Tunneled Fascia Iliaca Catheter Placement for Chronic Pain From Advanced Osteosarcoma.

The fascia iliaca compartment block (FICB) is a regional anesthetic technique for hip and femoral surgery that blocks the femoral, obturator, and lateral femoral cutaneous nerves. We report the case of a middle-aged female patient who presented with excruciating left lower extremity pain secondary to metastatic left femur osteosarcoma. A FICB with the tunneled catheter was sterilely placed in the operating room as palliative therapy due to the difficulty in pain control, as the patient experienced severe somnolence with high-dose opioid therapy. Conventional techniques such as a femoral nerve block were also precluded due to difficult anatomy secondary to tumor compression. Near-total pain relief was achieved postoperatively and lasted over seven weeks until discharge. This case report demonstrates the unique use of the FICB as a primary pain management technique for the control of chronic lower extremity cancer pain.

Electrolyte and transporter responses to angiotensin II induced hypertension in female and male rats and mice.

AIM: Sexual dimorphisms are evident along the nephron: Females (F) exhibit higher ratios of renal distal to proximal Na+ transporters' abundance, greater lithium clearance (CLi ) more rapid natriuresis in response to saline infusion and lower plasma [K+ ] vs. males (M). During angiotensin II infusion hypertension (AngII-HTN) M exhibit distal Na+ transporter activation, lower proximal and medullary loop transporters, blunted natriuresis in response to saline load, and reduced plasma [K+ ]. This study aimed to determine whether responses of F to AngII-HTN mimicked those in M or were impacted by sexual dimorphisms evident at baseline. METHODS: Sprague Dawley rats and C57BL/6 mice were AngII infused via osmotic minipumps 2 and 3 weeks, respectively, and assessed by metabolic cage collections, tail-cuff sphygmomanometer, semi-quantitative immunoblotting of kidney and patch-clamp electrophysiology. RESULTS: In F rats, AngII-infusion increased BP to 190 mm Hg, increased phosphorylation of cortical NKCC2, NCC and cleavage of ENaC two to threefold, increased ENaC channel activity threefold and aldosterone 10-fold. K+ excretion increased and plasma [K+ ] decreased. Evidence of natriuresis in F included increased urine Na+ excretion and CLi , and decreased medullary NHE3, NKCC2 and Na,K-ATPase abundance. In C57BL/6 mice, AngII-HTN increased abundance of distal Na+ transporters, suppressed proximal-medullary transporters and reduced plasma [K+ ] in both F and M. CONCLUSION: Despite baseline sexual dimorphisms, AngII-HTN provokes similar increases in BP, aldosterone, distal transporters, ENaC channel activation and K+ loss accompanied by similar suppression of proximal and loop Na+ transporters, natriuresis and diuresis in females and males.

First-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency, nasal bone, tricuspid regurgitation and ductus venosus flow combined with maternal serum free ß-hCG and PAPP-A: a 5-year prospective study.

OBJECTIVE: To investigate the performance of first-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency thickness (NT), nasal bone (NB), tricuspid regurgitation (TR) and ductus venosus (DV) flow combined with maternal serum free ß-human chorionic gonadotropin (fß-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at a one-stop clinic for assessment of risk (OSCAR). METHODS: In total, 13,706 fetuses in 13,437 pregnancies were screened for chromosomal abnormalities during a period of 5 years. Maternal serum biochemical markers and maternal age were evaluated in combination with NT, NT + NB, NT + NB + TR, and NT + NB + TR + DV flow data in 8581, 242, 236 and 4647 fetuses, respectively. RESULTS: In total, 51 chromosomal abnormalities were identified in the study population, including 33 cases of trisomy 21, eight of trisomy 18, six of sex chromosome abnormality, one of triploidy and three of other unbalanced abnormalities. The detection rate and false-positive rate (FPR) for trisomy 21 were 93.8% and 4.84%, respectively, using biochemical markers and NT, and 100% and 3.4%, respectively, using biochemical markers, NT, NB, TR and DV flow. CONCLUSION: While risk assessment using combined biochemical markers and NT measurement has an acceptable screening performance, it can be improved by the integrated evaluation of secondary ultrasound markers of NB, TR and DV flow. This enhanced approach would decrease the FPR from 4.8 % to 3.4 %, leading to a lower number of unnecessary invasive diagnostic tests and subsequent complications, while maintaining the maximum level of detection rate. Pre- and post-test genetic counseling is of paramount importance in either approach.

