The safety and efficacy of pediatric lingual tonsillectomy

OBJECTIVE

Lingual tonsillar hypertrophy is recognized as a cause of persistent obstructive sleep apnea (OSA) after adenotonsillectomy in children. However, little has been reported regarding the complications, postoperative course and effectiveness of lingual tonsillectomy (LT). Our objective was to review the safety and effectiveness of LT in children.

METHODS

Retrospective review of children undergoing LT from January 2009 to December 2015 at a tertiary children's hospital. Complications, postoperative course and polysomnographic (PSG) outcomes were recorded for all patients.

RESULTS

We identified 92 children (mean age = 8.6 years, 50% female) who underwent LT; 43.5% had a syndromic diagnosis. The most common complications were emergency department presentation for bleeding (4.4%) and poor oral intake (3.3%). The readmission rate was 4.4% including 2 children (2.2%) who required operative control of hemorrhage. No children required unplanned reintubation or ICU admission. In children with PSG data (n = 18), the median apnea-hypopnea index (AHI) decreased from 8.5 to 3.8 events/hour (p = 0.022) and the median obstructive AHI (oAHI) decreased from 8.3 to 3.1 events/hour (p = 0.021). In addition, the oxygen saturation nadir increased from 83.8% to 89.0% (p = 0.0007). After surgery the percentage of patients with oAHI<5 events/hour increased from 27.8% to 61.1% (p = 0.08).

CONCLUSIONS

Readmission and bleeding rates after lingual tonsillectomy in children were similar to that seen with tonsillectomy. Polysomnographic data showed that lingual tonsillectomy resulted in a significant reduction of both AHI and oAHI with a postoperative oAHI <5 achieved in 61% of patients.

Utility of a Paediatric Bleeding Questionnaire as a screening tool for von Willebrand disease in apparently healthy children

von Willebrand disease (VWD), an inherited bleeding disorder caused by deficiency or dysfunction of von Willebrand factor (VWF) is diagnosed when a personal and often a family history of excessive mucocutaneous bleeding is present along with abnormal laboratory studies. An accurate assessment of haemorrhagic symptoms is key in suspecting VWD but presents a challenge especially in children due to overlap between normal and abnormal bleeding. Bleeding questionnaire (BQ) scores have been validated in adults and have recently been validated in children with VWD for assessing bleeding severity. However, there are limited data supporting their use prospectively in healthy children with bleeding complaints.

AIM

The objectives of this study were to obtain normative data from children and validate a paediatric BQ (PBQ) to determine the discriminative ability of its total score and its individual components for identifying children likely to have VWD.

METHODS

The PBQ was administered to 1281 multiethnic, healthy children between 30 days and 18 years of age presenting to a general paediatric office and to 35 children with VWD based on VWF antigen, activity and multimer pattern.

RESULTS

When children with total BQ scores of 3 or more were predicted to have VWD, the sensitivity was 97.2%, the specificity was 97.1%, the positive predictive value was 48.6% and the negative predictive value was 99.9%.

CONCLUSIONS

The PBQ may help discriminate a significant bleeding history from trivial bleeding, may be integrated into the primary care algorithm for evaluating children suspected with VWD.

Lower initial dose desoxycorticosterone pivalate for treatment of canine primary hypoadrenocorticism

OBJECTIVE

To evaluate the efficacy of initial doses of desoxycorticosterone pivalate (DOCP) that are lower and less expensive than the presently recommended initial dose of 2.2 mg/kg for treating dogs with primary hypoadrenocorticism.

METHODS

A retrospective study was performed on 49 dogs with primary hypoadrenocorticism, including 36 with initial DOCP doses less than 2.2 mg/kg. Medical records were reviewed for clinical data. All study dogs were followed up with telephone calls to owners or veterinarians to determine the date of death or last follow-up. Data were analysed to investigate relationships between initial DOCP dose and survival and serum Na, K and their ratio.

RESULTS

Regardless of their initial DOCP dose, none of the dogs developed uncontrolled hypoadrenocorticism or severe electrolyte abnormalities or clinical problems that would have made an increase in the DOCP dose necessary. Over time, most dogs had a decrease in their DOCP dose in mg/kg, because of weight gain during treatment. No statistically significant relationships were found between initial DOCP dose and survival or post-treatment serum Na, K or Na : K, with the exception of one statistically significant result that suggested lower efficacy for higher doses.

CONCLUSION

Initial DOCP doses less than 2.2 mg/kg may be effective in controlling serum electrolyte concentrations in dogs with primary hypoadrenocorticism without adversely affecting survival. If confirmed by additional research, these findings would enable practitioners to reduce the cost of DOCP treatment by using lower initial doses, potentially saving the lives of dogs that would otherwise be euthanased because of treatment expense.

In vivo measurement of the subchondral bone thickness of lumbar facet joint using magnetic resonance imaging

OBJECTIVE

To measure in vivo thicknesses of the facet joint subchondral bone across genders, age groups, with or without low back pain symptom groups and spinal levels.

METHODS

Lumbar (L1-L2 to L5-S1) magnetic resonance (MR) imaging was performed in 81 subjects (41 males and 40 females, mean age 37.6 years). Thicknesses of the subchondral bone were measured in 1620 facet joints using the MR images with custom-written image processing algorithms together with a multi-threshold segmentation technique using each facet joint's middle axial-slice. This method was validated with 12 cadaver facet joints, scanned with both MR and micro-computed tomography images.

RESULTS

An overall average thickness value for the 1620 analyzed joints was measured as 1.56±0.01 mm. The subchondral bone thickness values showed significant increases with successive lower spinal levels in the subjects without low back pain. The facet joint subchondral bone thickness in asymptomatic females was much smaller than in asymptomatic males. Mean subchondral bone thickness in the superior facet was greater than that in the inferior facet in both female and male asymptomatic subjects.

CONCLUSIONS

This study is the first to quantitatively show subchondral bone thickness using a validated MR-based technique. The subchondral bone thickness was greater in asymptomatic males and increased with each successive lower spinal level. These findings may suggest that the subchondral bone thickness increases with loading. Furthermore, the superior facet subchondral bone was thicker than the inferior facet in all cases regardless of gender, age or spinal level in the subjects without low back pain. More research is needed to link subchondral bone microstructure to facet joint kinematics and spinal loads.

Bone mineral density in the proximal tibia varies as a function of static alignment and knee adduction angular momentum in individuals with medial knee osteoarthritis

Based on the premise that bone mass and bone geometry are related to load history and that subchondral bone may play a role in osteoarthritis (OA), we sought to determine if static and dynamic markers of knee joint loads explain variance in the medial-to-lateral ratio of proximal tibial bone mineral density (BMD) in subjects with mild and moderate medial knee OA. We utilized two surrogate markers of dynamic load, the peak knee adduction moment and the knee adduction angular momentum, the latter being the time integral of the frontal plane knee joint moment. BMD for medial and lateral regions of the proximal tibial plateau and one distal region in the tibial shaft was measured in 84 symptomatic subjects with Kellgren and Lawrence radiographic OA grades of 2 or 3. Utilizing gait analysis, the peak knee adduction moment (the external adduction moment of greatest magnitude) and the time integral of the frontal plane knee joint moment (the angular momentum) over the entire stance phase as well as for each of the four subdivisions of stance were calculated. The BMD ratio was not significantly different in grade 2 (1.32 +/- 0.27) and grade 3 knees (1.47 +/- 0.40) (P = 0.215). BMD of the tibial shaft was not correlated with any loading parameter or static alignment. Of all the surrogate gait markers of dynamic load, the knee adduction angular momentum in terminal stance explained the most variance (20%) in the medial-to-lateral BMD ratio (adjusted r(2) = 0.196, P < 0.001). The knee adduction angular momentum for the entire stance phase explained 18% of the variance in the BMD ratio (adjusted r(2) = 0.178, P < 0.001), 10% more variance than explained by the overall peak knee adduction moment (adjusted r(2) = 0.081, P < 0.001). 18% of the variance in the BMD ratio was also explained by the knee alignment angle (adjusted r(2) = 0.183, P < 0.001), and the total explanatory power was increased to 22% when the knee adduction angular momentum in terminal stance was added (change in r(2) = 0.041, P < 0.05, total adjusted r(2) = 0.215, P < 0.001). The BMD ratio and its relationship to dynamic and static markers of loading were independent of height, weight, and the body mass index, demonstrating that both dynamic markers of knee loading as well as knee alignment explained variance in the tibial BMD ratio independent of body size.

