An essential need: creating opportunities for veterinary students and graduates to gain an appreciation of responsibilities and opportunities in global veterinary issues

Globalisation trends and bioterrorism issues have led to new concerns relating to public health, animal health, international trade and food security. There is an imperative to internationalise and strengthen global public health capacity by renewed emphasis on veterinary public health in veterinary education and increasing opportunities for elective experiential learning in public practice programmes for veterinary students. Recent experience with a US-Brazil Higher Education Consortia Program is used as an example of potential ways in which veterinary students can gain an appreciation for global veterinary issues.

Epidemiology and outcome of postural headache management in spontaneous intracranial hypotension

BACKGROUND AND OBJECTIVES

Spontaneous intracranial hypotension is a postural headache syndrome unrelated to dural puncture. Due to the apparent failure of epidural blood patch to relieve headache in spontaneous intracranial hypotension, we investigated the epidemiologic features and treatment outcomes of this condition.

METHODS

The clinical findings and management of 22 cases (21 published + 1 reported) of spontaneous intracranial hypotension were analyzed retrospectively. The study population was stratified by age and sex; continuous variables were compared for differences by t-tests; categorical variables were compared by Fisher exact tests. Significant differences were identified by P values of.05 or less.

RESULTS

The mean age of the study population was 43 +/- 16 years, with a female:male ratio of 3.4:1.0. Females with spontaneous intracranial hypotension were younger (P =.050) than males. Men presented with tinnitus (P =.021) and visual field defects (P =.009) more often than women. Meningeal enhancement on contrast magnetic resonance imaging was the most consistent radiographic finding. Radionuclide cisternography showed thoracolumbar dural leaks in 7 of 9 patients. Cerebrospinal fluid opening pressure was low in all patients (33.13 +/- 31.02 mm H(2)O). Epidural blood patch was performed in 8 patients, repeated in 3 patients, failed in 3 patients, and offered only transient improvement in 5 patients.

CONCLUSIONS

Spontaneous intracranial hypotension was more common in women than men, was not uniformly responsive to epidural blood patch, and had significant comorbidities. The management of postural headache in spontaneous intracranial hypotension by other techniques to restore cerebrospinal fluid dynamics and prevent its leakage should be investigated.

Carpal tunnel syndrome in female nurse anesthetists versus operating room nurses: prevalence, laterality, and impact of handedness

Nurse anesthesia may be a high-risk occupation for carpal tunnel syndrome (CTS) in the workplace. We designed a cross-sectional investigation to study the prevalence of CTS in nurse anesthetists (NAs) as compared with operating room nurses (ORNs). Two-hundred forty-four female operating room workers were classified by job title as NAs (n = 63) and ORNs (n = 181). The case definition of CTS was established by a history of surgical correction or a combination of four positive historical and physical findings. There were 10 cases of CTS in NAs and 10 cases of CTS in ORNs. The crude odds ratio (OR) for CTS in NAs was 3.23 (95% confidence interval, 1.27-8.17, P = 0.021). The crude OR for left-hand CTS in NAs was also 3.23 and 3.58 for bilateral CTS. When adjusted for nondominant left-hand or bilateral CTS, the OR for CTS in NAs was 3.85. The Yates-corrected chi(2) for CTS in NAs was 5.346 (P = 0.021) and 5.075 (P = 0.024) for nondominant left-hand or bilateral CTS in NAs as compared with ORNs. On the basis of our data analysis, nondominant left-hand CTS and bilateral CTS were significantly more prevalent in NAs than ORNs.

IMPLICATIONS

Repetitive stress injuries have now exceeded back injuries as the most commonly reported workplace injuries in the United States. Female nurse anesthetists may face greater occupational risks for developing left hand and bilateral carpal tunnel syndrome than female operating room nurses.

Perioperative management of infants with the linear naevus sebaceous syndrome of Jadassohn: a report of two cases

Neurofibromatosis and tuberous sclerosis are the most well-recognized of the congential phakomatoses, a group of six hereditary neuro-oculo-cutaneous disorders. Although easily diagnosed at birth by a parasagittal line of facial sebaceous naevi, the linear naevus sebaceous syndrome (LNSS) of Jadassohn is the rarest phakomatosis, one often characterized by airway and anaesthetic considerations that do not apply to the other phakomatoses. In addition to its obvious cutaneous manifestations, LNSS is characterized by hemifacial asymmetry, an anatomic predictor of difficult trachael intubation, and intractable seizure activity, a condition that limits selection of anaesthetics. The perioperative management challenges of LNSS are depicted in the presentation of two cases of LNSS with different outcomes and contrasted with the major anaesthetic considerations in the perioperative management of other, more common phakomatoses.

