latecomer to the managed care marketplace, the challenges of getting quickly up to speed were significant. This article describes the simultaneous efforts of the company to develop a substantial new presence in the managed care marketplace, while also applying the basic principles of quality assurance and continuous quality improvement to its organizational transformation.

Molecular characterization of the 3' terminus of the simian hemorrhagic fever virus genome

The 3' end of the simian hemorrhagic fever virus (SHFV) single-stranded RNA genome was cloned and sequenced. Adjacent to the 3' poly(A) tract, we identified a 76-nucleotide noncoding region preceded by two overlapping reading frames (ORFs). The ultimate 3' ORF of the viral genome encodes the capsid protein, and the penultimate ORF encodes the smallest SHFV envelope protein. These two ORFs overlap each other by 26 nucleotides. Northern (RNA) blot hybridization analyses of cytoplasmic RNA extracts from SHFV-infected MA-104 cells with gene-specific probes revealed the presence of full-length genomic RNA as well as six subgenomic SHFV-specific mRNA species. The subgenomic mRNAs are 3' coterminal. In its virion morphology and size, genome structure and length, and replication strategy, SHFV is most similar to lactate dehydrogenase-elevating virus, equine arteritis virus, and porcine reproductive and respiratory syndrome virus.

Pattern profile analysis of hominid and chimpanzee hand bones

In a study designed to complement morphological research on hominid hand bones, length and width measurements of the thumb, index, and middle rays were obtained from radiographs of modern human hands. These rays are primary in precision-gripping postures and are therefore the ones most relevant for investigating evolutionary changes in fine manipulation. Pattern profile analysis allows individuals or samples to be plotted against a reference sample in standard deviation units, or Z-scores. It provides an indication of how different measurements are from modern human averages, while taking into consideration the degree of variation present within modern human samples. A pattern profile for chimpanzees is clearly distinct from humans but quite similar to that of a bonobo, demonstrating the promise of pattern analysis. Partial pattern profiles of several of the more complete early hominid bones from Hadar, Swartkrans, and Olduvai (O.H. 7) are presented and compared. Hadar bones are long and wide at midshaft relative to articular widths; both body-size effects and functional differences are likely. Thumb distal phalanges from Swartkrans and Olduvai both have relatively small base widths, but they differ in other proportions. Two first metacarpals from Swartkrans show distinct patterns. The profiles of La Ferrassie I and Shanidar IV show the characteristically large Neanderthal distal phalanges. Profiles of Skhul IV and Predmost III are alike in some regions with reference to modern North American white males, though they are less similar overall than are those of the two Neanderthals.

Dynamic monitoring of total-body absorption by 19F NMR spectroscopy: one hour ventilation of HFA-134a in male and female rats

Six male and six female Sprague-Dawley rats were ventilated head-only for 1 h on a 15% atmosphere of 1,1,1,2-tetrafluoroethane (HFA-134a) in air in a magnetic resonance imaging spectrometer. Results from these dynamic 19F NMR studies suggest that a steady-state in vivo concentration of HFA-134a was approached at approximately 25 min into the exposure. Quantitative integration analysis using an external standard estimated this plateau to be 58.3 +/- 11.9 mg of absorbed HFA-134a per rat. The HFA-134a 19F NMR signal disappeared rapidly following removal of the test atmosphere, with an elimination half-life of 4.6 +/- 0.6 min in the male rats and 4.9 +/- 1.5 min in the female rats. The data suggest that there was no statistical difference between the sexes in amount absorbed or in elimination half-lives.

Assessing and treating anxiety in elderly persons

Although anxiety disorders appear to occur less frequently in elderly persons, subsyndromal anxiety and anxiety associated with other medical and psychiatric disorders are significant sources of morbidity. Theories of etiology of anxiety range from the psychodynamic to the neurobiologic. Treatment of anxiety syndromes hinges on a thorough diagnostic evaluation, with attention to the tendency of older adults to prefer somatic descriptors and to view psychiatric illness as stigmatizing. The efficacy of nonpharmacologic treatment strategies such as relaxation training and psychotherapy for elderly anxious patients has not been well researched, but these interventions have been reasonably successful with younger adult populations and avoid the potential for harmful side effects of medication. Pharmacologic treatment strategies can be effective when used with appropriate caution.

