MIS Distal Metatarsal Metaphyseal Osteotomy in the treatment of metatarsalgia: MOXFQ patient reported outcomes

INTRODUCTION

The aim of this paper is to present validated patient reported outcomes for MIS Distal Metatarsal Metaphyseal Osteotomy (DMMO) in the treatment of metatarsalgia. The study aims to evaluate the DMMO procedure, report patient satisfaction with the operated foot and report any complications of this procedure.

PATIENTS AND METHODS

Between 2014 and 2016, patients who had failed conservative treatment for metatarsalgia were identified in the orthopaedic outpatient clinic. Twenty four consecutive patients requiring DMMO plus/minus toe straightening were prospectively studied. Patients requiring additional procedures at the time of surgery were excluded. Patients completed the validated Manchester-Oxford Foot Questionnaire (MOXFQ) three weeks pre-operatively and 1 year postoperatively. The MOXFQ results were analysed using Paired t-tests. A supplementary question was asked regarding patient satisfaction with the operated foot.

RESULTS

There were 20 women and 4 men with a mean age of 64 years (sd 8.6). Statistically significant differences were found between the pre and postoperative MOXFQ. The postoperative MOXFQ score demonstrated a poorer result for two patients, no change for two patients and improvement in 20 patients, with four of these patients recording the lowest possible score. There was a 29.5 point improvement in mean metric MOXFQ Index score. Seventy-nine percent (n = 19) of patients were satisfied or very satisfied with the operated foot. The average recoil of the metatarsal heads following DMMO was M2 4.01 mm, M3 4.55 mm, M4 4.16 mm. There was one delayed union and no non-unions. Further reported complications were a gastric bleed, pulmonary embolism (VTE), and one intra operative broken burr.

CONCLUSION

Our study demonstrates a clinically important and statistically significant improvement in patient reported outcomes following DMMO, with 79% of patients satisfied or very satisfied with this procedure. The average recoil of the metatarsal heads following DMMO was M2 4.01 mm, M3 4.55 mm, M4 4.16 mm with one delayed union and no non-unions.

Two step capture and purification of IgG2 using multicolumn countercurrent solvent gradient purification (MCSGP)

A two-step chromatography process for monoclonal antibody (mAb) purification from clarified cell culture supernatant (cCCS) was developed using cation exchange Multicolumn Countercurrent Solvent Gradient Purification (MCSGP) as a capture step. After an initial characterization of the cell culture supernatant the capture step was designed from a batch gradient elution chromatogram. A variety of chromatographic materials was screened for polishing of the MCSGP-captured material in batch mode. Using multi-modal anion exchange in bind-elute mode, mAb was produced consistently within the purity specification. The benchmark was a state-of-the-art 3-step chromatographic process based on protein A, anion and cation exchange stationary phases. The performance of the developed 2-step process was compared to this process in terms of purity, yield, productivity and buffer consumption. Finally, the potential of the MCSGP process was investigated by comparing its performance to that of a classical batch process that used the same stationary phase.

Rabies control in Mexico

Rabies in dogs was unknown in the Americas before the arrival of the Spanish "Conquistadores". Until the mid-1980s rabies in animals and, in turn in humans, changed little from year to year, with the number of dog vaccinations reported annually rarely reaching one million. In Mexico, the national rabies control programme using mass parenteral vaccination of dogs started in 1990 with about seven million dogs vaccinated the same year. The number of vaccinated dogs exceeded 10 and 15 million in 1995 and 2005, respectively. Modern cell culture-based inactivated rabies virus vaccines were used. A key factor for the success of the dog rabies control program was the supply of potent canine rabies vaccines. Between 1990 and 2005, more than 150 million vaccine doses from 300 lots were administered. Each lot was tested for potency prior to use in the field. The required minimum content of rabies virus antigen for vaccines was 2 IU, in accord with WHO standards. Testing revealed antigen contents ranging from 3.28 to 5.59 IU. As a result of the mass dog vaccination campaigns, human rabies cases due to dog-mediated rabies decreased from 60 in 1990 to 0 in 2000. The number of rabies cases in dogs decreased from 3,049 in 1990 to 70 cases last year.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

BACKGROUND

There are a number of different approaches to physiotherapy treatment following stroke that, broadly speaking, are based on neurophysiological, motor learning and orthopaedic principles. Some physiotherapists base their treatment on a single approach, while others use a mixture of components from a number of different approaches.

OBJECTIVES

To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched May 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and CINAHL (1982 to May 2005). We contacted experts and researchers with an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function in adult participants with a clinical diagnosis of stroke. Outcomes included measures of disability, motor impairment or participation.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised the identified trials according to the inclusion and exclusion criteria, documented their methodological quality, and extracted the data.

MAIN RESULTS

Twenty-one trials were included in the review, five of which were included in two comparisons. Eight trials compared a neurophysiological approach with another approach; eight compared a motor learning approach with another approach; and eight compared a mixed approach with another approach. A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardised mean difference (SMD) 0.94, 95% confidence intervals (CI) 0.08 to 1.80). There was no significant evidence that any single approach had a better outcome than any other single approach or no treatment control.

