Initial surgical and pain management outcomes after Nuss procedure

PURPOSE

The purpose of this article was to report surgical and pain management outcomes of the initial Nuss procedure experience at the Children's Hospital of Wisconsin (Milwaukee) and to place this experience in the context of the published literature.

METHODS

The initial 118 consecutive Nuss procedures in 117 patients were retrospectively reviewed with approval of the Children's Hospital of Wisconsin human rights review board. Patient, surgical, complication, and pain descriptors were collected for each case. Statistical methods for comparison of pain strategies included the Kolmogorov-Smirnov test for normality, 1-way repeated measures analysis of variance, and paired t tests.

RESULTS

Patient, surgical, and complication descriptors were comparable to other large series. Complication rates were 7% early and 25% late. Epidural success rate was 96.4%. There was 1 episode of recurrence 2 years postbar removal (n = 114).

CONCLUSIONS

The institution of the Nuss procedure provides a highly desired result with significant complication rates. The ideal approach would deliver this result with lower risk. A pain service-driven epidural administration of morphine or hydromorphone with local anesthetic provides excellent analgesia for patients after Nuss procedure. The success of epidural analgesia is independent of catheter site and adjunctive medications. Ketorolac was an effective breakthrough medication.

Comparative proteomic analysis of PAI-1 and TNF-alpha-derived endothelial microparticles

Endothelium-derived microparticles (EMPs) are small vesicles released from endothelial cells in response to cell injury, apoptosis, or activation. Elevated concentrations of EMPs have been associated with many inflammatory and vascular diseases. EMPs also mediate long range signaling and alter downstream cell function. Unfortunately, the molecular and cellular basis of microparticle production and downstream cell function is poorly understood. We hypothesize that EMPs generated by different agonists will produce distinct populations of EMPs with unique protein compositions. To test this hypothesis, different EMP populations were generated from human umbilical vein endothelial cells by stimulation with plasminogen activator inhibitor type 1 (PAI-1) or tumor necrosis factor-alpha (TNF-alpha) and subjected to proteomic analysis by LC/MS. We identified 432 common proteins in all EMP populations studied. Also identified were 231 proteins unique to control EMPs, 104 proteins unique to PAI-1 EMPs and 70 proteins unique to TNF-alpha EMPs. Interestingly, variations in protein abundance were found among many of the common EMP proteins, suggesting that differences exist between EMPs on a relative scale. Finally, gene ontology (GO) and KEGG pathway analysis revealed many functional similarities and few differences between the EMP populations studied. In summary, our results clearly indicate that EMPs generated by PAI-1 and TNF-alpha produce EMPs with overlapping but distinct protein compositions. These observations provide fundamental insight into the mechanisms regulating the production of these particles and their physiological role in numerous diseases.

Use of a reference four-component model to define the effects of insulin treatment on body composition in type 2 diabetes: the 'Darwin study'

AIMS

To define the effects of insulin treatment on body composition and fat distribution, and investigate the potential role of body weight (BWt) gain predictors in patients with poorly controlled type 2 diabetes.

METHODS

Assessments of body composition, using a four-component model, and biochemical indices were obtained in 19 patients [mean (SD): age, 60 (8.3) years; BMI, 25.3 (3.3) kg/m(2)] with poorly controlled type 2 diabetes, despite maximal oral hypoglycaemic agents, receiving insulin [40 (12.2) units/day] at baseline and after 1, 3 and 6 months.

RESULTS

Insulin therapy significantly reduced plasma glucose [-6.0 (4.3) mmol/l], improved [HbA(1)c [-1.9 (1.8)%], and reversed the BWt lost [3.3 (1.8) kg] before treatment. The 6-month BWt gain [+5.2 (2.7) kg] consisted of body fat [+2.9 (2.7) kg] and fat-free mass [FFM; +2.3 (1.8) kg], with the FFM increase due solely to total body water [TBW; +2.4 (1.5) l], as there were no detectable changes in total body protein or bone mineral, thereby increasing FFM hydration by 1.3%. More body fat was deposited centrally in patients receiving insulin alone than those receiving insulin with an oral hypoglycaemic agent (metformin). Daily insulin dose, HbA(1)c and hip circumference were independent predictors of BWt gain.

