Incidence of symptoms and signs of TMD following third molar surgery: a controlled, prospective study.

The purpose of this prospective study was to investigate if third molar surgery is associated with the development of symptoms and signs of temporomandibular disorders (TMD) during a 6-month post-operative observation period using the Research Diagnostic Criteria for TMD (RDC/TMD) instrument. Seventy-two subjects eligible for third molar surgery under local anaesthesia (patients) were included. Patients were examined according to the RDC/TMD instrument at baseline, 1 week, 1 and 6 months after surgery. Twenty-five age- and sex-matched healthy non-operative control subjects (controls) were included and examined at baseline and at 6 months. In the patient group, we found: (i) reduced range of maximum jaw opening at one week after surgery (P < 0.001), (ii) increased characteristic pain intensity 1 week after surgery (P < 0.05), (iii) increased disability up to 1 month after surgery (P < 0.05), (iv) increased incidence of muscle pain on palpation up to 6 months after surgery (P < 0.05), (v) increased incidence of pain on palpation of the temporomandibular joint up to 6 months after surgery (P < 0.05) and (vi) increased incidence of painful TMD 6 months after surgery. But, when compared with untreated controls, subjects undergoing third molar surgery have a statistically insignificant increased incidence of TMD 6 months post-operatively.

Emergency physicians' practices and attitudes regarding procedural anaesthesia for nasogastric tube insertion.

OBJECTIVE: To determine practice and attitudes of emergency physicians regarding procedural anaesthesia for nasogastric tube insertion (NGT). METHODS: Survey of resident/attending emergency physicians working in a tertiary care medical centre. RESULTS: Of 68 physicians, 46 responded: 98% believed that awake and alert patients find NGT insertion uncomfortable/painful; 93% used measures to reduce this, most commonly lubricant gel, topical anaesthetic spray, lidocaine gel, and distraction/use of a child life worker; 28% believed these provided adequate pain control and 37% believed they were inadequate. Topical anaesthetic spray, lidocaine gel, and nebulised/atomised anaesthetics were believed the most practical to administer and 44% actually used these. Nebulised/atomised anaesthetics, systemic anxiolytics, and topical anaesthetic spray were believed the most effective at pain control but only 24% actually used these. While 39% of respondents were satisfied with their current practice, 46% were dissatisfied: 91% would change their practice if new literature were to show a convenient way to effectively reduce this pain. CONCLUSIONS: Emergency physicians do not actually use the measures they believe are most practical/most effective at reducing the pain associated with NGT insertion. Thus, there may be a barrier to the use of these measures. Improvement in procedural anaesthesia for NGT insertion in emergency departments is needed and desired by emergency physicians.

Interhemispheric subdural hematoma. Case report.

A case of interhemispheric subdural hematoma ( ISH ) is presented and discussed. This disorder is a rare form of intracranial hemorrhage, which classically presents as an isolated paresis of one leg or a hemiparesis worse in the leg than the arm. The majority of cases are due to occipital trauma because of the anatomy of the bridging veins. Chronic interhemispheric hematomas are rare since the natural history of these lesions is to spread out over the cerebral convexity. Conservative treatment for ISH may be beneficial unless neurological deterioration necessitates early operative intervention.

[Deep subacute accidental hypothermia. A case with an unusual clinical picture and course]. / Dyb subakut accidentel hypotermi. Et tilfoelde med usoedvanligt billede og forløb.

A case of a patient with core temperature of 24.4 degrees C, presenting an unusual clinical picture, is described. A 68 year-old man was found outdoors after being exposed to five to eight hours of coldness. He was found awake, with dry clothes and an alcohol foetor. After eight hours the serum ethanol was measured as 6 mmol/l. He could not speak but was able to move all four extremities. A sinus bradycardia of 23 beats per minute was present but no other arrhythmia was seen. The temperature rose to 31.2 degrees C within four hours and body temperature was normal after 10 hours. The only treatment given was passive rewarming with blankets and 2.5 l isotonic NaCl warmed to 40 degrees C given intravenously. This clinical picture supports the assumption that ethanol protects the myocardium against arrhythmias in deep hypothermia.

Onset of acetaminophen analgesia: comparison of oral and intravenous routes after third molar surgery.

