Compression-staple fixation for fractures, non-unions, and delayed unions of the carpal scaphoid.

We used the Richards scaphoid compression staple for operative fixation in a total of twenty-five patients who had a fracture of the carpal scaphoid: sixteen whom we reported on previously and nine whom we are reporting on for the first time here. In the current series, we extended the application of the method to fresh, unstable fractures (two patients) and treated an additional seven patients who had a non-union or delayed union. The procedure was simple, and no operative complications were encountered. Both patients who had a fresh fracture had a satisfactory result. Of the other twenty-three patients, only two had a result that was not satisfactory. One patient had a persistent non-union. Three patients had doubtful radiographic evidence of a persistent non-union; however, all three had a good result clinically, and only one had moderate loss of function. Although the over-all results were good, there was some worsening of the clinical results on long-term follow-up compared with those that we reported earlier. This deterioration probably was due to secondary degenerative changes in the articular surfaces.

A randomized trial of rizatriptan in migraine attacks in children.

OBJECTIVE: To examine the efficacy of rizatriptan and the consistency of treatment response in migraine attacks of children and adolescents. METHODS: We conducted a double-blind, placebo-controlled three-way crossover trial in patients ages 6 to 17 years diagnosed with migraine in two pediatric hospital outpatient clinics. Two doses of rizatriptan and a matching placebo were administered at home during three attacks. Rizatriptan dose was 5 mg for those with a body weight of 20 to 39 kg, and 10 mg for those with a body weight of 40 kg or more. The primary efficacy endpoint was headache relief by two grades on a five-grade face scale at 2 hours. RESULTS: Ninety-six patients used all three treatments, 10 used two, and 10 only the first. At 2 hours, the primary endpoint was reached twice as often after both treatments of rizatriptan (first 74%, n = 71/96; second 73%, n = 70/96) as after placebo (36%, n = 35/96) (p < 0.001). Already at 1 hour, rizatriptan was clearly more effective as headache relief was reported by 50% (n = 48/96) and 55% (n = 53/96) of children after the first and the second dose of rizatriptan, compared to 29% (n = 28/96) after placebo (p = 0.004). Rizatriptan was superior at 3 and 4 hours, and the other endpoints also favored rizatriptan. Efficacy of rizatriptan was constant over the two treated attacks, and the findings were similar in children using the dose of 5 and 10 mg. No serious adverse effects were observed. CONCLUSIONS: Oral rizatriptan is effective and well-tolerated for migraine attacks in children over age 6 years.

The fate of elderly patients treated in the surgical intensive care unit. A survey of 174 patients over 60 years old.

The fate of 174 patients over 60 years old treated in the surgical intensive care unit was investigated. During their stay in the hospital the mortality was 39% and 24% in the selected group when hopeless cases with malignancies, mesenteric thrombosis and severe brain lesions were excluded. The prognosis was not affected by the age or concomitant diseases. The importance of meticulous preoperative treatment and surgery is stressed. Modern intensive care in special units has changed the prognosis of aged patients greatly.

A comparative study of carticaine and prilocaine in epidural anaesthesia.

Carticaine and prilocaine (without adrenaline) in epidural anaesthesia were compared in a double blind study. Carticaine and prilocaine were used in 2 % concentration without adrenaline. The latency time was not significantly different, but carticaine was a shorter acting local anaesthetic. The motor block in both series was similar. Carticaine is a good and reliable analgesic in short operations but in operations longer than one and a half hours catheter technique, adrenaline addition or local anaesthetics of longer duration ought to be used.

[Porphyria and anesthesia. A case report and a short review (author's transl)]. / Porphyrie und Anästhesie Fallbericht und kurze Ubersicht

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

Prolongation of thiopentone anaesthesia by probenecid.

In a double-blind study, probenecid 0.5 or 1.0 g or placebo was given to 86 patients undergoing uterine curettage or gynaecological laparotomy 3 h before operation. The duration of anaesthesia in patients anaesthetized with thiopentone 7 mg kg-1 and premedicated with pethidine and atropine, was prolonged by 65% by probenecid 0.5 g, and by 46% by probenecid 1.0 g, compared with control (P < 0.05). In the absence of pethidine premedication, probenecid 0.5 g prolonged anaesthesia by 26% (P < 0.1). In patients without pethidine premedication anaesthetized with only thiopentone 4 mg kg-1 but who had no surgical stimulus during anaesthesia, probenecid increased the duration of the anaesthesia by 109% (P < 0.1). In this group the frequency of sleeping was 100%, as compared with 80% in the placebo-treated patients. Probenecid did not modify the response to pain and had no effect on apnoea, arterial pressure or heart rate.

Fatal brain lesion following spinal anaesthesia. Report of a case.

Leakage of cerebrospinal fluid following dural puncture and subsequent downward sagging of the brain have been suggested as a cause of the rare subdural haematomas occurring after spinal or attempted epidural anaesthesia which have been reported in the literature. We report a case where this mechanism probably produced a fatal brain lesion, due to the herniation of the uncus against the tentorium cerebelli 15 days after spinal anaesthesia. The patients complained of severe headache and nausea after the procedure. The reported case shows that postdural-puncture headache may be a sign of more serious sequelae and should be treated by the means available.