The radiographic joint space width in clinically normal hips: effects of age, gender and physical parameters

OBJECTIVE

The aim of the study was to assess the relationship of the radiographic joint space width (JSW) in the hip with age and a variety of physical parameters in a clinically non-arthritic population in order to identify potential age-related changes.

DESIGN

One hundred and eighteen patients (58F/60M, age range 20-79 years) who underwent supine abdominal radiography for non-rheumatological indications and had no hip pain were evaluated. Height, weight and leg lengths were measured. JSW was quantified manually by a dial caliper, and femoral head diameters were determined for each hip.

RESULTS

Overall, JSW was 3.61mm+/-0.58 (mean+/-SD) in the right (R) and 3.63mm+/-0.59 in the left (L) hip (range 2.34-6.1mm). There was no age-related decline in the JSW, either by decade (P=0.5 and 0.6, for R and L hips, respectively), or by individual age (Spearman's rho=-0.108 and 0.057, P=0.3 and 0.5 for R and L hips, respectively); similarly, no age-related changes were observed when each gender was analyzed separately. Women had significantly narrower hip JSW than men (P=0.001 and 0.01, R and L hips, respectively). However, gender was no longer significant after height was taken into account (P=0.26 and 0.45, for R and L hips, respectively). JSW correlated significantly with height, weight (which also correlated with height) (r=0.31/0.27 and 0.29/0.28 for height and weight R/L, respectively, P<0.004 for each), but not with body mass index (P=0.62 and 0.57, R and L, respectively). Hip JSW significantly correlated also with femoral head diameter and leg length (r=0.38/0.29 and 0.25/0.19 for femoral head and leg length, R/L, respectively).

CONCLUSIONS

No effect of aging was detected on the radiographic JSW of the hip among normal individuals even at advanced ages. In contrast, height, femoral head diameter and leg length were directly related to JSW.

Effects of IGF-I gene therapy on the injured rat pudendal nerve

Injured nerves and their motor units may undergo enhanced recovery when exposed to recombinant human insulin-like growth factor-I (rhIGF-I). The external anal sphincter muscle in the female rat was denervated to model incontinence. The treatment-group muscle was injected with rhIGF-1 plasmid, whereas in the control group the plasmid lacked the cDNA insert and the normal group received neither surgery nor treatment. Electromyography data at 56 days post surgery indicated more reinnervation without fibrillation potentials in the treatment group (2 of 6) than in the control group (0 of 6). The histology of the regenerated axons in the pudendal nerve distal to the crush site also suggested an improved recovery in the treatment group. The number of motor neurons retrogradely labeled with horseradish peroxidase was decreased by 50% following pudendal nerve crush in both experimental groups compared to the normal group. We conclude from these preliminary results that rhIGF-I gene therapy may improve the distal recovery of structure and function.

HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care

The multidisciplinary team model of HIV care evolved out of necessity due to the diverse characteristics and needs of people living with HIV disease. Though it is now accepted as the international standard of care, it represents a significant departure from methods of care for other infectious diseases, and debate continues regarding the effectiveness of its interventions. The debate has been largely uninformed by data; for example, little is known about the relationship between ancillary support services and primary care outcomes. We hypothesized that support services increase access to and retention in HIV primary care in an inner city public hospital clinic. We conducted a retrospective analysis of clinical data sets on 2,647 patients at the CORE Center, Chicago from 1997-1998 to investigate the relationship between four support services-case management (CM), transportation (TRANS), mental health (MH) and chemical dependency (CD)-and access to and retention in HIV primary care. We found that patients who received each of these services were significantly more likely to receive any care, regular care and had more visits than patients with no service, and retention increased by 15-18%. Female gender, younger age, self-pay status and IDU predicted less regular care. Need for all services was substantial and significantly greater in women. Outcomes improved to the greatest extent among patients who needed and received each service. We conclude that support services significantly increased access to and retention in HIV primary care. Our findings validate the multidisciplinary team model of HIV care, and suggest that health services that are tailored to the express needs of patients lead to better care and improved health outcomes. Further testing of changes in health care delivery to meet the rapidly changing needs of people living with HIV disease and respond to the constantly changing practice of HIV medicine is urgently needed to maintain and extend the advances in HIV care outcomes of the past decade.

Bother arising from urinary frequency in women

Patients commonly express bother with the symptom of frequent urination. The relationship between actual voiding frequency and this symptom is undocumented. We reviewed records of 200 women who had completed 24-hour frequency-volume charts, and had indicated their degree of bother with urinary frequency utilizing the short form of the Urogenital Distress Inventory. The degree of bother was correlated with daytime and nighttime voiding frequency, maximum functional capacity, mean voided volume, and demographic variables. Among 200 women, 180 (90%) indicated at least a minor degree of bother with urinary frequency. A voiding frequency of eight or more times in 24 hours was reported by 166 (83%) of women. Among the 34 women voiding fewer than eight times/24 hours, 26 (76%) reported bother with urinary frequency. There was large variation in the degree of bother reported at a given voiding frequency. Postmenopausal women without hormone replacement therapy (HRT) recorded more nighttime voids than those on HRT. Among postmenopausal women without HRT, mean voided volume and maximum functional capacity were inversely related to patient age. Our study suggests that the currently utilized cutoff value of eight daily voids to define urinary frequency, may not be helpful in the management of women in this country. A racially diverse study of the voiding habits of asymptomatic North American women is mandated.

Poor surgical outcomes after fascia lata allograft slings

The objective of this retrospective case control study was to determine whether our poor surgical outcomes were associated with the material used to construct our pubovaginal slings. Autologous rectus fascia was used in 33 patients and cadaveric fascia lata was used in 12 patients who underwent pubovaginal sling placement for intrinsic urethral sphincter deficiency (ISD). Treatment was successful in 78.8% and 33.3% of patients who underwent rectus fascia and fascia lata allograft slings, respectively (P=0.006). Based on regression analysis, the sling material was found to be strongly associated with surgical outcome after controlling for all confounding variables (beta coefficient = 1,204.6, P<0.00005). We conclude that fascia lata allografts are a poor choice for pubovaginal slings.

The analgesic effects of subhypnotic doses of propofol in human volunteers with experimentally induced tourniquet pain

This double-blind, placebo-controlled study was performed to determine whether subhypnotic doses of propofol have analgesic or sedative effects. Of 48 subjects randomly assigned to 1 of 4 bolus-infusion treatment groups, group 1 (n = 16) received propofol at 16 micrograms/kg per minute; group 2 (n = 16) received propofol at 32 micrograms/kg per minute; and group 3 (n = 8) received 10% intralipids at 16 micrograms/kg per minute; and group 4 (n = 8) received 20% intralipids at 32 micrograms/kg per minute. Following a bolus of the study drug, a maintenance infusion was started and continued throughout the study. Thirty minutes after the study drug began infusing, an Observer's Assessment of Alertness/Sedation Scale was completed, a tourniquet was inflated, and a maximum tourniquet tolerance time (TTT) was obtained. Pain was assessed every 5 minutes while the tourniquet was inflated and immediately before deflation using a 0 to 10 verbally administered numeric rating scale (NRS). No significant differences in TTT were noted between the 2 propofol groups. However, the TTT for both propofol groups differed significantly from the control group (intralipid groups combined) (P < .05). There was a statistically significant difference in the time it took the propofol groups to reach a NRS score of 8 or greater when compared with the control group (P < .05). Sedation scores differed significantly between the control and the propofol at 32 micrograms/kg per minute groups (P < .05). The results of this study suggest that propofol given at subhypnotic doses could serve as a valuable adjunct for acute postoperative pain management.