AUTHORS' CONCLUSIONS

There is evidence that physiotherapy intervention, using a mix of components from different approaches, is significantly more effective than no treatment or placebo control in the recovery of functional independence following stroke. There is insufficient evidence to conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of clearly described individual techniques and task-specific treatments, regardless of their historical or philsophical origin.

How we do it: Regular infusion of local anaesthetic in the pedicle of pectoralis major myocutaneous flap to shorten hospitalization of surgically treated head and neck cancer patients

Keypoints *Regular infusion of the flap with local anaesthetic for 6 days postoperative via an indwelling catheter is easy. *It does not cause any complications. *It shortens hospitalization by 7 days. *The necessary catheter is readily available.

The recovery of walking ability and subclassification of stroke

BACKGROUND AND PURPOSE

The recovery of walking after a stroke is a key functional goal for many patients. Reports vary, but approximately 50-80% of patients will regain some degree of walking ability following stroke (Skilbeck et al., 1983). There are few data available to show whether different subclassifications of stroke have distinct patterns of gait recovery. The present paper describes the pattern of walking recovery in a population of stroke patients classified according to the Oxfordshire Community Stroke Project classification (Bamford et al., 1991).

METHOD

A prospective observational study. Stroke patients (n = 238) admitted to the inpatient Stroke Rehabilitation Unit at the Western General Hospital, Edinburgh were initially included, with data for 185 patients ultimately available for analysis. Standardized measures of recovery of 10 steps and a 10-metre walk were used routinely to examine recovery time of walking ability. The main outcome measures consisted of days taken to achieve a 10-step walk, days to achieve a 10-metre walk, and initial and discharge gait velocity over 10 meters.

RESULTS

Eighty-nine per cent of the sample (n = 164) achieved a 10-step walk in a median time of five days and a 10-metre walk in eight days. The median initial gait velocity was 0.45 m/s which improved by discharge to 0.55 m/s. Further analysis by subgroup revealed that subjects sustaining a partial anterior circulation infarct, lacunar infarct or posterior circulation infarct recovered significantly more quickly than those subjects with a total anterior circulation infarct (Kruskal Wallis test for days to achieve 10 steps (H = 22.524, N = 164, df = 3) p < 0.001; Kruskal Wallis test for days to achieve a 10-metre walk (H = 22.586, N = 164, df = 3) p < 0.001.

CONCLUSIONS

An hierarchical pattern of recovery of gait was observed with definite variation between the subclassifications of stroke. It is suggested that further work needs to be undertaken to identify more accurately the factors that may influence the recovery of walking following stroke.

Role of Chlamydia pneumoniae and Mycoplasma pneumoniae as causative agents of community-acquired pneumonia in hospitalised children and adolescents

The aim of the study presented here was to determine the prevalence of Chlamydia pneumoniae versus Mycoplasma pneumoniae infections in paediatric patients with community-acquired pneumonia. A total of 50 patients (mean age, 5.5 years; median, 3.9 years) with community-acquired pneumonia were enrolled. Four patients were found to have Chlamydia pneumoniae infection (1 culture positive, 1 PCR positive and 2 serology positive) and 16 patients had Mycoplasma pneumoniae infection (2 PCR positive, 4 PCR and serology positive, 10 serology positive), including three patients with coinfection. The rates of Mycoplasma pneumoniae infection were 22%, 35% and 40% in children aged 1-3, >3-7 and >7 years, respectively. Acute Chlamydia pneumoniae infection was substantially less common than Mycoplasma pneumoniae infection in our study cohort.

Potential of cell retention techniques for large-scale high-density perfusion culture of suspended mammalian cells

This review focuses on cultivation of mammalian cells in a suspended perfusion mode. The major technological limitation in the scaling-up of these systems is the need for robust retention devices to enable perfusion of medium as needed. For this, cell retention techniques available to date are presented, namely, cross-flow filters, hollow fibers, controlled-shear filters, vortex-flow filters, spin-filters, gravity settlers, centrifuges, acoustic settlers, and hydrocyclones. These retention techniques are compared and evaluated for their respective advantages and potential for large-scale utilization in the context of industrial manufacturing processes. This analysis shows certain techniques have a limited range of perfusion rate where they can be implemented (most microfiltration techniques). On the other hand, techniques were identified that have shown high perfusion capacity (centrifuges and spin-filters), or have a good potential for scale-up (acoustic settlers and inclined settlers). The literature clearly shows that reasonable solutions exist to develop large-scale perfusion processes.

