Reduction in the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven year prospective study.

The effect of occupational therapy for patients awaiting surgery for isolated osteoarthritis of the carpometacarpal joint of the thumb was assessed. Thirty-three patients awaiting joint replacement because of pain were randomised into three groups. One group was treated with technical accessories, two other groups had in addition one of two types of splints, and all patients received extensive advice on how to accommodate activities of daily living. They all had an initial seven months' trial on this regimen at which time 23/33 (70%) no longer required an operation. During the following seven years four patients died, but only two of the remaining 19 patients wanted an operation. We therefore recommend that patients with osteoarthritis of the carpometacarpal joint of the thumb are offered a similar programme in addition to access to accessories and splints preoperatively.

Scoring of extensive deep leg vein thrombosis displayed as wide-spread non-filling of contrast on phlebography. A comparison with colour doppler ultrasonography.

PURPOSE: To evaluate whether wide-spread non-filling of contrast in vein segments, displayed on phlebography, is interpreted as deep venous thrombosis (DVT) on colour Doppler ultrasonography (CDU) and if the same score value is obtained. MATERIAL AND METHODS: Twenty consecutive patients were analysed by both phlebography and CDU with a scoring system. RESULTS: One hundred and fifty-one venous segments were initially analysed, but 19 (12.6%) were excluded because their entire extent could not be interpreted by CDU. The total score was 366 (mean 18.3) according to the phlebograms and 298 (mean 14.9) when interpreted by CDU, p=0.0001. The difference was due mainly to the scoring of the anterior tibial vein found to be open on CDU in most cases, and then the thrombotic burden percentage was 84% and 75%, respectively. In 19 of the 20 patients (95%) a DVT was confirmed by CDU. The great saphenous vein, the femoropopliteal vein, and the deep femoral vein, formed the main collateral circulation. CONCLUSION: Wide-spread non-filling of vein segments is due to an extensive DVT in the vast majority of cases. Scoring is possible by both phlebography and CDU and the difference in the results of the scoring is generally of minor importance.

The amount of brainstem gliosis in sudden infant death syndrome (SIDS) victims correlates with maternal cigarette smoking during pregnancy.

Brainstem gliosis is elevated in some SIDS victims and has been associated with hypoxic-ischaemic events. Factors which increase the risk of SIDS include possible risk factors for hypoxic-ischaemic events during foetal and perinatal life. In this study a scoring system was developed whereby possible risk factors for hypoxic-ischaemic events during pregnancy, birth and in the perinatal period were correlated with the level of gliosis in the nucleus olivaris inferior in SIDS victims (n = 19). The mothers' antenatal care and obstetric records and the SIDS infants' perinatal hospital records were investigated, and each possible risk factor for hypoxic-ischaemic events was given one point. The points were summarized for each infant, and this sum was correlated with the level of gliosis in the infant's nucleus olivaris inferior. The number of cigarettes the mothers smoked during pregnancy was also compared with the level of gliosis. Our results show that in SIDS victims there is 41% probability that the more the mothers smoked during pregnancy, the more gliosis in the nucleus olivaris inferior is found in their infants (p < 0.01). Gliosis in the nucleus olivaris inferior also correlated with the possible risk factors for hypoxic-ischaemic events during pregnancy, birth and the perinatal period (r2 = 0.28, p < 0.05). However, if cigarette smoking was excluded as a possible hypoxic-ischaemic risk factor, no correlation was found.

[Should pethidine still be administered to women in labor?]. / Skal vi fortsatt gi petidin til fødende?

According to surveys from 1988, 1992 and 1996, Norwegian obstetric departments are still to a large extent using pethidine as birth analgesia. In this article we report recent knowledge of various pharmacological effects of pethidine in mothers and newborns. Pethidine has mainly a sedative effect, but very little analgesic effect in parturients. Pethidine has relatively long-acting behavioural and neurological effects in the newborn due to slow elimination. As a result, breastfeeding is delayed and the mother-infant interaction is disturbed according to recent studies. There is concern about the more or less routine administration of pethidine in many hospitals. We conclude that obstetric departments should reconsider their use of pethidine.