Bacterial contamination of blenderized whole food and commercial enteral tube feedings in the Philippines

Hospital-prepared tube feedings from four Philippine acute-care hospitals were analysed for microbial contamination. Two feedings were prepared on three separate days at each hospital. The tube feedings were either blended natural whole foods or a reconstituted commercial powdered nutritional product. Samples of each feeding were collected for coliform count and standard plate count at the time of preparation and at 1, 2 and 4 h after preparation after maintenance at room temperature (26-31 degrees C). At the time of preparation, mean coliform and standard plate counts for all samples were 10.3 most probable number per gram (MPN/g) and 7.4x10(4)colony-forming units per gram (cfu/g), respectively. Nine of 24 samples (38%) had coliform counts greater than 10 MPN/g, and 22/24 (92%) samples had standard plate counts greater than 10(3) cfu/g. There were significant increases in mean coliform and standard plate counts over 4 h (P=0.0005 and P=0.008, respectively). At 4 h after preparation, the mean coliform and standard plate counts were 18.2 MPN/g and 2.1x10(5) cfu/g, respectively. At this time, 18/24 (75%) samples had coliform counts greater than 10 MPN/g and 20/24 (83%) samples had standard plate counts greater than 10(5) cfu/g. The results of this study show that the microbial quality of the majority of the hospital-prepared enteral tube feedings analysed were not within published guidelines for safety.

Accuracy and precision of radiostereometric analysis in the measurement of THR femoral component translations: human and canine in vitro models

Radiostereometric analysis (RSA) is used to measure translations of joint replacement components with respect to the host bone in vivo. We used two cadaveric models of hip arthroplasty, one human and one canine, to evaluate the accuracy and precision of RSA-based estimates of translations of the femoral component with respect to the femur under ideal conditions. The femoral components were attached rigidly to a micrometer stage that provided standard displacements in increments of 25 and 50 microm in the interval from zero to 500 microm along three orthogonal axes. Radiostereometric examinations were performed for each increment. Accuracy was calculated as the 95% prediction intervals from regression analyses between the measured and actual displacements. Precision was evaluated as the standard deviation of five repeated measurements of a 200 microm displacement along each axis. Both accuracy and precision were best along the longitudinal axis, with a prediction interval of +/-47 microm in the human model and +/-45 microm in the canine model and a standard deviation of 30 microm in the human model and 40 microm in the canine model. The use of only the prosthetic head as a landmark (as opposed to three markers placed on the femoral stem) led to a 3-fold larger prediction interval in the human model and a 2-fold greater prediction interval in the canine model.

Bacteriocin susceptibility of Gardnerella vaginalis and its relationship to biotype, genotype, and metronidazole susceptibility

OBJECTIVE

Our purpose was to investigate the bacteriocin susceptibility of Gardnerella vaginalis and its relationship to biotype, genotype, and resistance to metronidazole.

STUDY DESIGN

Bacteriocin susceptibility of 36 G vaginalis clinical isolates was tested against a vaginal strain of Lactobacillus acidophilus by a growth-inhibition method. The relationship to biotype, genotype, and resistance to metronidazole were analyzed by the chi2 test and Fisher exact test.

RESULTS

Eight G vaginalis strains (22%) were bacteriocin-resistant. Biotypes 5 and 7 were found to be the most frequent among these resistant strains. Eight (42%) of the 19 isolates classified as biotype 5, 6, or 7 were bacteriocin-resistant compared with none of the isolates that were classified as other biotypes (P <.01). Biotype 5 was found in higher prevalence among the isolates resistant to bacteriocin (62%) than among the susceptible isolates (14%) (P =.01). Genotype B was found more frequently among the bacteriocin-resistant strains, but this finding was not statistically significant (P =.71). Seven (88%) bacteriocin-resistant strains were also resistant to metronidazole.

CONCLUSION

An association between biotype and an increased resistance to bacteriocin was found. The ability of G vaginalis to resist the antibacterial activity of Lactobacillus bacteriocin may be a pivotal factor in understanding bacterial vaginosis.

Effect of metronidazole on the growth of vaginal lactobacilli in vitro

Objective: To determine whether metronidazole has an adverse effect on the growth of Lactobacillus.

Methods: Hydrogen peroxide- and bacteriocin-producing strains of Lactobacillus were used as test strains. Concentrations of metronidazole used ranged from 128 to 7000 μg/ml. Susceptibility to metronidazole was conducted by the broth microdilution method recommended by the National Committee for Clinical Laboratory Standards.

Results: Growth of Lactobacillus was partially inhibited at concentrations between 1000 and 4000 μg/ml (p = 0.014). Concentrations ≥ 5000 μg/ml completely inhibited growth of Lactobacillus. Concentrations between 128 and 256 μg/ml stimulated growth of Lactobacillus (p = 0.025 and 0.005, respectively). Concentrations of metronidazole between 64 and 128 μg/ml or ≥ 512 μg/ml did not have an inhibitory or a stimulatory effect on the growth of Lactobacillus compared to the control.

Conclusions: High concentration of metronidazole, i.e. between 1000 and 4000 μg/ml, partially inhibited the growth of Lactobacillus. Concentrations ≥ 5000 μg/ml completely suppressed the growth of Lactobacillus. Concentrations between ≥ 128 and ≤ 256 μg/ml stimulated the growth of Lactobacillus. Further investigation to determine the ideal concentration of metronidazole is needed in order to use the antimicrobial agent effectively in the treatment of bacterial vaginosis.

T cell receptor excision circle (TREC) content following maximum HIV suppression is equivalent in HIV-infected and HIV-uninfected individuals

BACKGROUND

The adult human thymus contributes to de novo T cell synthesis; such synthesis can be assessed by analyzing T cell receptor excision circles (TREC).

METHODS

TREC levels were measured in total peripheral blood mononuclear cells (PBMC) and CD4- and CD8-enriched cells of 29 HIV-positive patients with maximal viral suppression. The expression of CD45RA+CD45RO-, CD45RA+CD62L+, CD45RO-CD27+CD95low and HLA-DR+CD38+ was assessed using three-color flow cytometric analysis of whole blood. Thymic index score was based on computed tomographic scans of the thymus. The relationship of TREC with thymic index and the expression of the naive phenotypes was evaluated.

RESULTS

TREC expression was not statistically different in these HIV-positive patients from that in age-matched HIV-negative controls. Among HIV-positive patients with CD4 cell count of > 500 x 10(6) cells/l after antiretroviral therapy (n = 15), PBMC TREC levels correlated with the expression of CD45RA+CD45RO- and CD45RA+CD62L+ naive phenotypes, and inversely correlated with the expression of HLA-DR+CD38+. The change between pre- and post-therapy CD4 cell counts for these 15 patients significantly correlated with both thymic index and expression of the CD45RA+CD45RO- phenotype.

CONCLUSIONS

The finding that TREC expression was equivalent between HIV-positive patients after therapy and HIV-negative donors suggests that there is no reduction in thymic output among HIV-positive individuals after therapy. Given that TREC is inversely correlated with HLA-DR/CD38 expression, its analysis in studies of thymopoiesis should be evaluated in the context of maximum viral suppression to reduce HIV-mediated immune activation and/or by normalizing for cell turnover.

Data-driven practice improvement: the AANA Foundation closed malpractice claims study

Research in anesthesia risk management has focused primarily on adverse patient outcomes. Most risk management studies have evaluated the practices of the physician anesthesiologist, while minimal research has been conducted to examine anesthesia care provided by Certified Registered Nurse Anesthetists (CRNAs). For this reason, the American Association of Nurse Anesthetists Foundation supported an examination of closed malpractice claim files from St Paul Fire and Marine Insurance Company that involved insured CRNAs. A team of 8 CRNA researchers investigated 223 closed claim files that involved incidents from 1989 to 1997. The results indicated that preoperative physical status, patient age, surgical procedure, type of anesthetic, age of anesthesia provider, and the type of anesthesia providers, (e.g., CRNA alone vs CRNA and anesthesiologist working together) did not have a statistically significant relationship with adverse anesthetic outcomes. However, providing appropriate care, being vigilant, encountering a less severe adverse outcome, and not being able to prevent the outcome were associated with smaller monetary awards. The findings of this study support those of similar studies.