Comparison of recombinant human luteinising hormone (r-hLH) and human menopausal gonadotropin (hMG) in assisted reproductive technology

Follicle-stimulating hormone (FSH) and luteinising hormone (LH) act in concert in the stimulation of folliculogenesis and ovulation. However, high levels of LH promote follicular atresia and early miscarriage, and this has led to the concept of a 'therapeutic window' of LH for successful conception in assisted reproductive technology (ART) and ovulation induction. Until now, urinary-derived human menopausal gonadotropin (hMG) has been the only available source of exogenous LH activity. hMG preparations contain highly variable levels of LH, and are often augmented with human chorionic gonadotropin (hCG), which mimics LH activity. Accumulation of hCG bioactivity, however, may have detrimental effects on follicular development and oocyte quality. Recombinant human LH (r-hLH) (Luveris) is the only pure source of LH activity. r-hLH is well characterised and production is tightly controlled, resulting in a highly consistent product. Clinical studies in hypogonadotropic hypogonadal women have demonstrated the efficacy of r-hLH, 75 IU/day, together with r-hFSH, 150 IU/day, in promoting optimal follicular development, oestrogen secretion and endometrial thickness. r-hLH therefore provides the clinician with the opportunity for precise and consistent dosing within the therapeutic window for patients requiring exogenous LH, without the risk of LH overexposure that is associated with hCG.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

BACKGROUND

There are a number of different approaches to physiotherapy treatment following stroke. Central to these are approaches based on 'neurophysiological' principles, 'motor learning' principles and 'orthopaedic' principles.

OBJECTIVES

To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles.

SEARCH STRATEGY

This review drew on the search strategy developed by the Stroke Group as a whole. Relevant trials were identified in the Stroke Group Trials Register of Controlled Trials which was last searched in May 2001. We also searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999) and CINAHL (1982-1999) and contacted experts and researchers with an interest in stroke.

SELECTION CRITERIA

Studies - randomised or quasi-randomised controlled trials. Participants - adults with a clinical diagnosis of stroke. Interventions - physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function. Outcomes - measures of disability, motor impairment or participation.

DATA COLLECTION AND ANALYSIS

Two independent reviewers categorised the identified trials according to the inclusion/exclusion criteria, documented the methodological quality and extracted the data.

MAIN RESULTS

Eleven trials were included in the review, three of which were included in two comparisons. Four trials compared a neurophysiological approach with another approach; four trials compared a motor learning approach with another approach; four studies compared a mixed approach with another approach; two trials reported comparisons of sub-groups of the same approach. A large number of heterogeneous outcome measures were used, limiting the comparison of trial results. No one type of approach had a significantly better outcome than any other type of approach.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to conclude that any one physiotherapy treatment approach is more effective than another in promoting the recovery of postural control or lower limb function.

Quantification of follicle stimulating hormone (follitropin alfa): is in vivo bioassay still relevant in the recombinant age?

Quantification of follicle-stimulating hormone (FSH) for clinical use has traditionally involved the use of in vivo bioassays, particularly the Steelman-Pohley bioassay. This assay has limited precision, requires large numbers of laboratory animals and involves cumbersome procedures for data generation and interpretation. Recent advances in manufacturing procedures for recombinant human FSH (r-hFSH) have resulted in a preparation (follitropin alfa; Gonal-F) that is highly consistent in both isoform profile and glycan species distribution. As a result, follitropin alfa can be reliably quantified using an optimised size exclusion high-performance liquid chromatography (SE-HPLC) method, and vials can be filled by mass. Preliminary clinical studies suggest that the fill-by-mass process results in a product that delivers a more consistent clinical response and is more effective than follitropin alfa vials filled by bioassay in women undergoing controlled ovarian stimulation. Non-bioassay methods such as SE-HPLC are likely to become increasingly important for quality testing and regulatory purposes, provided that the manufacturing process is well controlled and produces a protein of highly consistent physico-chemical properties.

Evidence from gabbro of the Troodos ophiolite for lateral magma transport along a slow-spreading mid-ocean ridge

The lateral flow of magma and ductile deformation of the lower crust along oceanic spreading axes has been thought to play a significant role in suppressing both mid-ocean ridge segmentation and variations in crustal thickness. Direct investigation of such flow patterns is hampered by the kilometres of water that cover the oceanic crust, but such studies can be made on ophiolites (fragments of oceanic crust accreted to a continent). In the Oman ophiolite, small-scale radial patterns of flow have been mapped along what is thought to be the relict of a fast-spreading mid-ocean ridge. Here we present evidence for broad-scale along-axis flow that has been frozen into the gabbro of the Troodos ophiolite in Cyprus (thought to be representative of a slow-spreading ridge axis). The gabbro suite of Troodos spans nearly 20 km of a segment of a fossil spreading axis, near a ridge-transform intersection. We mapped the pattern of magma flow by analysing the rocks' magnetic fabric at 20 sites widely distributed in the gabbro suite, and by examining the petrographic fabric at 9 sites. We infer an along-axis magma flow for much of the gabbro suite, which indicates that redistribution of melt occurred towards the segment edge in a large depth range of the oceanic crust. Our results support the magma plumbing structure that has been inferred indirectly from a seismic tomography experiment on the slow-spreading Mid-Atlantic Ridge.

Neurologic sequelae after caesarean section

BACKGROUND

Because pregnancy increases the sensitivity of nervous tissue to local anaesthetics, pregnant patients may be at higher risk of developing neurologic deficits after spinal block than non-pregnant patients. Therefore, we evaluated prospectively the incidence and type of neurologic symptoms after spinal anaesthesia with hyperbaric bupivacaine for caesarean section.

METHODS

In this prospective follow-up study we recorded neurologic complications during anaesthesia and postoperatively until discharge from the hospital of 219 patients, who underwent caesarean section under spinal anaesthesia with hyperbaric bupivacaine (5 mg/ml, mean 13 mg). The patients filled in a questionnaire on the first and fifth postoperative days. In the case of complaints typical of neurologic symptoms they were checked first by the anaesthesiologist and, in the case of persistent symptoms, afterwards additionally by a neurologist.