CONCLUSIONS

Insulin treatment increased fat and FFM similarly in poorly controlled type 2 diabetes patients, with the FFM gain due entirely to TBW. The possible role of metformin in reducing central fat accumulation following insulin treatment warrants further investigation into its mechanism and potential long-term benefits.

Children of the Philippines: attitudes toward visible physical impairment

OBJECTIVE

This pilot study was designed to evaluate children's attitudes and understanding of physical disabilities with special reference to those with craniofacial anomalies in the Philippines. Children with and without craniofacial anomalies were studied.

DESIGN

This was a two-group correlational design with additional statistical assessment of subgroup differences. Each group was interviewed and information obtained on a standard disability preference task, attributions for playmate choice, and frequency of contact with disabilities. Parents completed a structured interview.

SETTING

Participants were 122 children recruited from Negros, Philippines.

PARTICIPANTS

Fifty-four children with craniofacial anomalies (aged 7 to 12 years) were enrolled in the study, and 68 children without any disabilities were recruited from a local school in Bacolod City, Negros, Philippines.

MAIN OUTCOME MEASURES

Participants completed a picture-ranking interview of specific physical disabilities and provided their reasons for their play choices and their contact with physical disabilities.

RESULTS

The Kendall W correlation was significant for the children with craniofacial anomalies and for those without physical disabilities. Both groups reported lower preferences for disabilities that interfere with play and social interactions. Children depicted with facial anomalies received lower preference, compared with other physical disabilities. Children with craniofacial anomalies who have experienced surgical repair reported more positive rankings for the child depicted with a facial cleft. Sex differences in disability preference were noted.

CONCLUSIONS

Children in the Philippines with and without craniofacial differences revealed similarities in preferences to children in several Western (United States) and non-Western countries. Children depicted with facial anomalies received lower preference than other visible physical differences. Children reported both positive and negative explanations for their disability play preferences. Facial differences may result in illogical and negative explanations for social avoidance among children. Similar reactions are noted in other parts of the world.

Fatty acid composition of erythrocytes and plasma triglyceride and cardiovascular risk in Asian diabetic patients

The excess of coronary heart disease in Indian Asians compared with Europeans is unexplained by conventional risk factors, although the high prevalence of diabetes may play a part. To explore the contribution of diet we compared the fatty acid composition of erythrocyte membrane phospholipid and plasma triglyceride in 36 Gujarati Asians and 24 Europeans with non-insulin-dependent diabetes. Erythrocytes from Asian subjects contained higher proportions of linoleic, dihomogammalinolenic, and arachidonic acids, and lower proportions of oleic and n-3 series fatty acids; triglycerides contained higher linoleic and lower oleic acid levels. For example, mean percentage (SE) of oleic acid (18:1n-9) in erythrocytes was 16.7 (0.2) in Asians and 20.5 (0.6) in Europeans (p = 0.0001), and total n-6:n-3 ratio was, respectively, 12.8 (0.7) and 6.7 (0.7) (p = 0.0001). A high dietary intake of linoleic acid may not be cardioprotective unless balanced by significant intakes of oleic and n-3 series fatty acids, at least in diabetic Indian Asians. By itself, the conventional recommendation to substitute polyunsaturated for saturated fat in the diet may be inadequate to reduce thrombogenesis, and the overall balance of fatty acids, including monounsaturates, should be considered.

Cryogenic far-infrared Fabry-Perot étalon

A small cryogenic Fabry-Perot étalon was fabricated for the far-infrared region. This design used freestanding metal meshes for the reflecting elements. Using a combination of gold-coated copper mesh on stainless steel, we reproduced the spacing to 1 part in 10(6) with repeated cooling. The properties and methods used for alignment and calibration are presented.