Elevated blood viscosity in systemic lupus erythematosus

OBJECTIVES

It has been proposed that elevated blood viscosity contributes to atherothrombotic and thromboembolic processes. We evaluated whether there is increased blood viscosity in systemic lupus erythematosus (SLE) that might contribute to cardiovascular complications and reduced tissue perfusion.

METHODS

Blood viscosity profiles were evaluated in SLE patients to determine whether rheologic disturbances contribute to the cardiovascular risk profile. Blood viscosity profiles were evaluated in 27 patients with SLE and 46 age- and gender-matched controls. Blood viscosity was measured at 37 degrees C and shear rates of 1 s(-1) and 100 s(-1), then corrected to the average hematocrit of the SLE patients.

RESULTS

Corrected blood viscosity values were higher in SLE patients than in controls at 100 s(-1) (P =.002). Positive correlations were found between the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index for SLE, which quantifies damage to 12 organ systems and fibrinogen (rho =.39; P =.042) and plasma viscosity (rho =.38; P =.049).

CONCLUSIONS

Our data indicate that blood viscosity values at a standard hematocrit are elevated in SLE patients. Further investigations are needed to evaluate whether the increased blood viscosity values in SLE patients contribute to cardiovascular complications and tissue ischemia.

CLINICAL RELEVANCE

Because blood viscosity values correlate with the clinical severity of SLE, blood viscosity may contribute to the cardiovascular complications and reduced tissue perfusion in SLE patients. Semin Arthritis Rheum 31:52-57.

Defense factors of vaginal lactobacilli

OBJECTIVE

To determine the antagonistic relationship between vaginal lactobacilli and endogenous vaginal microflora.

STUDY DESIGN

Twenty-two Lactobacillus strains were studied for the production of lactic acid, hydrogen peroxide, and bacteriocin.

RESULTS

Under standardized growth conditions, most strains increased their biomass by more than 4 times. Lactobacillus species grew best at a pH > or = 4.5, and growth was retarded at a pH < 4.5. Lactic acid levels were 0.68 to 2.518 mg/mL and were not related to the number of cells or the pH of media. The pH of the media was caused by the secretion of lactic and other organic acids. Approximately 80% of the strains produced H(2)O(2) and were graded as 2+ in one third of the strains and 1+ in others. No statistical correlation was found between H(2)O(2) lactic acid and bacteriocin production. Bacteriocin activity was tested on 4 strains of Gardnerella vaginalis. Approximately 80% of the lactobacilli tested produced bacteriocin that inhibited growth of G vaginalis. Six of the strains did not produce bacteriocin. Thirteen strains produced all 3 defense factors, whereas the others lacked 1 or 2 properties.

CONCLUSIONS

Lactobacillus species grow best at a pH > 4.5. The pH of the media is dependent on the cell mass and on all organic acids produced by Lactobacillus species. Although all species produce organic acids, not all produce H(2)O(2) and bacteriocin. Not all strains of G vaginalis can be inhibited by lactobacilli-producing bacteriocin.

Responsiveness of quality of life measurements to change after reconstructive pelvic surgery

OBJECTIVE

We sought to determine whether Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) scores are sensitive to changes in clinical status after surgery for genuine stress incontinence (GSI) or pelvic organ prolapse (POP).

STUDY DESIGN

Patients were included in this study if they had completed the IIQ-7 and UDI-6 scales and had undergone urodynamic testing before and 3 months after surgery for GSI or POP. Kruskal-Wallis tests and logistic regression were used to compare IIQ-7 and UDI-6 scores according to the outcome of surgery.

RESULTS

Among 55 patients satisfying inclusion criteria for the study, 34 (62%) underwent Burch colposuspension, and 21 (38%) underwent suburethral sling procedures for GSI; 44 (80%) patients were subjectively continent after surgery. Thirty-four (62%) patients underwent surgical treatment of their POP; 31 (90%) were subjectively cured of their POP symptoms. Mean IIQ-7 and UDI-6 scores were lower in patients who were subjectively continent, and UDI-6 scores were lower in patients who were objectively cured of GSI.

CONCLUSION

UDI-6 and IIQ-7 scores change after surgery for GSI and POP, with patients who are subjectively continent having lower postoperative scores on both scales.

Human immunodeficiency virus type 1 stimulatory activity by Gardnerella vaginalis: relationship to biotypes and other pathogenic characteristics

Stimulation of human immunodeficiency virus (HIV) type 1 expression by Gardnerella vaginalis is one possible cause for an increase in the amount of virus in the genital tract. The ability of G. vaginalis to induce HIV expression in chronically infected U1 cells was investigated, along with its possible relationship to biotype, genotype, and resistance to metronidazole and bacteriocin. Significant HIV stimulatory activity was found in 5 (50%) lysates of G. vaginalis. The ability to induce HIV expression in U1 cells was statistically associated with G. vaginalis biotype (P=.048) but not with genotype or resistance to metronidazole and bacteriocin. Further studies to explore the in vivo relevance of HIV activation by G. vaginalis in the female genital tract are warranted, since prevention strategies of bacterial vaginosis and colonization by certain biotypes of G. vaginalis may be valuable in reducing the risk of sexual transmission of HIV.

Role of urethral electromyography in predicting outcome of Burch retropubic urethropexy

OBJECTIVE

To establish preoperative urethral electromyographic parameters that predict which women are unlikely to be cured of genuine stress incontinence by Burch retropubic urethropexy procedures.

STUDY DESIGN

Eighty-nine women who underwent preoperative urodynamic testing with urethral electromyography and retropubic urethropexy for genuine stress incontinence were prospectively studied. Raw electromyographic signals were processed by an electromyographic instrument equipped with automated motor unit analysis software programs. Quantitative electromyographic software was used to analyze the electrical activity of the urethral sphincter with use of mean rectified voltage (MRV)-mean amplitude calculated over the entire tracing after the waveform is rectified-with women at rest and during voluntary urethral squeezing, repetitive coughing, and bladder filling. Objective outcomes were determined 3 months after the operation with single-channel cystometrograms performed while subjects were standing. Nonparametric statistical analyses included the chi(2) test of association for nominal data and the Mann-Whitney test for comparison of population medians.

RESULTS

All women had urethral hypermobility and met our standard clinical criteria for retropubic urethropexy. Fifteen women had incomplete follow-up data and were excluded from final analysis. Fifty-nine of 74 women (80%) were objectively cured, and 15 women had persistent genuine stress incontinence. Women who were cured did not differ from those who were not cured in age, parity, menopausal status, maximum urethral closure pressure, Valsalva leak point pressure, maximum cystometric capacity, detrusor instability, or prolapse stage. Women with persistent genuine stress incontinence were more likely to have had previous pelvic operations (P =.01). There were no differences in any electromyographic parameters at rest, with urethral squeezing, or during bladder filling between the groups. Women who were objectively cured had larger MRV values with repetitive coughing (P =.05) and larger increases from resting MRV values (DeltaMRV) with repetitive coughing (P =.04). Twenty-seven of 30 women with MRV values > or =25 microV with repetitive coughing were cured (positive predictive value [PPV] = 90%; negative predictive value [NPV] = 32%), and 22 of 24 women with more than a 10-microV increase in resting MRV values with repetitive coughing (DeltaMRV > 10 microV) were cured (PPV = 92%; NPV = 29%). If women had both an MRV value > or =25 microV and a DeltaMRV value >10 microV, the PPV was 100%; however, the NPV remained at 30%.

CONCLUSION

Women who were cured of genuine stress incontinence with Burch retropubic urethropexy procedures had better motor unit action potential activation with repetitive coughing than women with persistent genuine stress incontinence. Urethral electromyography may be used to assess the neuromuscular integrity of the striated urethral sphincter and to help predict which women will have successful retropubic urethropexy procedures.