The relationship between pronunciation and listening discrimination when Japanese natives are learning English

Two Japanese students were taught to pronounce and discriminate English words that contain unfamiliar phonemic contrasts (e.g., rock and lock). Teaching pronunciation was found to be easier than teaching listening discrimination. Teaching listening discrimination resulted in collateral improvement in pronunciation and, to a lesser extent, vice versa.

Sharing the tools of primary care

Emphasizing community-based primary care as the dominant mode of clinical practice presents an opportunity for greater self determination among retirees, dependents, and active duty personnel. Physician certification of patients' knowledge of personal profiles, problem lists, medication lists, and plans--described as the tools of primary care--permits patient and doctor agreement on mutual agendas of prevention as well as treatment. This opening for primary care involves interaction among all three of the variables in classic medicine--doctors, illnesses, and patients.

Patterns of postnatal weight changes in infants with very low and extremely low birth weights

OBJECTIVE

To describe (1) short-term postnatal weight loss and gain patterns in infants with very low and extremely low birth weights and (2) the variables that may affect these weight change patterns.

DESIGN

Descriptive, retrospective review.

SETTING

University hospital in the intermountain western United States.

SUBJECTS

Sixty-two charts of infants admitted to a university neonatal intensive care unit from July 1990 through November 1992 were reviewed. Infants who weighed 1000 grams or less were categorized as extremely low birth weight (ELBW) and infants weighing 1001 to 1500 grams were categorized as very low birth weight (VLBW). Each group was comprised of 31 infants. Fifty percent of the sample were male, and 50% were female. Eighty-five percent of the sample were Anglo-American, and 15% were non-Anglo-American.

MEASURES

Data were collected on a three-part data collection tool and included demographic and treatment variables.

RESULTS

A significant difference was found in the maximum percent weight lost between the two groups, with the ELBW group losing a mean of 14.77% of birth weight and the VLBW group losing a mean of 11.35% of birth weight (t = 2.45, p < 0.05). The day the infants reached their nadir weight was significantly different between the two groups. The ELBW group reached their nadir on day of life 7, and the VLBW group reached their nadir on day of life 6 (t = 2.00, p < 0.05). No significant difference was noted in the time to return to birth weight between the two groups, with a mean of 15 days to return to birth weight. Factors associated with postnatal weight changes were intraventricular hemorrhage, use of diuretics and steroids, day of life when nadir weight occurred, and maximum percent of weight lost. Many of the independent variables were significantly interrelated to each other (r = -0.90 to r = 0.91, p < 0.01 to p < 0.001). However, only the variables that correlated with time to return to birth weight were entered into the regression analysis. These variables included number of days diuretics were given before return to birth weight, maximum percent of weight lost, and day of life the infants reached their nadir weight. Number of days diuretics were given before return to birth weight correlated significantly with time to return to birth weight (r = 0.77, F = 26.66, p < 0.0001) although maximum percent of weight lost and day of life the infants reached their nadir weight had a minimal effect.

CONCLUSIONS

Further research into the effects of diuretic therapy on weight changes in this population of infants may lead to interventions to minimize the negative effects of diuretics on return to birth weight. In addition, the older growth charts may not be applicable to this population of infants. Generation of new growth charts that provide growth curves based on these data could be useful in developing nutritional therapies that would promote growth and possibly decrease the length of hospital stay for these infants.

The impact of previous sexual abuse on children's adjustment in adoptive placement

This article explores the effects of previous sexual abuse on the adjustment of children in adoptive placement. A conceptual model is used to interpret the findings of a study comparing the adoptive placements of 35 sexually abused children with the placements of 113 children who had no identified history of sexual abuse. Data were gathered from the children's case records. Results indicate that sexually abused children experienced more moves when in care, increased frequency of disrupted adoptive placements, greater behavioral difficulties, and more attachment problems than the comparison group. This article examines the interaction of sexual abuse and adoption issues and discusses the implications of the findings for social work practice with sexually abused children and their adoptive families.