Maternal progesterone level in fetal growth restriction and its relationship with Doppler velocimetry indices.

BACKGROUND/OBJECTIVE: To verify whether progesterone concentration is changed in the maternal serum of intra-uterine growth retardation (IUGR) pregnancies and to assess if there is a relationship between maternal progesterone and fetal Doppler velocimetry. PATIENTS AND METHODS: Thirty-five patients with intrauterine growth retardation infants and thirty-seven pregnant women with appropriate for gestational age (AGA) fetuses were enrolled in the study. Maternal progesterone serum was determined. Doppler velocimetry of umbilical and middle cerebral arteries (MCA) were obtained in all fetuses. RESULTS: Maternal progesterone level in IUGR infants (58.49±7.06 ng/ml) had no significant difference with AGA fetuses (58.13±7.87 ng/ml) (p=0.96). In the IUGR group, umbilical artery resistive index (RI), pulsatility index (PI) and systolic/diastolic (S/D) ratio were higher than the normal group (p<0.001), and MCA RI (p value=0.014) and PI (p=0.012) were significantly less than the IUGR group. Besides, RI C/U in the IUGR group was significantly less than the normal group (p<0.001). A negative significant correlation was detected between maternal progesterone level and MCA PI (r=-0.38) and RI (r=-0.38) in the AGA group. CONCLUSION: It seems that progesterone has no effect on fetal placental circulation and serum progesterone can not discriminate IUGR infants from AGA infants. Progesterone is a poor marker for placental dysfunction.

Risk factors for meconium aspiration in meconium stained amniotic fluid.

Meconium aspiration syndrome (MAS) is a life-threatening respiratory disease in infants born through meconium stained amniotic fluid (MSAF). The purpose of this study was to determine risk factors for MAS in the newborns of mothers who had meconium stained amniotic fluid in labour. A retrospective study of all full-term pregnancies with MSAF from May 2003 to October 2004 was designed at a teaching hospital. Development of MAS was the primary outcome. Maternal details, mode of delivery and neonatal details (Apgar score, reassuring or non-reassuring fetal heart rate tracing and birth weight) were evaluated. During the study period, there were 2,603 deliveries of whom 302 (11.6%) had MSAF. MAS developed in 64 of these infants (21.1%). Compared with healthy neonates with MSAF, those with MAS had higher rate of non-reassuring fetal heart rate (FHR) tracing, thick meconium and Apgar score < or =5 at 5 min. The neonatal birth weight was lower in the MAS group, maternal age, parity, gestational age and mode of delivery were not significantly different in the two group. We found the severity of meconium, low Apgar score at 5 min and non-reassuring FHR tracing was associated with MAS in MSAF pregnancies.

Estimation of probability of malignancy using a logistic model combining color Doppler ultrasonography, serum CA125 level in women with a pelvic mass.