The impact of nalmefene on side effects due to intrathecal morphine at cesarean section

Nalmefene is a long-acting opioid antagonist that provides long-term relief from side effects of intrathecal morphine sulfate. A randomized, double-blind, placebo-controlled study was conducted to determine whether prophylactic nalmefene could decrease side effects of intrathecal morphine given during cesarean section, without affecting analgesia. Sixty parturients were given 0.25 mg of intrathecal morphine, 12.5 micrograms of fentanyl, and 11.25 to 15 mg of bupivacaine. A dose of 0.25 microgram/kg of nalmefene or placebo was given by intravenous piggyback immediately after delivery of the neonate. Nausea, vomiting, pruritus, and level of sedation were assessed for a 24-hour period using a 4-point ordinal scoring system. Pain was assessed by using a 0- to 10-point verbal analogue scale. A 5-point analgesic satisfaction survey also was completed. Subjects who received nalmefene required supplemental analgesia at a median of 6.00 hours after intrathecal morphine, compared with 14.12 hours in the placebo group (P = .037). No differences were found between the groups in the incidence of pruritus, nausea and vomiting, level of sedation, or analgesic satisfaction. We concluded that nalmefene at a dose of 0.25 microgram/kg does not decrease the incidence of side effects but increases the need for supplemental analgesics.

Myosin isoforms in female human detrusor

The aim of this study was to document the relative proportions of two isoforms of myosin heavy chain in detrusor smooth muscle of women with detrusor overactivity and in asymptomatic controls. Women aged 35-65 with documented detrusor overactivity and without a history of neurologic disease, prior incontinence surgery, elevated post-void residual urine volume, or indwelling urinary catheter were eligible for the study. Full-thickness biopsies of extraperitoneal bladder dome were obtained at the time of laparotomy in six patients with documented detrusor overactivity and in a control group of eight continent patients. Biopsies were frozen in liquid nitrogen, crushed with a frozen mortar and pestle at -80 degrees C, and homogenized in buffer, and the extracts were electrophoresed on 6% polyacrylamide sodium dodecyl sulfate gels and stained with Coomassie blue. The gels were de-stained and then the protein bands were scanned with a densitometer. The mean patient age was 48 years (range, 36-59). Seven patients were Caucasian and seven patients were African American. Detrusor smooth muscle contains a mean of 34% (range, 27-43%) SM1 and 66% (range, 57-73%) SM2 isoforms. There was no difference in isoform composition when patients were compared according to urogynecologic diagnosis or according to race. In detrusor biopsies from women, approximately 34% of myosin is of the SM1 isoform and approximately 66% is of the SM2 isoform. This ratio is relatively constant in the two races studied and unchanged in women with detrusor overactivity. Animal models utilizing outlet obstruction of the bladder to provoke detrusor instability and detrusor hypertrophy are known to alter myosin isoform distribution and may not be appropriate models of detrusor instability in human females.

The inhibitory effect of clindamycin on Lactobacillus in vitro

OBJECTIVE

To evaluate the in vitro effect of varying concentrations of clindamycin on Lactobocillus spp.

METHODS

Concentrations of clindamycin ranging from 1.95-20,000 microg/ml were studied for their effect on the growth of six strains of Lactobacillus.

RESULTS

Clindamycin concentrations between 1.95-31.25 microg/ml had no statistically significant effect on growth of lactobacilli (p > 0.05). Concentrations 125 and 250 microg/ml had a bacteriostatic effect. The mean minimum inhibitory concentration (MIC) for studied Lactobacillus strains was determined as 1,000 microg/ml.

CONCLUSION

High concentrations of clindamycin achieved in the vagina by intravaginal application might be inhibitory for Lactobacillus.

Functional and structural effects of GM-1 ganglioside treatment on peripheral nerve grafting in the rat

Peripheral nerve regeneration after traumatic injury and standard repair with a nerve autograft is usually incomplete. This study tested the influence of graft vascularity and pharmacological intervention with GM-1 ganglioside on nerve regeneration in a rat sciatic nerve model. Controls included an unoperated contralateral side and sham-operated groups either with or without the GM-1. During the 5 months of recovery, locomotion was tested by the sciatic function index (SFI). At killing, anesthetized animals were prepared for nerve conduction velocity (NCV) studies, followed by the wet weight of the gastrocnemius muscle (expression of atrophy), toe-chewing (expression of lesion severity and sensory loss), and histological examination of the nerve segments. The SFI showed a slight but significant recovery for both the vascular and avascular groups (34% at 20 weeks), but when GM-1 ganglioside treatment was included, the SFI was poor throughout (20-33%). The average NCV of the graft groups without GM-1 was 46% to 57% of the normal nerve (52.7 m/s), whereas for the groups treated with GM-1, it was 63% to 64% of normal; treatment of the non-vascular graft group significantly improved recovery. A uniformly poor recovery from muscle atrophy was seen for all nerve graft groups (62-67%) compared with normal controls. The mean number of toes per foot chewed was 1.9 and 2.4 in graft groups without GM-1 treatment and 0.9 and 1.3 in graft groups treated with GM-1. This treatment significantly reduced both the extent and the number of animals exhibiting autotomy. The qualitative microscopic appearance of the distal nerve segment in all surgical groups was similar. We conclude that the systemic addition of GM-1 ganglioside enhances only some aspects of regeneration in grafted nerves, possibly with a preferential effect on sensory nerve regeneration and functional recovery.

Methicillin-resistant Staphylococcus aureus otorrhea after tympanostomy tube placement: an emerging concern

OBJECTIVES

To review the treatment of pediatric patients with methicillin-resistant Staphylococcus aureus (MRSA)-positive cultures as a result of otorrhea after tympanostomy tube placement in terms of both medication and isolation strategies and to highlight an emerging problem faced by the clinician with reference to treatment options as well as to the treatment of these patients in an outpatient setting.

PATIENTS

Between December 1998 and January 2000, a total of 8 children between the ages of 1 and 11 years had MRSA-positive cultures as a result of otorrhea after tympanostomy tube placement.

MAIN OUTCOME MEASURES

The Department of Infectious Diseases was notified, and a variety of topical antibiotic treatments were administered. Arch Otolaryngol Head Neck Surg. 2000;126:1440-1443

Evaluation of thymopoiesis using T cell receptor excision circles (TRECs): differential correlation between adult and pediatric TRECs and naïve phenotypes

To determine whether the thymus is still functional despite age-related involution, we measured a biomarker for thymopoiesis known as the T cell receptor excision circle (TREC) from peripheral blood mononuclear cells (PBMCs) of 148 healthy children and from PBMCs, CD4(+), and CD8(+) cells of 32, 30, and 50 healthy adults, respectively. We demonstrate that during the first 5 years of life, thymic output is decreased (P 0.002) but not dramatically (r = -0. 282). Among adults aged 23-58, thymic output was inversely correlated with age, as measured from PBMCs (r = -0.628, P < 0.0005), CD4(+) (r = -0.530, P 0.003), and CD8(+) fractions (r = -0.385, P 0. 006). A strong correlation existed between pediatric PBMC TRECs and the expression of three naïve phenotypic markers (CD45RA(+)CD45RO(-), CD45RA(+)CD62L(+), and CD45RO(-)CD27(+)CD95(low)). Adult PBMC TRECs correlated only with the expression of CD45RA(+)CD45RO(-) (r = 0.459, P 0.012). Our data suggest that in adults CD45RA(+)CD45RO(-) may be enriched for TRECs and add to a growing body of evidence illustrating intact thymic function in adulthood.