RESULTS

Twenty-six of 219 patients were not included in the further evaluation because of incomplete return of their questionnaires. Seventeen mothers (8.8%) complained of transient neurologic symptoms (TNSs), lasting mostly 1-2 days, in the buttocks and/or legs during the first three postoperative days. Eleven patients (5.7%) complained of postdural puncture headache. Two patients (emergency caesarean section because of protracted labour in one and elective caesarean section because of previous caesarean section in the other) complained of persisting pain or sensory abnormalities. Neither of them felt paraesthesia during lumbar puncture.

CONCLUSION

Women after caesarean section under a spinal block seem to suffer more often from TNSs than non-pregnant women. The conclusions are, however, uncertain since we had no control group operated on under other than spinal anaesthesia. The persisting neurologic symptoms in two patients might also be due to the obstetric procedure itself. To find out about the validity and possible underlying causes of our results, we need randomised studies with control groups receiving epidural or general anaesthesia.

Histamine in the control of porcine and human sphincter of Oddi activity

Histamine decreases sphincter of Oddi (SO) contractility in vivo in opossum, but increases contractility in vitro in guinea-pig. In resistor-like SO, such as in pig and man, the histamine effect is poorly known. We investigated the effect of histamine on pig SO in vivo and in vitro and on human SO in vitro. Perfusion manometry catheter and two silver electrodes for simultaneous pressure and electromyography registration were inserted into the SO transduodenally by laparotomy in six anaesthetized pigs weighing for 25-28 kg. Histamine (5-10 microgram kg-1) was infused intra-arterially (i.a.) into the pancreaticoduodenal artery with and without diphenhydramine (75 microgram kg-1) i.a. premedication. Acetylcholine (4 microgram kg-1) i.a., a potent SO stimulator, was used as positive control. After these experiments, the SO was removed and, together with seven human SO from Whipple specimens, were cut into 1.0-1.5 mm thick transverse sections (rings). The rings were placed between two hooks in oxygenated organ bath solution at 37 degrees C. The SO contraction force was measured with isometric force-displacement transducers and registered on a polygraph. SO rings were incubated with histamine (10-100 micromol L-1) and acetylcholine (100 micromol L-1) with or without diphenhydramine (10 micromol L-1), cimetidine (10 micromol L-1), or atropine (1 micromol L-1). Acetylcholine induced huge electrical bursts, and basal SO pressure increased by 20 +/- 10 mmHg. Histamine (10 microgram kg-1) induced strong SO contraction and the SO remained oedematous for over 10 min. Histamine (5 microgram kg-1) resulted in electromyographic burst activity with phasic SO contractions and increase in basal SO pressure by 34 +/- 19 mmHg for over 15 min. Diphenhydramine did not alter acetylcholine-induced SO motility, but significantly decreased histamine-induced contractions and almost abolished electrical activity. In vitro, acetylcholine induced SO contractions in pig (335 +/- 111 mg) and in man (323 +/- 54 mg). Histamine did not change SO tone in man, but in pig it induced dose-dependent contractions in the same way as acetylcholine. These contractions could be inhibited by diphenhydramine, but not by cimetidine or atropine. We conclude that histamine has a stimulatory effect, mediated by H1-receptor, on the pig SO motility. The SO response to histamine is different in adult humans from that observed in young pigs.

Recovery characteristics of sevoflurane or halothane for day-case anaesthesia in children aged 1-3 years

BACKGROUND

Our objective was to compare the recovery characteristics of sevoflurane and halothane for short day-case anaesthesia in a specifically limited age group of children 1-3 yr.

METHODS

Eighty unpremedicated children undergoing day-case adenoidectomy were randomly assigned to receive inhalational induction with either sevoflurane 8% or halothane 5% and nitrous oxide in oxygen (70/30) via a face mask. Tracheal intubation was performed without a muscle relaxant. Anaesthesia was continued with the volatile anaesthetic, adjusted to maintain heart rate and blood pressure within +/-20% of initial values. Recovery was evaluated using a modified Aldrete score, a Pain/Discomfort scale and by measuring recovery end-points. A postoperative questionnaire was used to determine the well-being of the child at home until 24 h after discharge.

RESULTS

Emergence and interaction occurred significantly earlier after sevoflurane than halothane but discharge times were similar. More children in the sevoflurane group achieved full Aldrete scores within the first 30 min after anaesthesia, although this group suffered more discomfort during the first 10 min. The amount of postoperative analgesic administered was higher and the first dose given earlier in the sevoflurane group. Postoperative vomiting was more common with halothane, but side-effects in the two groups were otherwise similar in the recovery room and at home.

CONCLUSIONS

In children 1-3 yr, sevoflurane provided more rapid early recovery but not discharge after anaesthesia of <30-min duration. Apart from more vomiting with halothane and more discomfort during the first 10 min after awakening with sevoflurane, the quality of recovery was similar with the two anaesthestics.