Controlled hypotension and moderate haemodilution in major hip surgery.

This study presents a series of 38 patients in whom total hip replacement was performed by using a hypotensive anaesthetic technique with moderate haemodilution. 17 patients operated on during normotension without haemodilution served as controls. Halothane, d-tubocurarine and pentolinium tartrate were the agents used. During the operation circulation was monitored carefully. Hypotension with haemodilution decreased the amount of the transfused blood to 1/3, compared with the normotensive group. The bloodless field during the hypotension also shortened the duration of the operations. No complications attributable to the hypotensive technique occurred. The results suggest that the hypotensive anaesthetic technique with haemodilution reduces the need for blood transfusion in major surgery. However, only patients in good cardiovascular status are suitable for this technique, and careful monitoring of the circulation is mandatory during the anaesthesia.

Risk factors in surgical patients with verified preoperative myocardial infarction.

A series of 89 surgical patients (111 operations) with preoperative myocardial infarction (MI) was analysed for factors predisposing to the development of a postoperative reinfarction. Six of them suffered postoperative MI, and three of these patients died. In the statistical analysis the following risk factors emerged: age over 60 years, anaemia, hypertension, and the fact that the previous MI had been posterior. Abdominal operations were more dangerous concerning reinfarction than other operations. In the other series of 11 deceased patients with postoperative reinfarction collected from the autopsy material, about the same risk factors were found. The most important factor seemed to be hypotension, which complicated the surgery. All 11 patients had arrhythmias in their preoperative electrocardiogram. Previously treated heart failure was present in five of these patients. Postoperative symptoms analysed in the first series suggest that if a patient with preoperative MI has arrhythmias, hypotension, dyspnoea, diffuse unlocalized pain or chest pain after surgery, he is very likely to have a reinfarction.

A comparison of carticaine and lidocaine in spinal anaesthesia.

The effects of Lidocaine and the new local anaesthetic carticaine in spinal anaesthesia were compared in a double blind study in 120 elderly male patients scheduled for small urological procedures. The variables investigated were: analgesia examined by pin prick method, loss of tactile sensation, motor block, and skin temperature on the big toe. Both local anaesthetics seem to act similarly, but the loss of tactile sensation and motor block began somewhat earlier with carticaine. The differences have hardly any clinical significance. The incidence of hypotension and postanaesthetic headache was similar in each group.

The antagonistic effect of pentazocine on fentanyl induced respiratory depression compared with nalorphine and naloxone.

The effect of pentazocine, a strong analgesic with a weak opiate antagonistic activity, on fentanyl-induced respiratory depression was studied after anaesthesia in patients undergoing gynaecological laparotomy. Pentazocine (1 mg/kg) was given intravenously at the end of operation. The postoperative respiratory depression in these patients was compared with that in patients who received strong opiate antagonists, nalorphine and naloxone, or no opiate antagonists. Respiratory depression was evaluated by measuring respiratory rate, respiratory minute volume and blood gases. The results show that pentazocine has a clear antagonistic effect on fentanyl-induced respiratory depression but the effect of 1 mg/kg is weaker and shorter than that produced by 5 mg of nalorphine or 0.4 mg of naloxone. Postoperative analgesia in patients who received pentazocine was not longer than that in patients who received no opiate antagonists at the end of the operation.

Modelling rubella in Europe.

The prevention of congenital rubella syndrome (CRS), as a complication of rubella infection during pregnancy, is the main aim of rubella vaccination programmes. However, as vaccination of infants leads to an increase in the average age at which those who were not immunized become infected, certain rubella vaccination programmes can lead to an increase in the incidence of CRS. In this paper we use a mathematical model of the transmission dynamics of rubella virus to investigate the likely impact of different vaccination policies in Europe. The model was able to capture pre- and post-vaccination patterns of infection and prevalence of serological markers under a wide variety of scenarios, suggesting that the model structure and parameter estimates were appropriate. Analytical and numerical results suggest that endemic circulation of rubella is unlikely in Finland, the United Kingdom, The Netherlands, and perhaps Denmark, provided vaccine coverage is uniform across geographical and social groups. In Italy and Germany vaccine coverage in infancy has not been sufficient to interrupt rubella transmission, and continued epidemics of CRS seem probable. It seems unlikely that the immunization programmes in these countries are doing more harm than good, but this may be partly as a result of selective immunization of schoolgirls. Indeed, in both these countries, selective vaccination of schoolgirls with inadequate vaccination histories is likely to be an important mechanism by which CRS incidence is suppressed (unlike the other countries, which have had sufficiently high infant coverage rates to withdraw this option). Reducing inequalities in the uptake of rubella vaccine may bring greater health benefits than increasing the mean level of coverage.

Cornea plana congenita gene assigned to the long arm of chromosome 12 by linkage analysis.

We report the mapping of the locus for autosomal recessive cornea plana congenita (CNA2; MIM 217300) by linkage analysis to the approximately 10-cM interval between markers D12S82 and D12S327. The recessively inherited disorder studied here is more severe than dominant forms. Its main manifestations are reduced curvature and hazy limbus of the cornea, opacities in the corneal stroma, and marked corneal arcus at early age. Our results provide a starting point for the positional cloning of CNA2 and the elucidation of the pathogenesis of the disease.