Contributions of bone density and geometry to the strength of the human second metatarsal

We investigated, at the whole bone level, the contribution of bone density and geometry to the fracture load of the second metatarsal, a bone that is prone to stress fracture. Dual-energy X-ray absorptiometry (DXA) was used to determine the areal bone mineral density (BMD), projected area of bone, and bone mineral content. Peripheral quantitative computed tomography (pQCT) was used to determine the volumetric cortical bone mineral density (vCtBMD) and cross-sectional moment of interia. Various metatarsal linear dimensions were also measured. The load at failure in cantilever bending was determined. The only linear dimension that had a significant correlation with load at failure was the height of the metatarsal base (r(2) = 0.30, p = 0.008). Utilizing all of the information provided by DXA gave no greater indication of whole bone strength than just BMD alone (adjusted r(2) = 0.40, p = 0.001). Using all of the information provided by pQCT gave no greater indication of whole bone strength than just vCtBMD alone (r(2) = 0. 46, p < 0.001). Volumetric cortical density and BMD were strongly correlated (r(2) = 0.81, p < 0.001). Our data suggest that, in the human second metatarsal, a variable such as material strength (as inferred from cortical density), and not geometry, may be the major factor in determining cantilever load to failure.

Current trends in the management of adamantinoma of long bones. An international study

BACKGROUND

Adamantinoma of long bones is a rare tumor. Published reviews of the orthopaedic management of adamantinoma have involved limited follow-up of small numbers of patients. The oncological aggressiveness of this tumor is unknown. Limb salvage is currently the treatment of choice for most adamantinomas. The purpose of this study was to evaluate the characteristics of adamantinoma of long bones as well as the oncological outcome and the complications of limb salvage operations.

METHODS

A retrospective study was designed to evaluate the clinical outcomes of limb salvage operations for the treatment of adamantinoma. Data on seventy biopsy-proven cases of adamantinoma treated between 1982 and 1992 at twenty-three different cancer centers in Europe and North America were obtained.

RESULTS

The median duration of follow-up was 7.0 years. The male:female ratio was 3:2, and the mean age was thirty-one years. Limb salvage was attempted in 91 percent (sixty-four) of the seventy patients, and the final rate of limb preservation was 84 percent (fifty-nine of seventy). Wide operative margins were obtained in 92 percent (fifty-eight) of sixty-three patients. An intercalary allograft was used to reconstruct the segmental bone defect in 51 percent (thirty-six) of the seventy patients. Reconstruction-related complications occurred in 48 percent (thirty) of sixty-two patients. Nonunion and fracture were the most common complications, occurring in 24 percent (fifteen) and 23 percent (fourteen) of sixty-two patients, respectively. Kaplan-Meier analysis demonstrated a rate of local recurrence of 18.6 percent at ten years. Wide operative margins were associated with a lower rate of local recurrence than marginal or intralesional margins were (p < 0.00005). Kaplan-Meier analysis showed a survival rate of 87.2 percent at ten years. There were no significant relationships between survival and the stage of the tumor (p = 0.058), duration of symptoms (p = 0.90), gender (p = 0.79), or wide operative margins (p = 0.14).

CONCLUSIONS

Current treatment of adamantinoma, including en bloc tumor resection with wide operative margins and limb salvage, provides lower rates of local recurrence than has been previously reported. In the present study, the limb preservation rate was 84 percent (fifty-nine of seventy), and the survival rate was 87.2 percent at ten years. The rate of complications related to the limb reconstruction was high.

CT-generated 3-dimensional models for complex acetabular reconstruction

Before undergoing complex acetabular reconstruction, 10 patients who met prospectively established criteria for severe acetabular bone deficiency received plain radiographs, computed tomography (CT) scans, and CT-generated 3-dimensional pelvic models. The radiographs, CT scans, and models each were graded according to the American Academy of Orthopaedic Surgery (AAOS) classification for acetabular deficiency. The classifications for the radiographs, CT scans, and models were then compared with findings at surgery. The models predicted acetabular deformity and AAOS classification significantly better than the other imaging modalities. The models agreed with the surgical findings in 9 of 10 cases, compared with 2 of 10 for the CT scans (P = .016) and 4 of 10 for the plain radiographs (P = .063). The models closely predicted the available space for the hemispheric acetabular shells, based on the size of the last reamer used, for the 6 hips reconstructed with standard components. Four patients required custom acetabular components; in 2 of those 4, the need for custom components was not anticipated by plain radiographs or CT scans. Three-dimensional CT-generated acetabular models were found to be useful in preoperative planning of complex acetabular reconstructions.

Bupivacaine for postoperative pain relief at the iliac crest bone graft harvest site

An inevitable side effect of iliac crest bone graft harvesting is postoperative pain at the donor site. Bupivacaine hydrochloride is a long-acting local anesthetic that is clinically effective for approximately 8 hours. The present study was undertaken to assess postoperative pain relief with locally injected bupivacaine at the iliac crest bone graft harvest site. Pain relief with locally injected bupivacaine or saline at the iliac bone harvest site using an indwelling catheter was studied in 13 patients in a prospective, double-blind, crossover study. Twelve patients had cervical diskectomy and arthrodesis with autograft and one patient had a triple arthrodesis of the foot. There were no statistically significant differences between patients given bupivacaine and patients given saline with respect to pain relief ratings and hip-pain ratings at rest and motion during the first 24-hour postoperative period and the second 24-hour postoperative period (Mann-Whitney test). The single diabetic patient who had a triple arthrodesis developed a wound infection at the catheter placement site. The number of patients was too small to draw conclusions about the differences in pain-medication requirements between patients undergoing single versus multiple diskectomies and fusions. In view of the lack of improvement in pain relief and the risk of infection, local administration of bupivacaine at the iliac bone harvest site is not recommended in its present form for postoperative analgesia.

Effect of high ambient temperature on contamination and physical stability of one-liter ready-to-hang enteral delivery systems

The effect of high ambient temperature on the physical stability and bacterial contamination of 1-L, prefilled, closed enteral feeding systems was examined under simulated clinical conditions. One hundred Jevity Ready-to-Hang enteral feeding systems (Abbott Park, IL, USA) were placed in a 37 degrees C incubator for 24 h. The Ready-to-Hang formula containers were visually inspected at 0 and 24 h. Formula samples were collected from the containers at 24 h and plated on trypticase soy agar. Two samples had insignificant bacterial growth of one colony-forming unit per milliliter that was not demonstrated in repeat culture. No growth was observed for any other sample. Additional samples collected from the two apparently contaminated delivery sets showed no growth. No set showed signs of formula instability, such as coagulation, clumping, or curdling. These findings suggest that, even at a high ambient temperature of 37 degrees C, the risk of bacterial contamination or compromised physical integrity is very low with the use of 1-L, prefilled, closed enteral feeding systems.

Occipitocervical stabilization for myelopathy in patients with rheumatoid arthritis. Implications of not bone-grafting

BACKGROUND

Approximately 0.9 percent of the white adult population of the United States and 1.1 percent of the adult population in Europe are affected by seropositive rheumatoid arthritis. As many as 10 percent of those patients may need an operation for atlantoaxial subluxation. Severe instability, especially when associated with vertical subluxation of the odontoid process, can result in progressive cervical myelopathy. Typically, occipitocervical fixation has been performed for these patients with use of autograft bone to achieve long-term stability through a solid fusion. Harvesting the bone graft increases the operative risk to the patient and may result in increased morbidity. In our experience, patients who have had no clear radiographic evidence of fusion following use of occipitocervical instrumentation seemed to have done as well as those who have had obvious fusion. One assumption is that the clinical improvement might be attributable simply to stabilization of the joint rather than to osseous fusion. A longitudinal study was performed on patients with rheumatoid arthritis who required an operation because of craniocervical or upper cervical instability.

METHODS

The results of clinical, radiographic, functional, and self-evaluations were studied to determine the efficacy of treatment and to compare the outcomes of bone-grafting with those of procedures done without bone-grafting in a group of 150 patients who underwent posterior occipitocervical stabilization with use of a contoured metal implant (a Ransford loop) that was affixed by sublaminar wires. Internal fixation was performed in 120 patients without bone-grafting and in thirty patients with use of autogenous bone-grafting. Preoperatively, 23 percent (thirty-five) of the 150 patients had mild neurological involvement (class II, according to the system of Ranawat et al.), 45 percent (sixty-eight) had objective findings of weakness and long-tract signs but were able to walk (class III-A), and 29 percent (forty-three) were quadriparetic and unable to walk (class III-B). The age of the patients at the time of the operation ranged from twelve to eighty-three years (mean, sixty-two years).