Induction characteristics of thiopentone/suxamethonium, propofol/alfentanil or halothane alone in children aged 1-3 years

The aim of this study was to compare the effect of three different induction techniques, with or without neuromuscular block, on tracheal intubation, haemodynamic responses and cardiac rhythm. Ninety children, aged 1-3 years, undergoing day-case adenoidectomy were randomly allocated to three groups: group TS received thiopentone 5 mg kg-1 and suxamethonium 1.5 mg kg-1, group H 5 Vol.% halothane and group PA alfentanil 10 micrograms kg-1 and propofol 3 mg kg-1 for induction of anaesthesia. No anti-cholinergics were used. Holter-monitoring of the heart rate and rhythm was started at least 15 min before induction of anaesthesia and continued until 3 min after intubation. Tracheal intubation was performed by an anaesthetist blinded to the induction method and judged as excellent, moderate or poor according to ease of laryngoscopy, position of vocal cords and incidence of coughing after intubation. Tracheal intubation was successful at the first attempt in all children in groups TS and H and but only in 80% in group PA (P = 0.001). Intubating conditions were excellent in 22 (73%), 22 (73%) and one (3%) of the patients in groups TS, H and PA, respectively (P = 0.001). Cardiac dysrhythmias (supraventricular extrasystole or junctional rhythm) occurred in two (7%) patients in groups PA and H each (NS). Bradycardia occurred in 0 (0%), four (14%) and six (21%) children in groups TS, H and PA, respectively (P = 0.007 PA vs. TS, P = 0.03 H vs. TS). In conclusion, induction of anaesthesia with propofol 3 mg kg-1 and alfentanil 10 micrograms kg-1 without neuromuscular block did not provide acceptable intubating conditions in children 1-3 years, although it preserved arterial pressure better than thiopentone/suxamethonium or halothane. Cardiac dysrhythmias were few regardless of the induction method.

A new system for the measurement of displacements of the human body with widespread applications in human movement studies

This paper reports the development, construction and use of a new system for the measurement of linear kinematics in one, two or three dimensions. The system uses a series of rotary shaft encoders and inelastic tensioned strings to measure the linear displacement of key anatomical points in space. The system is simple, inexpensive, portable, accurate and flexible. It is therefore suitable for inclusion in a variety of motion analysis studies. Details of the construction, calibration and interfacing of the device to an IBM PC computer are given as is a full mathematical description of the appropriate measurement theory for one, two and three dimensions. Examples of the results obtained from the device during gait, running, rising to stand, sitting down and pointing with the upper limb are given. Finally it is proposed that, provided the constraints of the system are considered, this method has the potential to measure a variety of functional human movements simply and inexpensively and may therefore be a valuable addition to the methods available to the motion scientist.

Recovery after halothane anaesthesia induced with thiopental, propofol-alfentanil or halothane for day-case adenoidectomy in small children

We studied recovery from halothane anaesthesia in 93 children, aged 1-3 yr, undergoing day-case adenoidectomy. Children were allocated randomly to receive thiopental 5 mg kg-1 (group TH), alfentanil 10 micrograms kg-1 and propofol 3 mg kg-1 (group PAH) or 5% halothane (group HH) for induction of anaesthesia. In group TH, tracheal intubation was facilitated with succinylcholine (suxamethonium) 1.5 mg kg-1. In groups PAH and HH, tracheal intubation was performed without neuromuscular block, and succinylcholine was used only if required. Anaesthesia was maintained with 1-3% halothane during spontaneous respiration. Times to achieving predetermined recovery end-points were recorded. Quality of recovery was assessed using a score of 1-9 (best to worst) for sedation, crying, restlessness and agitation. A postoperative questionnaire was used to determine the well-being of the child at home, 24 h after operation. Emergence from anaesthesia (response to non-painful stimuli) occurred earlier in group HH (mean 9 (SD 6) min) than in groups PAH (13 (6) min, P < 0.01) and TH (18 (14) min, P < 0.01). Sitting up, walking and home readiness were achieved earlier in groups PAH and HH than in group TH (P < 0.05 for each variable). Children in group TH were more sedated during the first 30 min after anaesthesia than those in the two other groups (P < 0.05) while emergence-related delirium was more common in group HH than in group TH (P < 0.01). Well-being at home was similar in all groups. We conclude that induction of halothane anaesthesia with propofol-alfentanil or halothane provided more rapid recovery and earlier discharge than that with thiopental.

Effect of pre-treatment with intravenous atropine or glycopyrrolate on cardiac arrhythmias during halothane anaesthesia for adenoidectomy in children

We studied the effect of anticholinergics on the incidence of cardiac arrhythmias during paediatric anaesthesia. ASA I-II children (n = 77) undergoing adenoidectomy were randomly allocated to three groups. Intravenous atropine 0.02 mg kg-1 was given in group A (n = 25), glycopyrrolate 0.004 mg kg-1 in group G (n = 27) and physiological saline in group P (n = 25) 3 min before the induction of anaesthesia. The children breathed spontaneously under halothane anaesthesia with 66% nitrous oxide in oxygen after induction with thiopentone and succinylcholine. Perioperative monitoring of the ECG (Holter recordings) and oxygen saturation was carried out. Ventricular tachycardia occurred in 16.0%, 18.5% and 12.0% of the children in groups A, G and P respectively (ns). The incidence of ventricular arrhythmias (ventricular tachycardia, ventricular bigeminy, ventricular premature beats > 10) was 20.0% in group A, 44.4% in group G and 36.0% in group P (ns). Bradycardia (< 70 beats min-1) was observed in 0.0%, 14.8% and 24.0% of patients in groups A, G and P respectively (A vs P, P < 0.05). The use of anticholinergics did not influence the incidence of ventricular arrhythmias during halothane anaesthesia in children. Bradycardia was more common in the placebo group than in the atropine group.