Corticotrophin releasing hormone (CRH1-41) stimulates the secretion of adrenocorticotrophin, vasopressin and oxytocin but not adrenocorticotrophin precursors: evidence from petrosal sinus sampling in man

To examine the relationship between corticotrophin releasing hormone (CRH), arginine vasopressin (AVP) and oxytocin (OXT) we have studied the responses of adenohypophyseal and neurohypophyseal hormones to CRH in eight patients (age 26-64 years, six female) with suspected pituitary-dependent Cushing's syndrome during bilateral, simultaneous inferior petrosal sinus catheterization. Blood samples were taken from both petrosal sinuses and a peripheral vein before, and at 5-min intervals for 15 min after, an intravenous injection of 100 micrograms human CRH1-41. CRH increased sinus AVP concentrations in all eight patients and OXT concentrations in four of five patients studied. Although AVP concentrations often increased in both sinuses, the side of maximal AVP rise was termed side(max-AVP). CRH did not affect peripheral or petrosal sinus mean concentrations of LH, FSH, GH or TSH. While there was no change in mean peripheral concentrations of AVP, OXT, ACTH, ACTH precursors or prolactin after CRH, sinus concentrations of OXT, ACTH and prolactin on side(max-AVP) were markedly elevated over contralateral values. CRH did not increase mean sinus concentrations of ACTH precursors. In seven patients with either no radiological abnormality or the pituitary fossa or a small adenoma the mean ACTH precursor/ACTH ratio in blood sampled from all sites was 2.1 +/- 0.16 (mean +/- SEM, n = 50). In a patient with a large, locally invasive tumour the mean ACTH precursor/ACTH molar ratio was 32.1 +/- 1.3 (n = 12; P less than 0.001), suggesting that alterations in this molar ratio may reflect the biological properties of the tumour. The source of CRH-stimulatable AVP and OXT remains uncertain.(ABSTRACT TRUNCATED AT 250 WORDS)

The responses of arginine vasopressin and adrenocorticotrophin to nausea induced by ipecacuanha

Ipecacuanha syrup induces emesis by an early peripheral (gastric irritant) action and a later central effect at the chemoreceptor trigger zone (CTZ). We have studied the responses of plasma AVP, ACTH and ACTH-precursors to early and late ipecacuanha-induced nausea in nine healthy male subjects. Symptom severity was assessed using a linear analogue scale. All subjects reported 'early' nausea (N1) with a latency of 16 +/- 2 min (mean +/- SEM) and eight subjects vomited. Six subjects experienced recurrent nausea (N2) (latency 106 +/- 10.4 min) of whom five also vomited. The interval between the cessation of N1 and the onset of N2 was 55 +/- 10.8 min (range 25-80 min). The severity of nausea at the onset of N1 or N2 was similar but the AVP and ACTH responses were highly variable. Thus, while mean plasma AVP concentrations increased during both symptom periods, in three subjects during N1 and in three subjects during N2 plasma AVP concentrations did not rise above the normal range, despite marked symptoms. No clear pattern of AVP response to distinguish early peripheral from late central ipecacuanha-induced emesis was demonstrated. Whilst mean plasma ACTH concentrations increased during both N1 and N2 there were no changes in mean plasma ACTH-precursor concentrations. Analysis of pooled data for N1 and N2 demonstrated direct correlations between the nausea score and the peak incremental plasma responses of either AVP or ACTH and, despite the variability, peak incremental concentrations of AVP and of ACTH were also correlated. The data indicate that there is no difference in the AVP responses to peripherally or centrally stimulated ipecacuanha-induced nausea.(ABSTRACT TRUNCATED AT 250 WORDS)

Change in plasma acetate levels in diabetic subjects on mixed high fiber diets

When 10 diabetic (five insulin-dependent) subjects with reasonable glycemic control were randomized from their usual (U) diet (about 30 g fiber/day) between two different but isocaloric high fiber diets, each sequentially over 6 wk [HF (55 g fiber/day) and HFS (55 g fiber/day with sucrose taken as 15 g three times daily, with meals)], plasma acetate (mmol/L) increased by 35% on both high fiber diets from 0.21 +/- 0.06 (SD) to 0.28 +/- 0.10 (HF) and 0.30 +/- 0.10 (HFS) (both p less than 0.01). This was higher than the random weekly variation in plasma acetate levels of 11% in six other glycemically stable diabetic patients. When the acetate value was expressed as acetate/glucose, i.e., relative to the fasting glucose level (since fasting levels of acetate and glucose consistently positively correlate), the increase was about 80%. Fasting plasma non-esterified fatty acid (NEFA) levels fell during the high fiber diets and correlated negatively with the fasting acetate level (rs -0.51, p less than 0.005). The fall in NEFA and rise in acetate levels appeared greatest with the sucrose-supplemented meals. These results suggest increased exogenous contribution to the plasma acetate level from increased colonic fermentation of dietary fiber and raise the possibility of using such measurements in the assessment of compliance to high fiber diets. The fall in NEFA levels associated with raised plasma acetate levels may contribute to the beneficial effects on glycemic control observed with the high fiber diets.