Direct measurement of hydroxyl radicals, lipid peroxidation, and blood-brain barrier disruption following unilateral cortical impact head injury in the rat

We present data correlating the time courses of hydroxyl radical (.OH) production, lipid peroxidation, and blood-brain barrier (BBB) damage following unilateral head injury in the rat. Using a controlled cortical impact device to inflict head injury, we have directly measured brain .OH levels via the salicylate trapping method, and phosphatidylcholine hydroperoxide (PCOOH) levels via the HPLC-chemiluminescence technique, at 5, 30, and 60 min postinjury. These results were then correlated with the time course of BBB disruption, as measured by the extravasation of Evans blue dye (EB) into the injured cortex, over the same time period. In the present study, .OH levels were 62% higher than sham at 5 min postinjury, 25% higher at 15 min (both p < or = 0.05), and no different from sham at 60 min. PCOOH, on the other hand, increased linearly between 5 and 60 min postinjury. Whereas PCOOH levels were 25% greater than sham at 5 min, they were 35% and 52% higher than sham at 30 and 60 min, respectively (both p < or = 0.05 vs sham). Blood-brain barrier disruption followed a similar time course to PCOOH generation, except that the magnitude of the effect was much greater. Whereas EB extravasation was only slightly elevated in the injured cortex at 5 min postinjury, there was nearly an 8-fold increase at 30 min and an 11-fold increase at 60 min (all p < or = 0.05 vs sham). An additional experiment demonstrated that BBB damage can be attenuated by treatment with the 21-aminosteroid lipid peroxidation inhibitor, tirilazad mesylate (U-74006F). Rats were given a single i.v. injection of 3 or 10 mg/kg of U-74006F 5 min postinjury and killed 30 min postinjury. The 10 mg/kg dose of U-74006F reduced EB extravasation 52% (p < 0.025) in comparison to vehicle-treated controls. This is the first study to correlate the time courses of .OH formation, lipid peroxidation, and BBB disruption in injured brain. The results suggest that there is an immediate, posttraumatic burst in .OH formation, followed by a progressive increase in lipid peroxidation and a similar, although slightly delayed, time-related opening of the BBB. The attenuation of BBB damage by U-74006F suggests that this chain of events can be interrupted by administration of an antioxidant/lipid peroxidation inhibitor.

Auditory evoked potentials in Rett syndrome

This study was designed to assess auditory function in subjects with Rett syndrome, a rare neurologic disorder that is characterized by progressive symptoms of dementia, ataxia, respiratory disorder, and communication disorder. Auditory evoked potentials, including the auditory brainstem response (ABR), middle latency response (MLR), and late vertex response (LVR), were recorded in 36 subjects with Rett syndrome. Results showed a systematic decline in auditory function from the peripheral to the central auditory system, with normal ABR in all subjects, normal MLR in 50 percent of subjects, and normal LVR in 36 percent of subjects. Results suggest that hearing sensitivity and the functional integrity of eighth nerve and auditory brainstem pathways are not affected in subjects with Rett syndrome. However, abnormality of both the MLR and LVR suggest the presence of central auditory disorder.

Factors determining the level of anxiety state in geriatric primary care patients in a community dwelling

The authors examined the association between anxiety state and various sociodemographic factors, as well as measures of general health, mood, and stress in a community-dwelling, geriatric population. A survey questionnaire designed for the study was completed by 123 randomly selected subjects. Univariable linear regression analysis showed anxiety state to have an inverse association with age (beta = -0.29, P = 0.0001) and general health measures (P = 0.0001), and to have a direct relationship with depression (beta = 0.78, P = 0.0001), life stress events (beta = 0.98, P = 0.01), and medical comorbidity (beta = 1.04, P = 0.01). Gender differences in anxiety state were not found. The results provide a framework to begin understanding those factors that contribute to anxiety states in late life. This study revealed anxiety and depression to be highly correlated even in elderly subjects who reported low levels of anxiety and depressive symptoms.