RESULTS

There were significant improvements in postoperative Ranawat classes at all time-periods (range, p < 0.00005 to p = 0.0066) and in patient ratings of neck pain (range, p < 0.00005 to p = 0.0044) compared with preoperative scores. With the numbers available, there were no significant differences between the patients managed with a graft and those managed without grafting with respect to survival after the operation, Ranawat class, head or neck-pain rating, presence of subaxial abnormalities, radiographic craniovertebral motion, or vertical subluxation. Overall mortality at one month was 10 percent (fifteen of 150), although this value varied directly with the degree of preoperative disability. A second cervical spine operation was required in 11 percent (sixteen) of the 150 patients.

CONCLUSIONS

While patients who have rheumatoid disease with anterior atlantoaxial subluxation should be treated with posterior atlantoaxial arthrodesis with use of bone-grafting and internal fixation, we believe that those who present with vertical instability and multi-level involvement can be treated with posterior occipitocervical stabilization with use of a contoured occipitocervical loop and sublaminar wire fixation without bone-grafting. Furthermore, we believe that the use of preoperative traction, bone cement, or a postoperative halo vest is unnecessary. Avoiding the harvesting of autogenous bone for grafting reduced the morbidity of this operation without compromising the outcome in these already sick patients.

Efficacy of a vibratory stimulus for the relief of HIV-associated neuropathic pain

Pain related to HIV disease is frequently debilitating. Of the many pain syndromes that occur in persons with HIV, distal symmetrical polyneuropathy (DSPN) is particularly devastating. Because DSPN often responds, at best, only partially to available pharmacologic interventions, non-pharmacologic interventions need to be investigated. Vibration has been suggested to be effective for reducing pain in other populations with chronic pain. This randomized, sham-controlled, double-masked study tested the short-term efficacy of a 45-min vibration treatment for DSPN foot pain in persons infected with HIV. Vibration therapy was delivered using a portable platform foot vibrator that provided stimulation at a frequency of 60 Hz. For all patients, the control box for the vibrator emitted an audible hum and part of the control box lit up during treatment, but only patients randomized to active treatment received vibration. Pain intensity (0-10) was measured immediately prior to and after treatment. Subjects were also questioned regarding pain relief (0-100%) immediately after the treatment. The mean percentage pain relief was 61.0+/-33.1% (median 70.0; range 0-100) for all patients, 67.3+/-34.0% (median 80.0; range 0-100) for vibration patients, and 55.0+/-32.0% (median 60.0; range 0-100) for sham patients. No statistically significant differences were found between the vibration and sham groups with respect to percentage pain relief (Mann-Whitney test; P=0.19) or the pre- and post-treatment current-pain difference (Mann-Whitney test; P=0.92). These results underscore the necessity for control groups in studies of non-pharmacologic therapies for pain.

Topical capsaicin in the management of HIV-associated peripheral neuropathy

Distal symmetrical peripheral neuropathy (DSPN) is a particularly distressing pain syndrome associated with human immunodeficiency virus (HIV) disease. Capsaicin has been found to be effective in relieving pain associated with other neuropathic pain syndromes, and is mentioned as a possible topical adjuvant analgesic for the relief of DSPN. This multicenter, controlled, randomized, double-masked clinical trial studied patients with HIV-associated DSPN and compared measures of pain intensity, pain relief, sensory perception, quality of life, mood, and function for patients who received topical capsaicin to the corresponding measures for patients who received the vehicle only. Twenty-six subjects were enrolled in the study. At the end of 1 week, subjects receiving capsaicin tended to report higher current pain scores than did subjects receiving the vehicle (Mann-Whitney test; P = 0.042). The dropout rate was higher for the capsaicin group (67%) than for the vehicle group (18%) (chi 2 test of association; P = 0.014). There were no other statistically significant differences between the capsaicin and vehicle groups with respect to current pain, worst pain, pain relief, sensory perception, quality of life, mood, or function at study entry or at any time during the 4-week trial. These results suggest capsaicin is ineffective in relieving pain associated with HIV-associated DSPN.

Effects of pudendal nerve injury in the female rat

To test a neurogenic hypothesis for external urethral sphincter (EUS) dysfunction associated with urinary incontinence, the proximal pudendal nerve was crushed in anesthetized retired breeder female rats (n = 5) and compared with a sham lesion group (n = 4). Outcome measures included concentric needle electromyograms (EMGs) from the target EUS, voiding patterns during a 2-hour dark period, and micturition data over a 24-hour period. Fast Blue (FB) was introduced to the crush site at the time of injury and Diamidino Yellow (DY) to the EUS at the time the rats were killed (3 months post-operative), when histological analysis of the nerve and urethra was also performed. EMG records indicated the EUS motor units undergo typical denervation changes followed by regeneration and recovery. Voiding patterns from the crush group show a significant increase of small urine marks in the front third of the cage. At 1-2 weeks post-op, the frequency of voids was significantly increased in the crush group compared to pre-op and late post-op time periods. The mean volume voided in the light phase at the early post-op time was significantly increased in the sham group. Light and electron microscopic patterns seen in nerve and muscle suggest the regenerating motor units maintain a structural integrity. Motoneurons in the lower lumbar cord were labeled with either DY (14. 5 +/- 6.8), FB (31.7 +/- 23.7), or both (35.0 +/- 17.5) tracers, indicating approximately 54% of the crushed pudendal neurons regenerated to the EUS. In conclusion, several measures suggest this reversible crush lesion induces mild urinary incontinence. This animal model is promising for further development of hypotheses regarding neural injury, the pathogenesis of incontinence, and strategies aimed at prevention and treatment. Neurourol. Urodynam. 19:53-69, 2000.

Outcome after rectovaginal fascia reattachment for rectocele repair

OBJECTIVE

This study was undertaken to determine the effects of rectovaginal fascia reattachment on symptoms and vaginal topography.

STUDY DESIGN

Standardized preoperative and postoperative assessments of vaginal topography (the Pelvic Organ Prolapse staging system of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons) and 5 symptoms commonly attributed to rectocele were used to evaluate 66 women who underwent rectovaginal fascia reattachment for rectocele repair. All patients had abnormal fluoroscopic results with objective rectocele formation.

RESULTS

Seventy percent (n = 46) of the women were objectively assessed at 1 year. Preoperative symptoms included the following: protrusion, 85% (n = 39); difficult defecation, 52% (n = 24); constipation, 46% (n = 21); dyspareunia, 26% (n = 12); and manual evacuation, 24% (n = 11). Posterior vaginal topography was considered abnormal in all patients with a mean Ap point (a point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen) value of -0.5 cm (range, -2 to 3 cm). Postoperative symptom resolution was as follows: protrusion, 90% (35/39; P <.0005); difficult defecation, 54% (14/24; P <.0005); constipation, 43% (9/21; P =.02); dyspareunia, 92% (11/12; P =.01); and manual evacuation, 36% (4/11; P =.125). Vaginal topography at 1 year was improved, with a mean Ap point value of -2 cm (range, -3 to 2 cm).

CONCLUSION

This technique of rectocele repair improves vaginal topography and alleviates 3 symptoms commonly attributed to rectoceles. It is relatively ineffective for relief of manual evacuation, and constipation is variably decreased.

Repair of full thickness rotator cuff tears. Gender, age, and other factors affecting outcome

Seventy-two full thickness rotator cuff tears (72 patients) were treated with an open rotator cuff repair between 1986 and 1993. The average postoperative followup was 54 months (range, 24-102 months; standard deviation, 22 months). Fifty-three (74%) patients had no pain, 16 (22%) patients had slight pain without restriction of activities, and three (4%) patients had moderate pain with activity compromise. Women with an associated biceps tendon rupture tended to have worse results. Women had a negative, statistically significant relationship between age and shoulder scoring scales, but age at the time of surgery was not related to any outcome variables for men. A rotator cuff tear greater than or equal to 5 cm2 as determined at the time of surgery was associated with a poorer outcome. The average University of California at Los Angeles score was 32 points (range, 7-35 points; standard deviation, 5 points). The average Constant-Murley score was 78 of 100 points (range, 12-95 points; standard deviation, 15 points). A yes response was given for an average of 10 of 12 questions on the Simple Shoulder Test (range, 0-12 questions; standard deviation, 3 questions). More than 4 years after open rotator cuff repair, patients had a 94% patient satisfaction rate with lasting relief of pain and improved function.