BACKGROUND: The purpose of this randomized double-blind study was to compare the efficacy and safety of propacetamol 2 g (an i.v. acetaminophen 1 g formulation) administered as a 2-min bolus injection (n=50) or a 15-min infusion (n=50) with oral acetaminophen 1 g (n=50) or placebo (n=25) for analgesia after third molar surgery in patients with moderate to severe pain after impacted third molar removal. METHODS: All patients were evaluated for efficacy during the initial 6 h period after treatment administration (T(0)) and for safety during the entire week after T(0). RESULTS: The onset of analgesia after propacetamol was shorter (3 min for bolus administration, 5 min for 15-min infusion) than after oral acetaminophen (11 min). Active treatments were significantly better for all parameters (pain relief, pain intensity, patient's global evaluation, duration of analgesia) than placebo (P<0.05). Adverse events were more frequent after propacetamol, especially pain at the injection site. Propacetamol bolus resulted in a much higher incidence of local adverse events than the infusion (propacetamol bolus 90% vs propacetamol infusion 52%) with no clinically significant benefits in terms of analgesic efficacy. CONCLUSION: I.V. propacetamol, administered as a 15-min infusion, is a fast-acting analgesic agent. It is more effective in terms of onset of analgesia than a similar dose of oral acetaminophen.

[The Infucommand. A PCA (patient-controlled analgesia) device using pulsoximetric bolus control]. / Der Infucommand. Ein PCA-Gerät mit pulsoximetrischer Boluskontrolle.

A physician who treats his patients with patient-controlled analgesia (PCA) must be aware of the possibility of unnoticed respiratory depression. A new device has been developed (Infucommand), which uses a pulsoximeter to monitor respiration and stops the infusion pump if the level of O2 saturation falls below a preset value. Thus, the danger of opioid overdosage can be reduced.

[Computer-controlled infusion]. / Computergesteuerte Infusion.

For complex treatment regimens in the field of modern infusion therapy and for the administration of potent drugs (liquid management), a special microcomputer (Infucommand III) has been developed which makes it possible to control commercial infusion pumps via a standardized interface. By this means, infusion pumps can be combined with other medical instruments or further pumps to form an intelligent unit. Due to its small dimensions and few operating elements, the control device is easy to handle. A high safety standard has been achieved in routine operation, from the aspects of both hardware and software. Large memories (ROM and RAM) enable a large number of different user programs to be stored. In initial clinical trials the devices have already stood the test with regard to patient-controlled and EEG-controlled-anesthesia.

[Patient-controlled analgesia. A technical toy or a contribution to the treatment of pain?]. / Patientenkontrollierte Analgesie. Eine technische Spielerei oder eine Bereicherung der Schmerztherapie?

PCA (patient-controlled analgesia) was used to treat postoperative pain after general surgery and gynecological operations in a total of 82 patients. In a prospective randomized study, 20 of these patients received pentazocine and 20 were treated with Fentanyl. The bolus quantity for pentazocine was 15 mg in 5 ml NaCl, and that for Fentanyl 0.05 mg in 5 ml NaCl. A maximum of 3 boluses was allowed within 1 h; the refractory period was 5 min. Both drugs were equally suited for the treatment of pain. With pentazocine, an average of 144 micrograms kg-1 min-1 was administered during the first 16 h after the operation; with Fentanyl, the quantity taken was 0.78 microgram kg-1 min-1. The inter- and intraindividual variance in the consumption of analgesics described by other authors was confirmed. The amount of analgesics required ranged between 0.05 and 1.95 mg for Fentanyl and between 15 and 435 mg for pentazocine in a period of 16 h. Three patients did not request an analgesic at all. The average consumption of analgesics constantly decreased in the first few postoperative hours, from 0.28 mg every 4 h after the operation to 0.18 mg every 4 h 16 h later (Fentanyl) and from 55 mg every 4 h after the operation to 31.5 mg every 4 h 16 h later (pentazocine). The majority of patients reported very positive experience with PCA. There were few side effects. Problems arose from the negative attitude of other doctors and the nursing staff, and from some misunderstandings.(ABSTRACT TRUNCATED AT 250 WORDS)

[Visual EEG analysis in controlling intravenous anesthesia using propofol]. / Visuelle EEG-Analyse zur Steuerung intravenöser Narkosen mit Propofol.