Enteral feeding of premature infants with Lactobacillus GG

The objectives of this study were to determine whether or not the probiotic Lactobacillus GG can colonise the immature bowel of premature infants and if so, does colonisation result in a reduction of the size of the bowel reservoir of nosocomial pathogens such as enterobacteriaceae, enterococci, yeasts or staphylococci, and does colonisation with Lactobacillus GG have any effect on the clinical progress and outcome. Twenty preterm infants with a gestational age of 33 weeks or less who were resident on a neonatal unit were studied from the initiation of milk feeds until discharge. The infants were randomised to receive either milk feeds or milk feeds supplemented with Lactobacillus GG 10(8) colony forming units twice a day for two weeks. The clinical features of the two groups of infants were similar. Orally administered Lactobacillus GG was well tolerated and did colonise the bowel of premature infants. However, colonisation with Lactobacillus GG did not reduce the faecal reservoir of potential pathogens and there was no evidence that colonisation had any positive clinical benefit for this particular group of infants.

Effects of feeding premature infants with Lactobacillus GG on gut fermentation

The study aimed to find out whether gut colonisation of premature babies with a probiotic, Lactobacillus GG, modified enteric carbohydrate fermentation. Twenty preterm infants were randomised to receive Lactobacillus GG 10(8) colony forming units twice a day for two weeks or to a control group. Faecal short chain fatty acids (SCFAs), ethanol, and urinary 2,3-butanediol, were measured in parallel with microbiological studies. Lactobacillus GG colonised nine babies. From 1-28 days of age faecal SCFAs did not differ significantly from controls. Median and ranges were (treated and controls, respectively): acetic acid: 173 (trace-799), 166 (trace-700); propionic acid: 44 (trace-169), 37 (11-229); butyric acid: 31 (5-107), 37 (2-118) mumol/g dry weight. Ethanol was detected in more faecal samples from treated babies (65% v 37%), and at higher concentration (6.3 (trace-40) v 3.3 (0.6-8.8; one 229) mumol/g). 2,3-Butanediol was found in 66% of urine samples from treated babies and 58% from controls. On 83% of these occasions Klebsiella sp, Enterobacter sp, or Serratia sp were cultured from faeces. Lactobacillus GG had no obvious adverse effects on nutritionally important SCFAs. The small increase in ethanol excretion is unlikely to have clinical significance.

Transfection of human astrocytoma cells with glial fibrillary acidic protein complementary DNA: analysis of expression, proliferation, and tumorigenicity

Glial fibrillary acidic protein (GFAP) is a M(r) 50,000 intracytoplasmic filamentous protein that constitutes a portion of, and is specific for the cytoskeleton of the astrocyte. GFAP appears to stabilize the astrocyte's cytoskeleton, and helps maintain normal astrocyte cell shape through complex interactions between it and the nuclear and plasma membranes. A critical observation from histopathological studies is that there is progressive loss of GFAP expression with increasing astrocytic anaplasia. To determine how GFAP expression affects human malignant astrocytoma cells that are GFAP-deficient, we have stably transfected GFAP-negative SF-126 human astrocytoma cells with a eukaryotic expression vector into which a complementary DNA for the entire coding sequence of the human GFAP protein has been inserted. Positive transformants were selected for neomycin resistance, and GFAP-positive astrocytoma cells have been identified by indirect immunofluorescence using anti-GFAP antibodies. Upon successful transfection, 5 stably transfected SF-126 astrocytoma cell clones were selected that produced GFAP, formed elongated processes in cell culture, and demonstrated decreased proliferation in a tritiated thymidine uptake assay when compared to the control. In addition, the 5 astrocytoma cell clones demonstrated marked reduction in the number and growth of colonies in soft agar when compared to the control. Southern analysis revealed extra copies of the GFAP complementary DNA that had become integrated into the SF-126 astrocytoma cell genome. Northern analysis revealed variable expression of a 3.5-kilobase GFAP mRNA transcript among the 5 cell clones. The amount of GFAP mRNA expression and immunoreactivity by the stably transfected SF-126 astrocytoma cell clones was found to correlate inversely with astrocytoma proliferation and growth in soft agar. The restoration of GFAP expression to GFAP-negative human astrocytoma cells has affected tumor cell morphology, proliferation, and growth in soft agar in this experimental cell system.