Influence of fast-track anesthetic technique on cardiovascular infusions and weight gain

OBJECTIVE

To evaluate whether cardiac surgical patients receiving conventional versus fast-track anesthetic management are statistically significantly different with regard to cardiovascular drug infusions, weight gain, cardiac and pulmonary morbidity, length of intubation, and length of stay.

DESIGN

Retrospective, (partially) sequential, cohort design.

SETTING

Surgical suite and intensive care unit (ICU) at a community hospital.

PARTICIPANTS

Two hundred seven patients who presented for coronary artery bypass graft and/or cardiac valve replacement.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Group comparisons of the seven individual cardiovascular drug infusions showed less frequent use in the fast-track patients for lidocaine (9% v 28%; p = 0.00046) only. However, the fast-track group received fewer combinations of cardiovascular drug infusions overall for the first 24-hour postoperative period (p < 0.0005). Hourly comparisons of inotropes showed significantly fewer combinations of dobutamine, norepinephrine, and epinephrine for the first postoperative hour and for postoperative hours 7 through 12 (p < 0.01 for each hour). Fast-track patients had less postoperative weight gain for days 1 through 4 (p < 0.01 for each day), shorter length of ICU stay (p < 0.00005), and shorter total length of postoperative hospital stay (p = 0.0004). No differences were found with respect to myocardial infarction, death, pulmonary complications, rate of reintubation, or length of hospital stay once discharged from the ICU.

CONCLUSIONS

Fast-track anesthetic management may be associated with decreased need for inotropic and antiarrhythmic drug infusions and decreased weight gain.

Predicting the risk of pressure ulcers in critically ill patients

BACKGROUND

Critically ill patients are at high risk for pressure ulcers.

OBJECTIVES

To determine the contributions of the Braden subscales in predicting pressure ulcers in critically ill patients and to investigate how often the Braden scale should be completed to assess the risk for pressure ulcers in critically ill patients.

METHOD

The Braden scale was used to assess repeatedly 136 adult patients without pressure ulcers in a medical intensive care unit, a surgical intensive care unit, and a noninvasive respiratory care unit, and the patients' skin was inspected routinely for pressure ulcers.

RESULTS

A total of 36 pressure ulcers, most commonly on the sacrum or coccyx and the heels (15 stage 1, 20 stage 2, 1 stage 3), developed in 17 patients (12%). In 14 (82%) of the 17, the ulcers developed within 72 hours of admission to the intensive care unit. The risk for pressure ulcers increased as the mean sensory perception (P = .01) and the mean total Braden (P = .046) scores decreased. The mean sensory perception scores obtained at 12 and 36 hours after admission also had a significant relationship to the risk for pressure ulcers (P = .03).

CONCLUSIONS

Patients in intensive care units have an increased risk for pressure ulcers. Although waiting until 12 hours after a patient's admission to the intensive care unit to obtain the initial Braden rating may be reasonable (with the second rating obtained 36 hours after admission), additional research is needed before this practice can be recommended.

Predicting the risk of pressure ulcers in critically ill patients

BACKGROUND: Critically ill patients are at high risk for pressure ulcers. OBJECTIVES: To determine the contributions of the Braden subscales in predicting pressure ulcers in critically ill patients and to investigate how often the Braden scale should be completed to assess the risk for pressure ulcers in critically ill patients. METHOD: The Braden scale was used to assess repeatedly 136 adult patients without pressure ulcers in a medical intensive care unit, a surgical intensive care unit, and a noninvasive respiratory care unit, and the patients' skin was inspected routinely for pressure ulcers. RESULTS: A total of 36 pressure ulcers, most commonly on the sacrum or coccyx and the heels (15 stage 1, 20 stage 2, 1 stage 3), developed in 17 patients (12%). In 14 (82%) of the 17, the ulcers developed within 72 hours of admission to the intensive care unit. The risk for pressure ulcers increased as the mean sensory perception (P = .01) and the mean total Braden (P = .046) scores decreased. The mean sensory perception scores obtained at 12 and 36 hours after admission also had a significant relationship to the risk for pressure ulcers (P = .03). CONCLUSIONS: Patients in intensive care units have an increased risk for pressure ulcers. Although waiting until 12 hours after a patient's admission to the intensive care unit to obtain the initial Braden rating may be reasonable (with the second rating obtained 36 hours after admission), additional research is needed before this practice can be recommended.

The anatomic and functional variability of rectoceles in women

Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.

A comparison of women with primary and recurrent pelvic prolapse

OBJECTIVE

Our purpose was to identify clinically relevant differences in women with primary and recurrent pelvic organ prolapse.

STUDY DESIGN

Consecutive women undergoing reconstructive surgery completed a urogynecologic history and physical examination and underwent either multichannel urodynamic testing or pelvic floor fluoroscopy, or both. Two groups were compared: primary (no prior surgery for pelvic organ prolapse) and recurrent.

RESULTS

One hundred eighty-one consecutive women were studied-103 with primary and 78 with recurrent prolapse. The groups were similar with respect to age, race, weight, vaginal parity, prolapse stage, urodynamic diagnosis, extent of visceral malposition, and common urinary, anorectal, and sexual symptoms. Clinically relevant differences were found, with the recurrent group having shorter vaginal lengths (P =. 0005), being more likely to have had a hysterectomy for a nonprolapse indication (P =.00018) and to be receiving hormone replacement therapy (P =.00003).

CONCLUSION

The women with primary and recurrent pelvic organ prolapse in this population were remarkably similar in many quantifiable parameters measured. The clinical differences may be related to previous surgery for pelvic organ prolapse.

Taste changes experienced by patients receiving chemotherapy

PURPOSE/OBJECTIVES

To increase knowledge about the nature, frequency, and quality-of-life (QOL) effects associated with taste changes after chemotherapy.

DESIGN

Cross-sectional, descriptive.

SETTING

11 outpatient urban and suburban oncology centers.

SAMPLE

284 adults who had received at least two chemotherapy cycles.

METHODS

Patients completed a taste change questionnaire and the Functional Assessment of Cancer Therapy-General, and nurses collected demographic and disease-related information. Descriptive statistics, Spearman correlations, chi-square, Mann-Whitney, and Kruskal-Wallis one-way analysis of variance were calculated.

FINDINGS

Taste changes were frequent and at least moderately severe for many patients, who often reported dry mouth, decreased appetite, nausea, and vomiting. Cisplatin and doxorubicin were the agents most likely to be related to severe taste changes and to have caused greater distress from taste changes, which also were associated with decreased QOL. Oncology nurses and physicians rarely discussed taste changes with patients, who often tried changing the ways they seasoned their food.

CONCLUSIONS

Taste changes are a frequent and significant problem for patients receiving chemotherapy and have negative effects on patients' QOL. Oncology nurses and physicians typically do not offer self-management suggestions to patients. IMPLICATIONS FOR NURSING RESEARCH AND PRACTICE: Repeated-measures research may provide a clearer understanding of chemotherapy-associated taste changes over time. Studies to examine strategies suggested from this and other research as well as clinical literature may determine which self-care interventions are most useful. Nurses should inform patients that taste changes may occur following chemotherapy, provide self-management information, and assess for related problems that could increase chemotherapy morbidity.

Preoperative PCA teaching program to manage postoperative pain

Patient-controlled analgesia (PCA) therapy was designed to provide patients with greater control in managing their pain. However, many patients continue to suffer from moderate to severe pain due to lack of knowledge about how to use PCA therapy. The results of this quasi-experimental study demonstrated that patients who received structured preoperative teaching had statistically significant higher knowledge regarding the use of PCA therapy and more positive attitudes toward using pain medicine. Patients who received the video teaching reported better pain control and satisfaction with pain management 4 and 8 hours following their surgical procedures.