Use of an unmanned police car to reduce traffic speed

OBJECTIVE

Motor vehicle collisions are the most common mechanism of traumatic death. Speeding is often implicated as a causal factor in motor vehicle crashes. One potential intervention, to prevent speeding, is the placement of a roadside unmanned police car. This study sought to answer the following questions: is speeding reduced by this intervention, does this intervention lose effectiveness over time, and when the car is removed, do motorists resume speeding?

METHODS

A radarless speed detector was placed on a roadway that had a history of speed-related collisions. Baseline speeds were recorded for 12 days. Thereafter, an unmanned police cruiser was parked near the road, and speeds were recorded for 10 days. The police car was removed, and data collection continued 1 more week. The difference between the proportion of motorists exceeding 45-mph in the baseline period and the decoy intervention period was tested by using a chi2 test.

RESULTS

During the baseline surveillance, 72.0% of vehicles (186,578 of 259,074 motorists) had speeds greater than 45 mph. After placement of the unmanned police car, 41.0% of motorists (92,272 of 225,026 motorists) exceeded 45 mph (p < .0001). Over the 10-day study period, when the decoy police car was in place, the percentage of motorists exceeding 45 mph gradually increased from 27.2% to 47.4%. Upon removal of the police car, speeding returned approximately to baseline, with 67.5% of motorists (120,640 of 178,752 motorists) exceeding 45-mph.

CONCLUSION

Parking an unmanned police car beside a road was associated with a large reduction in speeding over a 10-day period. Removal of the unmanned police car resulted in a return to preintervention speeding.

Intranasal ketamine preinduction of paediatric outpatients

A double-blinded, placebo-controlled study compared the outcomes of intranasal ketamine premedication with placebo in outpatients. Forty paediatric outpatients were assigned randomly in a prospective fashion to one of two separate study groups of equal size (20 patients per group). A placebo group received 2 ml of intranasal saline, 1 ml per naris. The study group received intranasal ketamine, 3 mg.kg-1, diluted to 2 ml with saline, 1 ml per naris. Using a cooperation index, a play therapist scored resistance to nasal instillation, separation of the child from parents at ten min, and acceptance of anaesthesia monitors and face mask at 15 min. Differences in age, weight, episodes of vomiting, recovery and discharge times among the two groups were not significant. Intranasal ketamine, 3 mg.kg-1, was associated with a significantly better (P = 0.013) cooperation index than intranasal placebo. Intranasal ketamine, permitted pleasant and rapid separation of children from their parents, cooperative acceptance of monitoring and of mask inhalation induction, and did not cause prolonged postanaesthetic recovery or delayed discharge home.

The anencephalic organ donor: a challenge to existing moral and statutory laws

OBJECTIVES

To inform physicians of the critical shortage of neonatal heart donors and to provide arguments for and against selecting brain-absent anencephalics as heart donors for brain-normal infants who are dying of hypoplastic left heart syndrome.

DATA SOURCES

International scientific journals of medicine, genetics, epidemiology, bioethics, and public health; adjudicated U.S. civil court cases; and state regulations and statutes.

STUDY SELECTION

Worldwide experience with anencephalics as homologous organ donors.

DATA EXTRACTION

Demographic and epidemiologic data on anencephalic births and natural histories; U.S. civil, district, and appellate court case decisions directing or prohibiting organ donation; state determination-of-death acts; state uniform-anatomical-gift acts.

DATA SYNTHESIS

Organization of all data into either moral challenges or legal challenges to anencephalic organ donation.

CONCLUSIONS

Statutory laws pose a greater challenge to anencephalic organ donation than moral laws. Case law reviews eliminate substituted judgment rulings in directing anencephalic organ donation. A redefinition of brain death applying only to human beings born without a brain would make more donor hearts available to brain-normal infants dying of hypoplastic left heart syndrome.

Perioperative management of paediatric microstomia

Paediatric microstomia may occur congenitally in the whistling face syndrome but is more often acquired after accidental thermal injuries such as biting an electrical extension cord or ingesting household lye. The surgical correction of microstomia includes separation and cosmetic reconstruction of the fused lips and postoperative oral splinting. Microstomia from lye ingestion may be associated not only with limited mouth opening but also with such severe intraoral scarring that common landmarks guiding either rigid or flexible fibreoptic laryngoscopy are obscured, rendering oral and nasotracheal intubation difficult or impossible. We report a case of paediatric microstomia after lye ingestion in which conventional direct laryngoscopy, flexible fibreoptic laryngoscopy, and multiple blind nasal approaches to tracheal intubation were unsuccessful. However, tracheostomy was avoided and successful tracheal intubation was accomplished using a new rigid tubular pharyngolaryngoscope.