Since the discovery of brain waves by Berger, repeated efforts have been made to use the electroencephalogram EEG for monitoring and controlling anesthesia. Owing to its susceptibility to failure and the high expenditure regarding technology and personnel, the technique has not yet been adopted in routine anesthesia, however. In the study now reported an attempt was made to apply the positive experience with the recording and interpretation of EEG in the development of new anesthetic agents in the experimental laboratory, during routine clinical operations. The anesthetic used in the study was Propofol, an induction hypnotic that has only recently been introduced, together with nitrous oxide and repeated doses of fentanyl. Propofol is distinguished by its fast onset of action and short inactivation time; it is therefore suitable for induction and maintenance of anesthesia. The aim of the study was to maintain predetermined stages of sleep during anesthesia with the aid of visual on-line analysis of the EEG and to establish the dose of Propofol required for this purpose. The operations-general and orthopedic surgery-lasted 70-190 min (average duration: 120 min). In accordance with the randomization plan, the maintenance dose of Propofol was controlled in such a way that in ten patients light sleep levels (C0 to D1) and in the other ten deep sleep levels were maintained. The EEG was recorded via five active scalp electrodes (FP2, F4, C4, P4, O2) with reference to a joint electrode (A2). The stages of sleep were classified according to Kugler.(ABSTRACT TRUNCATED AT 250 WORDS)

[Beta activation following the intravenous administration of benzodiazepines and the specific antagonist flumazenil (Ro 15-1788)]. / Beta-Aktivierung nach intravenöser Gabe von Benzodiazepinen und dem spezifischen Antagonisten Flumazenil (Ro 15-1788).

In a prospective randomized study involving 32 male subjects aged 18 to 38, the effects of flunitrazepam (0.25 to 2 mg/70 kg), lormetazepam (0.5 to 4 mg/70 kg), midazolam (1.5 to 12 mg/70 kg) and diazepam (4 to 32 mg/70 kg) on the beta-activity (13 to 20/s) were investigated. Each subject received four benzodiazepine injections of increasing dosage. The doses were selected so that the lowest had only a slight effect on the test person's condition, while the highest resulted in deep sedation. The increase in beta-activity started off with a latency of 30 to 60 s; it was proportional to the dosage and reached its maximum between the 2. and 3. minutes. The subsequent decrease in beta-activity could be represented by an exponential function. The effect could be cancelled temporarily by administering repeated doses of the specific antagonist, flumazenil (0.1, 0.3 and 0.9 mg/70 kg). The method is suited for describing pharmacodynamic processes, determining equipotential doses of benzodiazepines and detecting the interaction between benzodiazepines and specific antagonists.

Six-year results of annual colonoscopy after resection of colorectal cancer.

Colonoscopy is an important diagnostic and therapeutic tool that may also be useful in the surveillance of patients after curative resection of colorectal cancer. The yield of colonoscopy and the frequency with which it should be performed after operation, however, have not been clearly defined. Over the past 10 years, we have examined these patients annually with colonoscopy or barium enema. This study evaluates the results of a specifically designed protocol that followed 174 patients. Counting all sites, colorectal cancer recurred in 57 of 174 patients, three-quarters within the first 24 months. Nine anastomotic recurrences were detected in the 12-30 month interval; none was reoperated for cure; however, 4 metachronous colon cancers were found and resected for cure. In addition, 30 polyps larger than 1 cm in size and 7 villous adenomas were removed in 30 patients. Combined, these findings represent an interval yield of 3-5% per year. Based on these results and other reports, we recommend that patients undergo colonoscopy annually at least for the first 6 years postresection of colorectal cancer. The detection of new primary tumors and possibly predisposing lesions becomes more important in these patients than detection and cure of recurrent disease.

Gait assessment of fixed ankle-foot orthoses in children with spastic diplegia.

OBJECTIVE: To evaluate the effectiveness of ankle-foot orthoses (AFOs) in spastic diplegic cerebral palsy patients for whom orthoses were indicated to control equinus or pes planovalgus deformities. DESIGN: A retrospective, cross-sectional assessment was performed on diplegic subjects who had suitable barefoot and AFO gait trials on the same day. PATIENTS: Thirty-five subjects with a mean age of 8.7 yrs were included. Eighteen wore braces to control equinus and 17 to control pes planovalgus and crouch. OUTCOME MEASURES: Gait data assessed in all subjects included temporal-distance factors and sagittal kinematics. Force plate data to determine joint moments and powers were obtained in 20. Repeated measures analysis of variance was used to compare across conditions and indications. RESULTS: The cohort demonstrated increased velocity (10 cm/sec; p < .001), stride length (10 cm; p < .001), and percent single-limb support (1.8%; p < .002) using AFOs compared with barefoot gait. In braces, ankle excursion was reduced (p < .0001), while pelvic, hip, and knee excursions were increased to account for the temporal changes (p < .009). Effects were similar in both indication groups. In neither indication group did the AFO significantly alter knee position in stance. Kinetic analysis showed a reduction of abnormal power burst (p < .05) in early stance and an increase in late stance ankle moment (p < .05) with AFOs. Differences in gait characteristics and bracing effects are shown for both indication groups. CONCLUSION: Compared with barefoot gait, AFOs enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature plantar flexion and improved progression of foot contact during stance. Effects on proximal joint alignment were not significant.