The goal of this study was to develop a scoring system using combination of Doppler characterization of pelvic/ovarian lesions and serum CA125 level. Our purpose was to maximize the preoperative discrimination between benign and malignant entities. In a prospective study, a total of 101 patients were evaluated preoperatively using a standard transvaginal ultrasound and color Doppler imaging with pulse spectral analysis and serum CA125 level within a week prior to surgery. The variables that were analyzed by the multivariate logistic regression method are as follows: tumor structure, ascites, presence of septum, the peak systolic velocity (PSV), the resistance index (RI), and serum CA125 level. Of the 101 patients qualified for the study, 48 patients were diagnosed with benign (47.5%) and 53 (52.5%) with malignant tumors. Each criterion used alone provides statistically significant discrimination between benign and malignant tumors. Four criteria could be combined in a malignancy score which is calculated using the product of the serum CA125 level (1 if CA125 > or =40 U/mL and 0 if CA125 <40 U/mL), the result of sonography for presence of septum in tumor (1 if there was septum > or =3 mm, 0 if there was no septum or <3 mm), result of Doppler flow imaging as RI (1 if RI < or =0.5 and 0 if RI >0.5) and the PSV (1 if PSV > or =40 cm/s and 0 if PSV <40 cm/s). This scoring system devised was statistically more effective discriminator between cancer and benign lesions than formal methods. Using malignancy score cutoff level of two, the sensitivity was 98% (CI 88.62-99.9.), the specificity was 85% (CI 71.62-93.45), the positive predictive value was 87.5%, and the negative predictive value was 97.6%. Area under curve of receiver operative characteristic curves was 0.987 (CI 0.971-1.004). These values were statistically more significant than those obtained from the independent use of RI, PSV, or serum CA125 level at their optimum decision values (P < 0.05). There is a need for a prospective evaluation of this score using a larger sample of patients.

Amniotic fluid lamellar body count and its sensitivity and specificity in evaluating of fetal lung maturity.

This prospective study was designed to perform lamellar body count of amniotic fluid to evaluate fetal lung maturity. Lamellar body counts of 80 amniotic fluid samples from 80 pregnant women (28-40 weeks of gestation) were evaluated. After delivery, each infant was evaluated for any evidence of respiratory distress syndrome. Standard clinical and radiographic criteria were used to diagnose respiratory distress syndrome, and the diagnosis was confirmed by reviewing newborn records. Twenty (25%) infants delivered within 24 hours of sample collection developed RDS. Lamellar body count more than 50,000/microl predicted pulmonary maturity. Seventeen out of 20 respiratory distress syndrome cases had been predicted correctly. The negative predictive value of lamellar body count>50,000/microl was 93% and positive predictive value was 48% and the sensitivity for prediction of RDS was 85% and specificity was 70%. Lamellar body count can be used as a favourable predictor of fetal lung maturity because it is quick, simple and universally available. Also it can be used as an extremely inexpensive, reliable screening test for evaluating fetal lung maturity.

Vitamins C and E in the latency period in women with preterm premature rupture of membranes.

OBJECTIVE: To determine whether supplementation with vitamins C and E after preterm premature rupture of membranes (PPROM) is associated with an increased latency period. METHODS: In this double-blind, randomized, controlled trial, 60 women with singleton pregnancies of 26 to 34 weeks' duration and PPROM were randomly assigned to vitamin C (500 mg/day) and vitamin E (400 IU/day) or placebo until delivery. All women received 2 doses of betamethasone in the first 24 h after admission as well as broad-spectrum antibiotic prophylaxis. RESULTS: Important demographic, as well as clinical characteristics such as number of cases of chorioamnionitis, early neonatal sepsis, and respiratory distress syndrome, were similar in the 2 groups. A statically significant difference in the mean+/-S.D. number of days of latency was found between the groups (10.5+/-5.2 days vs. 3.5+/-4.0 days (P = 0.03). CONCLUSION: Vitamins C and E supplementation of after PPROM is associated with a longer latency before delivery.

An approach to allocating limited health resources.

This paper considers the effectiveness of the Oregon Health Plan method for allocating limited health resources. The Plan is narrow in scope and leaves many difficult questions unanswered. Criteria for developing a comprehensive plan for allocating limited health resources are discussed. It is suggested that when a resource is scarce, any allocation decision implicitly or explicitly must reflect the notion of social worth. The determination of social worth of a patient is outlined. This paper supports the notion of allocating medical dollars on the concept of worth.