The perioperative management of neonates with congenital oropharyngeal teratomas

Oropharyngeal teratomas are rare congenital neoplasms that distort orofacial anatomy and often cause respiratory embarrassment at birth. Immediate management of such lesions should include establishment of a secure upper airway, radiographic exclusion of midline central nervous system anomalies, and early surgical excision to prevent asphyxia or permanent disfigurement. Perioperative assessment and surgical management are reported for three oropharyngeal teratomas.

The difficult intubation kit

A kit for difficult intubation can be assembled quickly from vascular catheters and sheaths commonly available in surgical facilities. The kit provides for continuous oxygen administration throughout all phases of its application in difficult upper airway management. Such applications include stylet-guided endotracheal intubation, cricothyroid puncture, transtracheal ventilation, and translaryngeal catheter-guided retrograde tracheal intubation. A technical description of the Difficult Intubation Kit and guidelines for its use in difficult airway management are presented.

Anesthetic management of chemonucleolysis with chymopapain

Chemonucleolysis and lumbar laminectomy after unsuccessful chemonucleolysis are now common and accepted surgical procedures that require precise perioperative management based on a thorough understanding of the pathophysiology of chymopapain-induced anaphylaxis and the herniating nucleus pulposus syndrome. Preoperative management with appropriate screening tests, antihistamines, and steroids, combined with thoughtful premedication and vigilant monitoring during local or general anesthesia, can provide safe anesthetic management of patients having chemonucleolysis with chymopapain.

Halothane anesthesia in infancy: identification and correlation of preoperative risk factors with intraoperative arterial hypotension and postoperative recovery

Infants are well known to be sensitive to the myocardial depressant effects of halothane. In this study of more than 300 infants, 0 to 24 weeks of age, who received halothane anesthesia, preoperative risk factors were correlated with intraoperative outcome and postoperative recovery. Possible risk factors considered were age, history of respiratory distress syndrome (RDS), preoperative fasting time, and anemia. Intraoperative morbidity was evaluated by occurrence of significant hypotension, slow heart rates, or serious bradycardias. Parameters of postoperative recovery included postanesthetic recovery room admission score, duration of recovery room stay, and time to first feeding. Arterial hypotension occurred with an unexpectedly high frequency of 49.2%. Infants younger than 8 weeks of age (particularly newborns), infants 9-16 weeks of age (fasting eight or more hours), and RDS survivors 0-16 weeks of age were found to be most susceptible to hypotension. Only age and history of RDS, however, proved to be statistically significant risk factors in predicting the probability of intraoperative circulatory depression. Though circulatory depression during halothane inhalation was common, it was not associated with significant intraoperative or postoperative morbidity in terms of cardiorespiratory arrests, serious dysrhythmias, prolonged postanesthetic recovery, or delayed feeding times.

Cold hemagglutination pathophysiology. Evaluation and management of patients undergoing cardiac surgery with induced hypothermia

The widespread induction of systemic hypothermia and use of iced cardioplegic solutions in cardiac surgery may promote occasional cold autoagglutination. Routine laboratory methods used to detect cold-agglutinating autoantibodies may not take into account the extremely low temperatures that the heart and body may attain during cardiopulmonary bypass. Several cold-mediated complications have now been encountered during cardiac surgery in patients with both known and unsuspected cold-reactive autoantibodies. This review will provide the clinician with a working knowledge of the cold autoimmune disorders, a rapid method for differential diagnosis in unproved cases, and an ability to select techniques for reliable myocardial and renal protection in both known and unsuspected cases.

Early diagnosis and airway management of acute epiglottitis in children

The technics for early diagnosis and airway management of acute epiglottitis in children continue to provoke disagreement. In 104 cases of children with acute epiglottitis, early diagnosis was confirmed by cervical roentgenograms, direct pharyngoscopy, or both. Airway maintenance was provided by nasotracheal intubation of conscious patients in most cases. No tracheostomies were performed. Blood cultures obtained after, rather than before, nasotracheal instrumentation resulted in a significant increase in positive Haemophilus influenzae cultures.

Hypotensive anaesthesia for craniectomy in infancy

Deliberate hypotension using halothane and controlled ventilation without positive end-expiratory pressure was employed in 18 of 30 patients undergoing craniectomy for unilateral or bilateral craniosynostosis over a 3-yr period. The technique was simple, resulted in good control of arterial pressure and diminished blood loss, and did not involve extensive monitoring or the use of potentially toxic adjuvant drugs. In the hypotensive group mean systolic arterial pressure was decreased from 92.5 to 65.0 mm Hg. Estimated blood loss was decreased from 111 to 89 ml (mean) for all ages and from 133 to 72 ml (mean) for infants between 8 and 32 weeks of age compared with the normotensive control group.