The inhibitory role of nitric oxide in the control of porcine and human sphincter of Oddi activity

BACKGROUND

The possible role of nitric oxide in the regulation of the sphincter of Oddi is not known in species with a resistor-like sphincter of Oddi such as humans and pigs.

METHODS

Sphincter of Oddi perfusion manometry and simultaneous electromyography (EMG) were recorded transduodenally in eight anaesthetised pigs. Acetylcholine (4 micrograms/kg) was given intra-arterially, with or without sodium nitroprusside (10-100 micrograms/kg), an exogenous nitric oxide donor. For in vitro studies the sphincter was removed from the eight pigs and from six patients undergoing pancreaticoduodenectomy, cut into rings, and the amplitude of contraction was measured in an ex vivo bath. Each ring was stimulated with acetylcholine (100 microM) and KCl (125 mM). The stimulation was repeated after incubation with L-NAME (a stereospecific competitive inhibitor of nitric oxide synthase), with L-NAME plus L-arginine (a substrate for nitric oxide synthase), and with sodium nitroprusside. The sphincter rings were then submersed in liquid nitrogen and stored. Immunohistochemical analysis was used to localise nitric oxide synthase in the pig and human sphincter specimens.

RESULTS

In vivo EMG revealed 2-3 phasic bursts per minute with the basal pressure variation 6-40 mm Hg. Acetylcholine induced a large electrical burst and the pressure increased by (mean (SE)) 20 (10) mm Hg (p < 0.01) for 17 (4) seconds. After sodium nitroprusside (10 micrograms/kg) acetylcholine did not induce pressure changes and electrical activity was almost abolished. In vitro, L-NAME increased the KCl induced sphincter contraction in both pig and human specimens (p < 0.01). In human, but not in pig, specimens L-NAME increased the amplitude of acetylcholine induced contraction (p < 0.01). L-Arginine partly reversed the effect of L-NAME in both pig and human specimens. Sodium nitroprusside decreased the acetylcholine and KCl induced contractions in both pig and human specimens. Immunohistochemical studies localised nitric oxide synthase to rich plexi of nerve fibres in the mucosa and the muscle in both pig and human sphincter of Oddi.

CONCLUSIONS

The sphincter of Oddi in both pigs and humans has endogenous nitric oxide synthase activity and immunoreactivity. Inhibition of endogenous nitric oxide production enhances contractility while exogenous nitric oxide decreases sphincter contractility and electrical activity.

MEG burst suppression in an anaesthetized dog

Recording of the magnetic fields of the brain, magnetoencephalography (MEG), has proved to be a valuable method in neurophysiological research. In order to study the feasibility of MEG recording during anaesthesia we recorded magnetoecephalographic burst suppression in a dog during enflurane and propofol anaesthesia. The observed signal distribution implies a complex current distribution underlying the burst activity. This experiment also proves that an essentially artefact-free MEG recording can be obtained during respirator-assisted anaesthesia.

Spatial arrangement of sigma-factor and core enzyme of Escherichia coli RNA polymerase. A neutron solution scattering study

By means of neutron solution scattering we determined the position and orientation of core enzyme and sigma-factor within the Escherichia coli RNA polymerase holoenzyme with the aim of improving existing models. The individual components, core enzyme (E) and sigma-factor (sigma), were highlighted by deuterium labeling and their center-to-center distances determined in the monomeric and the dimeric holoenzyme. The following distance parameters were obtained: dE1-sigma 1 = 8.6(+/- 1) nm, dE1-E2 = 11.5(+/- 1) nm, d sigma 1-sigma 2 = 12.0(+/- 0.7) nm, dE1-sigma 2 = 9(+/- 3) nm. Using a triangulation procedure the position of the sigma-factors, sigma 1 and sigma 2, were determined with respect to the mass center of the core enzyme molecules, E1 and E2, assuming a symmetrical arrangement of the holoenzyme molecules in the dimer (C2 symmetry). In addition, the orientation of the sigma-factor with respect to core enzyme was estimated by means of model calculations. The obtained model of holoenzyme depicts the sigma-factor as buried in a groove of core enzyme, probably between the large subunits beta' and beta.

Optic nerve enlargement and central retinal-artery occlusion secondary to retrobulbar anesthesia

Optic nerve injury after retrobulbar injection of anesthetic agents may damage the optic nerve and vascular supply to the eye. We describe a case of documented orbital optic nerve injury with central artery occlusion after retrobulbar injection before cataract surgery. Early computed tomography documentation of optic nerve injury associated with retrobulbar injection is suggested to allow early consideration of optic nerve sheath decompression.