Fixation of titanium and hydroxyapatite-coated implants in arthritic osteopenic bone.

Retrieval studies of porous-coated prostheses have demonstrated deficient bony ingrowth in high percentages. Possible reasons for this are lack of initial mechanical stability and the presence of osteopenia. The authors studied ingrowth of osteopenic bone into titanium alloy (Ti) porous-coated implants with and without hydroxyapatite (HA) coating in an experimental dog model. Unilateral osteopenia of the knee with a 20% reduced bone density as judged by computed tomography (CT) scanning (P less than .001) was induced in 12 mature dogs by weekly intraarticular injections of Carragheenin into the right knee for 12 weeks, with the left knee serving as control. Ti porous-coated cylinders were inserted in press-fit bilaterally in the lateral femoral condyles in six dogs. HA-coated titanium plugs were implanted similarly in another sex-, age-, and weight-matched group of six dogs. Bony ingrowth after 4 weeks was significantly reduced for Ti implants in osteopenic bone compared to control bone, but HA-coated implants were covered by equal amounts of bone tissue. Bone-implant shear strength of Ti implants also was reduced in osteopenic bone compared to control bone. In control bone, the anchorage of Ti implants was stronger than HA-coated implants, whereas the fixation of Ti and HA-coated implants was equal in the osteopenic bone. The results demonstrate that the bony fixation of Ti porous-coated implants is weakened by the presence of experimentally induced osteopenia. However, the fixation of HA-coated implants was not affected by the osteopenic condition in the surrounding bone. The fixation of Ti and HA-coated implants was equal in osteopenic bone, whereas the fixation of Ti porous-coated implants was superior to that of HA-coated implants in control bone.

Gap healing enhanced by hydroxyapatite coating in dogs.

During prosthetic implantation, gaps between the implant surface and the surrounding bone may occur resulting in reduced implant stability. In these instances bone-conductive materials might augment the formation of hosting bone into the pores of the implant and insure earlier implant stabilization and fixation by bony ingrowth. Titanium-alloy cylinders with a porous-titanium-alloy plasma spray coating were implanted into the medial femoral condyles in six mature dogs. In another group of six dogs, matched in age, weight, and gender, hydroxyapatite (HA) coated implants were used. All implants were surrounded by a 1-mm gap. Unilateral osteopenia of the knee, with a 20% reduction of bone density as judged by computed tomography scanning, was induced by 12 weekly intraarticular injections of carrageenin into the right knee before surgery. Four weeks after implantation, the HA-coated implants were compared to the parent porous-titanium implants by mechanical testing and histomorphometry. A marked positive influence of HA coating on bone mineralization and the strength of the interfacial bone between the bone and implant was found. The increment in interface shear strength and shear stiffness was three- to fivefold in osteopenic bone and two-fold in control bone. Coating of an unloaded porous-titanium-coated implant with HA accelerates the rate of bone ingrowth and thereby provides relatively high, early interfacial shear strengths in the presence of an initial gap between bone and implant even in the presence of osteopenic host bone.

Physical bone changes in carragheenin-induced arthritis evaluated by quantitative computed tomography.

Repeated non-invasive measurements were performed in dogs of trabecular bone density (TBD), low density bone area (LDBA), and high density bone area (HDBA) in chronic arthritis using quantitative computed tomography (QCT). Unilateral chronic arthritis of the knee had been induced by weekly instillation of 2 ml carragheenin into the right knee joint for 12 weeks with the left knee serving as a control. CT scanning of the distal femoral condyles was performed in 12 mature dogs with chronic arthritis. Another 6 dogs underwent a longitudinal CT study starting immediately prior to induction of arthritis. During induction of arthritis TBD decreased (P less than 0.01), LDBA increased (P less than 0.05) and HDBA decreased (P less than 0.01) in the arthritic bone. Opposite changes were found on the control side, i.e. TBD increased (P less than 0.01), LDBA decreased (P less than 0.01) and HDBA increased (P less than 0.01). The chronic arthropathic bone showed 20% lower TBD (P less than 0.0001), greater LDBA (P less than 0.0001) and lower HDBA (P less than 0.0001) as compared with the control bone. Reproducibility tests of TBD showed a coefficient of variation of 0.8%. Indentation tests and histomorphometric analyses confirmed the bone density changes as measured by CT.