Breastfeeding in phenylketonuria.

Eighty-three infants with classical phenylketonuria have been born in Norway since 1979. The treatment of these children is centralized at the National Hospital in Oslo. Seventy-four have been breastfed in combination with a phenylalanine-free protein substitute. Dietary treatment was commenced in hospital between 5 and 33 d of age (mean 14 d). Normalization of serum phenylalanine (below 400 pmol/l) took between 1 and 35 d (mean 8 d). The period of breastfeeding lasted from 1 to 16 mo (mean 7 mo). Growth (weight, length and head circumference) fell within the normal range for age on the Norwegian growth chart.

4.5 year follow-up after surgical correction of upper extremity deformities in spastic cerebral palsy.

Reconstructive surgery was carried out on 27 upper extremities in 24 children with deformities due to spastic cerebral palsy. Functional evaluation of the affected extremities was made preoperatively, at 6 months and at a mean of 4.5 years postoperatively using a score added to the assessment system described by the Committee on Spastic Hand Evaluation. According to the score, dysfunction of the arm was significantly reduced 6 months after the reconstructive surgery and the improvements remained essentially unchanged at the later follow-up. The addition of a score to the original assessment system facilitated the overall assessment of postoperative results.

Hyperbaric oxygen treatment enhances regeneration of the rat sciatic nerve.

The effect of hyperbaric oxygen (HBO) treatment on regeneration of the rat sciatic nerve was studied. The sciatic nerve was crushed with a pair of pliers and the animals were either left untreated or subjected to a series of 45-min exposures to 100% O2 at 3.3 atm absolute pressure at 0, 4, and 8 h postoperatively and then every 8 h. Regeneration was evaluated using the pinch-reflex test at 3, 4, or 5 days following surgery and with neurofilament staining at 4 days. The regeneration distances at all time points were significantly longer in animals exposed to hyperbaric oxygen treatment independent of the evaluation procedure. A short initial period of the same HBO treatment schedule, with no more treatments after 25 h, appeared as effective as when treatments were maintained being given every 8 h until evaluation. We conclude that HBO treatment stimulates axonal outgrowth following a nerve crush lesion.

Smoking habits among pregnant women in Norway 1994-95.

AIMS: To investigate the smoking prevalence the last three months before pregnancy and at 18 weeks of gestation among women in Norway and to evaluate the impact of pre-pregnancy smoking habits, maternal age, level of education, civil status and parity on smoking cessation. MATERIAL AND METHODS: A prospective, multicenter survey. The study population included 4 766 pregnant women who attended a routine ultrasound examination at 18 weeks of pregnancy in six Norwegian hospitals during the period from September 1994 to March 1995. Smoking habits before and during pregnancy were recorded. RESULTS: The point prevalence of self-reported daily smoking among the women three months before the pregnancy was 34%. At 18 weeks of pregnancy, 21% of the women reported smoking daily (p<0.001). A multiple logistic regression analysis revealed that a low number of cigarettes smoked per day during the last three months before pregnancy was the best predictor for smoking cessation. Educational level, maternal age, parity and civil status were also statistically significant contributors to smoking cessation. Eighty percent of the women who were unable to stop smoking, reported a reduction in cigarette consumption. The mean number of cigarettes per day was reduced from 13.9 before pregnancy to 7.3 at 18 weeks of pregnancy (p<0.001). CONCLUSION: In a national survey, 21% of the pregnant women reported smoking daily in the second trimester. Thirty-eight percent of the women who were daily smokers before the pregnancy stopped smoking in early pregnancy. A low cigarette consumption prior to the pregnancy was the best predictor for smoking cessation.

Female gender and resistance to activated protein C (FV:Q506) as potential risk factors for thrombosis after elective hip arthroplasty.