The quaternary structure of Tet repressors bound to the Tn10-encoded tet gene control region determined by neutron solution scattering

The spatial arrangement of Tet repressor dimer, both free and in complex with an 80 bp DNA fragment spanning the wild-type Tn10-encoded tet transcriptional control sequence containing a tandem repeat of two operators, has been determined by neutron small-angle scattering. The active, free Tet repressor dimer is an elongated and flat molecule with a maximum dimension of 11 +/- 1.5 mm which can be approximated by an ellipsoid with the half-axes 6 nm, 2.5 nm and 1 nm. The overall conformation undergoes no detectable change when the repressor dimer is bound to a DNA fragment containing a single tet operator. The normal distance between the centre of gravity of the protein and the DNA axis is 3.0 +/- 0.1 nm, indicating that the repressor dimer is mainly located on one side of the DNA. When bound to the wild type tet control DNA, the two repressor dimers have a centre-to-centre distance of 11.0 +/- 0.5 nm. Their minimal distance is 5 +/- 2 nm. Protein-protein contacts via loop formation of the DNA by repressor binding is excluded. The repressors are well separated and have no direct contact. A model is proposed where the two repressor dimers are located on opposite sides of the DNA and the DNA is not strongly bent in the complex.

Spatial arrangement of DNA-dependent RNA polymerase of Escherichia coli and DNA in the specific complex. A neutron small angle scattering study

In this paper we demonstrate that neutron small angle scattering is a suitable method to study the spatial arrangement of large specific protein-DNA complexes. We studied the complex of DNA-dependent RNA polymerase of Escherichia coli and a 130 base-pair DNA fragment containing the strong promoter A1 of bacteriophage T7. Contrast variation of the complex with deuterium allowed us to "visualize" either RNA polymerase, or DNA, or both components in situ. From the corresponding scattering curves information was derived about: (1) Conformational changes of RNA polymerase and DNA by complex formation: comparison of the scattering profiles of the isolated and complexed components showed that by specific complex formation the cross-section of RNA polymerase decreases, while the DNA fragment does not undergo a gross conformational change. (2) The spatial arrangement of RNA polymerase and DNA in the specific complex from the cross-sectional radii of gyration of the complex the normal distance dn between the centre of gravity of the RNA polymerase and the axis of the DNA fragment was derived as 5.0 (+/- 0.3) nm. On the basis of these and footprinting data a low resolution model of the RNA polymerase-promoter complex is proposed. The main feature of this model is the positioning of RNA polymerase to only one side of the DNA.

Vaccinia virus recombinants expressing rabiesvirus glycoprotein protect against rabies

Six recombinants of New York Board of Health (NYBH) vaccinia virus containing cDNA for Challenge Virus Standard (CVS) rabiesvirus glycoprotein (G) were produced by directing gene insertion into the vaccinia thymidine kinase (TK) locus. To regulate expression of G the promoter P7.5 (functions at early and late times postinfection) from the gene for the vaccinia 7.5 kilodalton (kD) protein was used in two of the recombinants; late promoter P11 of the vaccinia 11 kD protein was used in four recombinants. The six differed in nucleotide sequences flanking the translation start codon; in two constructs the encoded signal peptide of G was fused to several additional amino acids. Cells infected with each recombinant made G that reacted with G-specific antibodies, comigrated with authentic G, and was transported to the plasma membrane. The highest amounts of G were made with fusion or standard versions of G with P11 provided that the mRNA leader sequences were identical to the natural gene. Each recombinant in mice and one in dogs induced rabiesvirus neutralizing antibodies and protection against lethal rabiesvirus challenge.

Large-scale preparation of a DNA fragment containing the strong promoter A1 of the phage T7

A procedure has been developed to isolate DNA fragments on a large scale. A DNA fragment of 130 base-pairs containing the strong promoter A1 of the phage T7 was purified to homogeneity in amounts of 10 mg. The procedure includes the rapid purification of gram amounts of plasmid DNA, a new, simple method to separate small DNA fragments from the vector by a phenol/water partitioning system, and a liquid-liquid PEG-dextran partition chromatography for the final purification of the fragment. The fragment was cloned in two vector systems: The vector pDS1, to1+ (1), containing an efficient terminator downstream from the promoter integration site, gives high yields, 3-4 mg plasmid DNA per liter medium. In the plasmid pWH802 (2), which is not specially designed for the amplification of a strong promoter, the integration of the promoter was possible but the yield decreased by a factor of about 50. The stability of the inserts was tested in both systems. Monomeric inserts were stable in both plasmids, multimeric inserts up to a tetramer were only stable in pWH802. Only one orientation of the fragment was found.

Solution structure of a short DNA fragment studied by neutron scattering

The solution structure of a DNA fragment of 130 base pairs and known sequence has been investigated by neutron small-angle scattering. In 0.1 M NaCl, the overall structure of the DNA fragment which contains the strong promoter A1 of the Escherichia coli phage T7 agrees with that expected for B-DNA. The neutron scattering curve is well fitted by that of a rigid rod with a length of 44 nm and a diameter of 2 nm. The results were confirmed by quasi-elastic light scattering and analytical centrifugation. The neutron measurements in H2O and D2O buffer reveal a cross-sectional inhomogeneity not detected by X-ray small-angle scattering. This inhomogeneity is caused by the hydration layer around the DNA core and not by the helical structure. The primary solvent shell has a density increased by at least 4-9% compared to bulk water.