Low dose guar in a novel food product: improved metabolic control in non-insulin-dependent diabetes

Sixteen non-insulin-dependent diabetic patients, mean age 60 years (range 47-69 years) and duration of diabetes 9 years (2-20 years), completed a randomized cross-over study of three 6-week periods separated by 2-week intervals to minimize carry-over effects, in which their usual bread was replaced by either control bread, guar bread (100 g guar/kg wheat flour), or control bread plus a guar granulate. The mean (+/- SEM) intake of guar taken in bread was 7.6 +/- 0.7 g/day (range 3.1-14.3 g/day). The granulate was taken in a dose of 5 g twice daily which provided 8.3 g guar/day. Significant reductions were found in glycosylated haemoglobin after guar bread (11.5 +/- 0.8% to 10.7 +/- 0.8%; p less than 0.02) and after guar granulate (11.2 +/- 0.8% to 10.6 +/- 0.7%; p less than 0.05) compared with control bread. Total cholesterol was also reduced significantly after both guar bread and guar granulate (p less than 0.01, p less than 0.02), the changes being due to LDL-cholesterol. Dietary intakes and body weight did not change. No significant side-effects were reported; 14 subjects found guar bread more palatable than guar granulate but 8 preferred the granulate for its convenience. We conclude that a lower than convential dose of guar can be effective and palatable. The incorporation of guar into food increases its metabolic benefits and palatability.

Sucrose in the diet of diabetic patients--just another carbohydrate?

The effects of regularly eating sucrose were studied in 23 diabetic patients, 12 Type 1 (insulin-dependent) and 11 Type 2 (non-insulin-dependent), with differing degrees of glycaemic control. Two diets, each lasting 6 weeks, were compared in a randomised cross-over study. Both diets were high in fibre and low in fat. In one diet 45 g of complex carbohydrate was replaced by 45 g of sucrose taken at mealtimes. There were no significant biochemical differences between the two diets in either Type 1 or Type 2 patients. In Type 1 patients the mean (+/- SEM) fasting plasma glucose was 10.5 (1.8)mmol/l on the control diet and 10.3 (1.5) mmol/l on sucrose. In Type 2 patients the levels were 9.1 (0.8) mmol/l and 8.9 (0.8) mmol/l respectively. Glycosylated haemoglobin for the Type 1 patients was 9.9% on control and 10.3% on sucrose; for Type 2 patients the figures were 9.3% and 9.0% respectively. There were no differences in mean daily plasma glucose levels or diurnal glucose profiles. Cholesterol (total and in lipoprotein fractions) was unchanged, as were diurnal triglyceride profiles and plasma insulin profiles in the Type 2 patients. There were no changes in medication or body weight. We conclude that a moderate amount of sucrose taken daily at mealtimes does not cause deterioration in metabolic control in diabetic patients following a high fibre/low fat diet.

Seizures in bacterial meningitis: prevalence, patterns, pathogenesis, and prognosis

Of 207 patients with acute bacterial meningitis previously reported by Dodge and Swartz, seizures occurred in 56 (27%). Most seizures began on the first or second day, and most stopped within two days. Seizures occurred most often at the extremes of life. Age-adjusted seizure frequency was greater with Hemophilus influenzae meningitis than with Streptococcus pneumoniae or Neisseria meningitidis. When seizures complicated bacterial meningitis, age-corrected mortality increased from 24% to 38%. Though seizures after recovery were infrequent (2.7% of cases), recurrences were five times more frequent in patients who convulsed acutely than in those who did not. When focal seizures accompanied focal pathology (extracranial or intracranial), the seizures were usually not lateralized to the opposite side of the body. Of factors of potential importance in causation of seizures, fever was the most important risk factor regardless of patient age.