Resistance to activated protein C (APC) caused by the R506Q mutation in factor V is the most common inherited risk factor for venous thrombosis. To elucidate whether APC-resistance is a risk factor for venous thrombosis after elective total hip replacement, the association between APC-resistance (presence of FV:Q506 allele) and postoperative thrombosis was investigated in patients (n = 198) randomised to received short (during hospitalisation, n = 100) or prolonged prophylaxis (three weeks after hospitalisation, n = 98) with low molecular weight heparin (LMWH). Among APC-resistant individuals receiving short prophylaxis, 7/10 developed thrombosis as compared to 2/12 receiving long prophylaxis (p <0.0179). Odds ratio for association between APC-resistance and thrombosis in the short prophylaxis group was 4.2 (CI 95% 1.02-17.5) (p <0.0465). Among those receiving prolonged prophylaxis, there was no increased incidence of thrombosis associated with APC-resistance. Two unexpected observations were made. One was that APC-resistance was much more common in women (19/109) than in men (3/89) (p <0.001). The other was that even women without APC-resistance were much more thrombosis-prone than men. Thus, 24/48 of women with normal FV genotype and short prophylaxis developed thrombosis vs 8/42 among men, p = 0.002. The increased risk of thrombosis associated with female gender and APC-resistance was neutralised by the prolonged treatment. In conclusion, among patients receiving short prophylaxis, female gender was found to be a strong risk factor for venous thrombosis. Even though APC-resistance appeared to be a risk factor for postoperative thrombosis, the uneven distribution of APC-resistance between men and women, taken together with the increased risk of thrombosis among women, precluded valid conclusions to be drawn about the association between APC-resistance and an increased risk of thrombosis. Our results suggest that prolonged prophylaxis with LMWH after hip surgery is more important for women than for men.

The post-discharge prophylactic management of the orthopedic patient with low-molecular-weight heparin: enoxaparin.

This prospective, double-blind trial was performed to determine whether 4 weeks' prophylaxis with enoxaparin after total hip replacement (THR) is more effective in protecting against deep vein thrombosis (DVT) than prophylaxis during hospitalization. Two hundred sixty-two patients undergoing THR were given enoxaparin 40 mg once daily during hospitalization (9 +/- 2 days) before being randomized at discharge to continue enoxaparin (N = 131) or receive placebo (N = 131) for a total of 1 month (30 +/- 4 days). According to intention-to-treat analysis, 43 DVT and 2 pulmonary emboli (PE) occurred in the placebo group (34.4%) versus 21 DVT and no PE in the enoxaparin group (P < 0.001). The reduction in proximal DVT was also significant (21.4 vs 6.1%; P < 0.001). No major bleeding complications developed. Prophylaxis with enoxaparin for one month significantly reduces venous thromboembolic disease in patients undergoing THR compared to conventional prophylaxis during hospitalization.

The post-discharge prophylactic management of the orthopedic patient with low-molecular-weight heparin: enoxaparin.

ABSTRACTThis prospective, double-blind trial was performed to determine whether 4 weeks' prophylaxis with enoxaparin after total hip replacement (THR) is more effective in protecting against deep vein thrombosis (DVT) than prophylaxis during hospitalization. Two hundred sixty-two patients undergoing THR were given enoxaparin 40 mg once daily during hospitalization (9 ± 2 days) before being randomized at discharge to continue enoxaparin (N=131) or receive placebo (N=131) for a total of 1 month (30 ± 4 days). According to intention-to-treat analysis, 43 DVT and 2 pulmonary emboli (PE) occurred in the placebo group (34.4%) versus 21 DVT and no PE in the enoxaparin group (P<0.001). The reduction in proximal DVT was also significant (21.4 vs 6.1%; P<0.001). No major bleeding complications developed. Prophylaxis with enoxaparin for one month significantly reduces venous thromboembolic disease in patients undergoing THR compared to conventional prophylaxis during hospitalization.