The use of skills training procedures in the treatment of a child-abusive parent

Recent behavioral formulations suggest that child abuse can often be conceptualized in terms of skill deficits of the parent. In the present case study, training was used to improve an abusive parent's anger-assertion, child management, and personal problem-solving skills; deficits in all three areas were functionally related to prior episodes of violence. Treatment across these skill areas was introduced in multiple baseline fashion. The effectiveness of treatment was demonstrated by assessments of assertion, child management, and problem-solving knowledge following each training session; parent monitoring data on the frequency of child-related and anger problems at home throughout the intervention; performance on skill generalization measures; and objectively-rated parent-child interactions during pre- and post-training home observation probes.

[Recovery after ketamine-diazepam and thiopental-fentanyl-infusion anesthesia with jet-ventilation for laryngomicroscopy]

Using two infusion anaesthesiamethods for laryngomicroscopy in 187 non-selected patients we studied the recovery phase with the aid of a special questionnaire filled in by the recovery room nurse. Premedication was with Thalamonal and atropine. Muscle relaxation was achieved by a succinylcholine drip. Induction doses: fentanyl 0.05-0.1 mg and thiopental 3-5 mg/kg bodyweight (Th-group) or diazepam 10-20 mg and ketamine 1 mg/kg bodyweight (K-group). Infusion doses: Thiopental 11.7 mg/min. (Th-group) or diazepam 0.2 mg/min. and ketamine 2 mg/min (K-group). Anaesthesia lasted for 20-30 min. We observed and noted during recovery: Breathing, cough-frequency and -quality, alertness, reaction to speech and stimulation, orientation, motor behaviour and well-being. Anaesthesia was sufficient in both groups. The patients of the K-group woke up earlier and their laryngeal reflexes seemed to stabilize quicker than in the Th-group. Because of the elevation of blood pressure caused by the stimulation of the laryngoscopy both methods are not recommended for patients at risk from high blood pressure.

[Documentation of central venous catheterization using a computer laboratory system (author's transl)]

Full documentation of every case of central venous catheterization is a prerequisite for reducing the incidence of failures and complications. A laboratory computer program already in use was modified for this purpose: the start of the operation is put in in "real time", abandoned or failed procedures or incomplete data are detected, and can be queried on the day of patient is discharged from hospital. Adverse effects are shown up at an early stage by the quarterly print-out. The program involves less work than a conventional system without computer. The experiences gained with this modified system in the course of one year (including the run-in period) are reviewed.

[Our experiences during cannulation of the subclavian vein in children (author's transl)]

With 260 children under 12 years of age we tried to cannulate the subclavian vein during 3 years 455 times, and were successful 391 times (85.9%). 43.8% of the patients were younger than 1 year. The success rate correlated to the childrens' bodyweight and was less with lower weight of the patients. - In 68.8% of the cases we found the tip of the cannula in the upper caval vein, 19.9% were in the internal jugular vein, and 6.1% were in the opposite subclavian vein. - In this study participated 7 members of the staff and 8 specializing doctors; catheterizations per participant, mean = 30,2, SD 21,49, minimum 6, maximum 65. - Cannulas functioned for 5 +/- 2, max. 19 days. - The most serious complications were 2 pneumo- and one pneumo-hydrothorax, 2 times suspicion of thrombosis and 1 hemorrhage due to a not known hemophilia. None of the complications caused therapeutical problems.

[Ketamine-induced psychopathological changes in normal volunteers during conditions used for experimental psychoses (author's transl)]

The psychotomimetic properties of ketamine were studied in 9 physically and psychically normal medical students and nurses during 20 single-blind experiments. During the experiments any disturbance to the subject was avoided. A dose of 0.25 mg/kg produced psychical changes in every case, and 1 mg/kg caused an experimental psychosis every time. The latter starts in an "ideal" case with an expressive disturbance of consciousness down to the level of surgical anesthesia. 5-7 minutes after the start of the experiments the scalar change of consciousness lessens enabling the qualitative changes to become obvious. Strong short-time memory disturbance however prevents the subjects from describing coherently the large number of hallucinations and illusions which are frequently experienced. For several moments at the end of the experiment a strong disturbance of body-feeling combined with ataxia may still be present when consciousness is almost normal. - According to the observed psychopathological changes ketamine may be classified as a not LSD-typical hallucinogen. - It should be possible to lower the frequency of adverse reactions to ketaminemonanesthesia by preparing the patients for the strange experiences possible during emergence.

[Porphyria and anesthesia. A case report and a short review (author's transl)]

The most important facts for the anesthesiologist about porphyria are presented on the basis of an own case. The acute abdomen with unusual accompanying symptoms (tachycardia, neurologic and psychic disorders) should rise suspicion of possible porphyria. The clinical diagnosis is most important for the anesthesiologist, because barbiturates may cause fatalities in 50% of the cases. Halothane should be avoided, too. Every suspected case should be carefully investigated including the family. The symptomatic therapy of the severe porphyria-attack is presented in short.