Expansion of neutrophil precursors and progenitors in suspension cultures of CD34+ cells enriched from human bone marrow

The growth and differentiation of selected bone marrow CD34+ cells stimulated with hematopoietic growth factors in lipid cultures were evaluated to determine whether cell types that may be useful for reducing the neutropenia associated with high-dose chemotherapy (HDC) can be produced and quantitated in vitro. CD34+ cells enriched from bone marrow were cultured for up to 5 weeks in interleukin-3 (IL-3), granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) with or without stem cell factor (SCF) (also termed c-kit ligand). The mixture of IL-3, GM-CSF and G-CSF resulted in an 18-fold increase in cells after 10 to 12 days of culture and a 94-fold increase after 21 days. A 3-fold increase in colony-forming unit granulocyte-macrophage (CFU-GM) was observed after 10 days of culture. The addition of SCF during the first 10 days of culture further augmented the proliferation of cell numbers to 24-fold and colony-forming cells (CFC) to 8-fold after 10 days while cell numbers increased 130-fold after 21 days. Two-color flow cytometry defined phenotypes expressing CD11b and CD15 that represented maturation stages of neutrophils. Maturation of neutrophils in these cultures could be followed by the initial appearance after 3 to 7 days of a CD15+CD11b- phenotype representing promyelocytes, which gave rise after 2 to 3 weeks to a CD15+CD11b+ phenotype representing more mature neutrophil forms (metamyelocytes to segmented neutrophils). In contrast to normal neutrophil development, only a small fraction (10 to 15%) of the culture-derived neutrophils expressed CD16. These data define the kinetics and differentiation of neutrophils and neutrophil precursors from selected CD34+ cells in liquid cultures.

Early clinical experience with the Baerveldt 350-mm2 glaucoma implant and associated extraocular muscle imbalance

PURPOSE

The Baerveldt glaucoma implant is a new commercially available aqueous drainage device. Clinical data on the performance of the implant are relatively limited. The purpose of this investigation is to explore potential advantages and disadvantages of this implant over the more widely used Molteno implant.

METHODS

Retrospective analysis was performed on 37 eyes of 36 patients with refractory glaucoma who underwent placement of a mid-sized Baerveldt 350-mm2 implant. Patient selection was based on previous failure of conventional medical, laser, and surgical management, with poor prognosis for further glaucoma surgery and adjunctive antifibrosis therapy.

RESULTS

Significant postoperative extraocular motility restriction and heterotropia were found in the operated eyes. Twenty-three (77%) of 30 eyes measured have significant heterotropia in primary gaze and restriction of gaze into the quadrant of the implant. As a result, 11 (65%) of 17 functionally binocular patients have diplopia in primary gaze.

CONCLUSIONS

Pending further study, the authors are avoiding placement of the Baerveldt 350-mm2 implant in both binocular and monocular patients due to the high frequency of induced heterotropia and motility restriction.

Protective effect of the 21-aminosteroid lipid peroxidation inhibitor tirilazad mesylate (U74006F) on hepatic endothelium in experimental hemorrhagic shock

The effects of the 21-aminosteroid lipid peroxidation inhibitor tirilazad mesylate (U74006F) on ultrastructural damage to the hepatic endothelium in a rat model of hemorrhagic shock were examined. Male Sprague-Dawley rats were anesthetized with urethane and subjected to a 2 hr period of hemorrhagic hypotension (mean arterial pressure clamped at 43-45 mm Hg), followed by reinfusion and follow-up for 2 hr. At the end of the experiment, light microscopic analysis of the livers of animals that received an i.v. injection of vehicle (citrate buffer) just prior to reinfusion showed substantial sinusoidal neutrophil influx. Electron microscopic morphometry revealed significant sinusoidal endothelial degeneration. In contrast, rats that received a 10 mg/kg i.v. bolus of U74006F just prior to posthemorrhage reinfusion displayed a significant preservation of endothelial structural integrity. However, this occurred despite the fact that there was the same degree of hepatic neutrophil influx as in the vehicle-treated rats. These results show that U74006F is capable of protecting endothelial structure, even in the face of significant neutrophil invasion, probably via protection from endothelial cell membrane free radical-induced lipid peroxidation.