In situ microdialysis for monitoring of extracellular glutathione levels in normal, ischemic and post-ischemic skeletal muscle.

Microdialysis probes were inserted into the tibialis anterior muscle and into the femoral vein of anaesthetised Sprague-Dawley rats for monitoring of reduced (GSH) and oxidized (GSSG) extracellular glutathione. The dialysates were analysed using HPLC. The levels of GSH and GSSG were high immediately after implantation in the skeletal muscle and declined to steady state levels after 90 minutes into the same range as that found in the venous dialysate. Total ischemia was induced two hours after implantation of the dialysis probe after steady state levels had been reached. The extracellular levels of GSH increased during total ischemia and had doubled at the end of the ischemic period compared to preischemic values. During the following initial 30 minutes of reperfusion the levels increased further to four-fold the preischemic levels. The levels of GSSG also increased (100%) during the initial 30 minutes of reperfusion. The extracellular GSH levels remained elevated for 1 hour of reperfusion, but the GSSG levels returned to preischemic levels. The results indicate that intermittent hypoxia or anoxia in muscle tissue through hypoperfusion or ischemia decreases intracellular GSH stores by leakage, reducing the intracellular antioxidative capacity and increasing the risk for oxidative reperfusion injury upon final normalization of tissue blood supply.

Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement.

BACKGROUND: The risk of venous thromboembolism in patients undergoing total hip replacement is known to be high. However, the optimal duration of prophylaxis with anticoagulant agents after this procedure is unknown. We sought to determine whether one month of anticoagulant therapy with the low-molecular-weight heparin enoxaparin is more effective than enoxaparin therapy given only during the hospitalization for surgery. METHODS: Two hundred sixty-two patients undergoing total hip replacement received enoxaparin during their hospitalizations (average stay, 10 to 11 days). They were then randomly assigned to receive enoxaparin or placebo (131 patients each). Blinded outpatient therapy (or placebo) was continued long enough that the total treatment period, inpatient plus outpatient, was one month for each patient. Bilateral ascending phlebography was performed 19 to 23 days after discharge, with deep-vein thrombosis as the primary end point. Distal and proximal thrombosis, pulmonary embolism, and hemorrhage were also recorded, as were deaths. RESULTS: Venography was adequate in 116 patients in the placebo group and 117 in the enoxaparin group. We observed 43 episodes of deep-vein thrombosis and 2 episodes of pulmonary embolism in the placebo group, but only 21 episodes of deep-vein thrombosis and no episodes of pulmonary embolism in the enoxaparin group (incidence of thromboembolism, 39 percent and 18 percent, respectively; P<0.001). The difference in the incidence of proximal deep-vein thrombosis was also significant (24 percent and 7 percent in the placebo and enoxaparin groups, respectively; P<0.001). Six enoxaparin groups, respectively; P<0.001). Six patients in the enoxaparin group and one patient in the placebo group had hematomas at their injection sites. No patients died or had major complications. CONCLUSIONS: There were significantly fewer venous thromboembolic complications in patients undergoing elective hip replacement when prophylaxis with enoxaparin was given for a total of one month, rather than only during the hospitalization.

Altered glutathione levels in ischemic and postischemic skeletal muscle: difference between severe and moderate ischemic insult.

The purpose of the present study was to investigate how the duration of ischemia and reperfusion affect the glutathione (GSH) levels in skeletal muscle and to assess the presence of oxidative stress by quantitating oxidized glutathione (GSSG) and the ratio of GSSG/GSH. The amounts of GSH and GSSG were quantitated in the tibialis anterior muscle of the rat hind limb after 2 and 4 hours of tourniquet ischemia and after 1 and 5 hours of reperfusion, and the levels were compared to those in nonischemic control tibialis anterior muscles. In muscles subjected to 2 hours of ischemia, the levels of GSH, GSSG, and the ratio GSSG/GSH did not differ significantly from those of nonischemic controls. After 4 hours of ischemia without reperfusion, the GSH levels were slightly increased, compared to controls (p < 0.05). After 1 hour of reperfusion following 4 hours of ischemia, the levels of GSH decreased by 50% compared to control (p < 0.01), and still after 5 hours of reperfusion the levels of GSH were 50% lower than control levels. The GSSG/ GSH ratio did not change during 1 and 5 hours of reperfusion compared to control. A major finding in this study was that, during reperfusion after severe ischemia of 4 hours, there was a marked depletion of glutathione, which was not seen after a moderate ischemic insult of 2 hours.

Videoradiography of patients with habitual snoring and/or sleep apnea. Technical description and presentation of videoradiographic results during sleep concerning occurrence of apnea, type of apnea, and site of obstruction.

PURPOSE: The videoradiographic examination described was designed for habitual snorers and sleep apnea syndrome (SAS) patients and was performed during wakefulness and sleep. During wakefulness the purpose was to reveal any dysfunction in deglutition and speech as well as morphologic abnormalities. The purpose during sleep, which usually was induced by low-dose midazolam intravenously, was to reveal the site and form of obstruction in obstructive sleep apnea patients and the site of snoring in habitual snorers. MATERIAL: The preoperative results of 104 patients are presented. In 57 patients who had apneas, the occurrence and type of apnea could be determined. RESULTS AND CONCLUSION: A continuous recording over some minutes gave a rough estimate of the degree of SAS and mean duration of apnea. Although much information on SAS can be obtained by this method, it cannot replace polygraphic sleep recording in the investigation of habitual snorers and SAS patients. However, these 2 methods are complementary and can be performed simultaneously as polygraphic videoradiography.

Hyperbaric oxygen reduces ischemia-induced skeletal muscle injury.

The effect of hyperbaric oxygen treatment on skeletal muscle submitted to 3 or 4 hours of ischemia was studied in a rat hindlimb model after 48 hours of reperfusion. Forty-eight male Sprague-Dawley rats were allocated to four groups. In the two treatment groups, hyperbaric oxygen was given for 45 minutes at 2.2 atm immediately and 4,8,16,24,32, and 40 hours after release of the ischemia-inducing tourniquet. The injury to skeletal muscle was quantified from the uptake of 99mtechnetium-pyrophosphate (injected intravenously after 45 hours of reperfusion) in anterior tibial muscle harvested 3 hours later. The uptake was significantly lower in hyperbaric oxygen-treated rats than in untreated rats with 3 or 4 hours of ischemia (p < 0.01 and P < 0.05). After 4 hours of ischemia, the changes in levels of the intracellular muscle compounds adenosine triphosphate, phosphocreatine, and lactate were less in the hyperbaric oxygen-treated rats than in the untreated animals.

Hyperbaric oxygen treatment attenuates glutathione depletion and improves metabolic restitution in postischemic skeletal muscle.

Glutathione serves as an important intracellular defence against reactive oxygen metabolites and has been shown to be depleted from a number of tissues upon oxidative stress. In the present study we have investigated the levels of total glutathione (reduced + oxidized) in skeletal muscle of the rat after prolonged ischemia and reperfusion with and without treatment with hyperbaric oxygen (HBO) for the initial 45 minutes immediately following reperfusion. A tourniquet model for temporary, total ischemia was used, in which one hind leg was made ischemic for 3 or 4 hours. Muscle biopsies were taken after 5 hours of reperfusion. In postischemic muscle there was a significant decrease of total glutathione compared to control muscle, but in the 3-hour-ischemia-groups the loss of total glutathione was less in HBO treated animals than in untreated. HBO treatment also preserved ATP and PCr and decreased edema formation in the postischemic muscle following 3 hours of ischemia and reperfusion when compared to untreated animals. However, after 4 hours of ischemia, HBO treatment failed to improve any of these parameters in the postischemic muscle. Thus, our results demonstrate that HBO treatment lessens the metabolic, ischemic derangements and improves recovery in postischemic muscle after 3 hours of ischemia followed by reperfusion.