Use of local anesthesia for inguinal hernia repair has decreased over time in the VA system.

PURPOSE: In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials' level 1 evidence. METHODS: We used the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time-series design to examine the trend and rate of change of the use of local anesthesia. RESULTS: We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64-67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P < 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year. CONCLUSION: The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20 + years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.

Autoantibodies to nucleosomal proteins: antibodies to HMG-17 in autoimmune diseases.

The relative amounts of autoantibodies against defined nucleosomal proteins present in serums from patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and mixed connective tissue disease (MCTD) have been examined by an enzyme-linked immunoassay. Autoantibodies to nucleosomal proteins were detected in 45 percent of the patients with SLE, 18 percent of the MCTD patients, and none of the RA patients. The results suggest that, in SLE, antibodies are formed against a subset of nucleosomes which contain protein HMG-17.

Determinants of lung bacterial clearance in normal mice.

The determinants of the lung clearance of Streptococcus pneumoniae, Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus were studied in normal mice after exposure to an aerosol of viable bacteria and 99mTc-labeled dead bacteria. The fraction of bacteria in lungs that remained viable 4 h after exposure were: S. pneumoniae, 7.3%; K. pneumoniae, 121%; E. coli, 88.5%; S. aureus, 27.6%. The rate of physical removal of bacterial particles (Kmc) was determined from the change in lung 99mTc counts with time: Kmc ranged between 7 and 12%/h and and was similar in all species. The rate of mucociliary clearance and of intrapulmonary bacterial killing (Kk + Kmc) was calculated from the change in bacterial counts with time in animals that had received tetracycline to inhibit bacterial multiplication. Kk, the rate of intrapulmonary killing, was obtained by subtraction of Kmc from (Kk + Kmc). The calculated values for Kk were: S. pneumoniae, - 87%/h; K. pneumoniae, - 17%/h; E. coli, - 18%/h; S. aureus, - 22%/h. The rate of intrapulmonary bacterial multiplication (Kg) was estimated from the relationship of bacterial counts in tetracycline and nontetracycline-treated animals, assuming that tetracycline altered only Kg. Kg, expressed as the doubling time, was: S. pneumoniae, 310 min; K. pneumoniae, 217 min; E.coli, 212 min; S. aureus, infinity (no multiplication). The data indicate that the marked differences in the clearance of these species from the normal mouse lung result from the interaction of differing rates of in vivo bacterial multiplication and killing.

The association of congenital heart disease with necrotizing enterocolitis in preterm infants: a birth cohort study.

OBJECTIVE: To test the hypothesis that congenital heart disease (CHD) in preterm infants with severe CHD (cyanotic or left-sided obstructive lesions, or congestive heart failure) is independently associated with necrotizing enterocolitis (NEC, stage II or greater). STUDY DESIGN: Single-institution retrospective birth cohort of preterm infants with gestational age 23(0/7) to 34(6/7) weeks delivered between 1 January 2002 and 31 December 2011, excluding infants who received comfort care. Patients were classified into severe CHD, mild CHD and control groups. RESULTS: Among 4678 infants, 170 (3.6%) had CHD and 118 (2.5%) developed NEC. The risk for NEC increased with severe CHD (adjusted relative risk (RR)=3.72; 95% confidence interval (CI)=1.37 to 10.10) but not with mild CHD (RR=0.65; CI=0.27 to 1.55). CONCLUSION: In this cohort, severe but not mild CHD was independently associated with increased risk for NEC. This finding, if confirmed by other studies, may help identify patients at risk for NEC.

Long-term improvement in renal function after short-term strict blood pressure control in hypertensive nephrosclerosis.

Seventy-nine hypertensive nephrosclerosis patients entered a prospective randomized single-blind study to 1) establish the pattern of decay of renal function in this population and the variability therein and 2) to determine if strict diastolic blood pressure (DBP) control (less than or equal to 80 mm Hg) is more effective than conventional levels (90-95 mm Hg) in conserving renal function. Because of unexpected significant improvement in renal function in patients from both groups, which changed the perspectives on the course of this disease as described herein, this report is being published before completion of the trial. The selection criteria were 1) serum creatinine concentration of 1.6-7.0 mg/dl, 2) glomerular filtration rate of less than 70 ml/min/1.73 m2, and 3) absence of diseases (other than hypertension) known to destroy renal function. Renal function was assessed by glomerular filtration rate [( 125I]iothalamate clearance) and serum creatinine concentration. Before randomization, DBP was aggressively treated to reduce it to less than 80 mm Hg. Twenty-two subjects (14 in the strict DBP control group and eight in the conventional DBP control group) have been enrolled in the study for 36 months. In contrast to results from previous studies in humans and rats, renal function improved in both patient groups. Thus, irrevocable progression of renal damage after onset of renal failure from high blood pressure does not necessarily occur, and in fact, long-term improvement of renal function resulted from the effects of the study itself.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomized trial.

Hypertensive putaminal hemorrhage remains a major cause of hemorrhagic stroke carrying extremely high morbidity. Considerable controversy remains regarding the optimal form of therapy. Between 1983 and 1989 we conducted a prospective randomized trial with three treatment strategies: best medical management, best medical management plus intracranial pressure monitoring, and surgical evacuation. Only patients with significant deficit harboring a putaminal hematoma at least 3.0 cm in diameter were entered. The study was interrupted after 21 patients had been studied (9, best medical management; 4, intracranial pressure monitoring; and 8, surgical evacuation). No differences were found among groups for age, admission blood pressure, and time interval between onset of symptoms and arrival at hospital. None of the subjects were capable of returning to prestroke activity. Fifteen (71%) died or remained vegetative at 6 months, and only 4 (19%) were capable of independent life at home. Of the 9 patients in the best medical management arm, 7 were dead or vegetative. In the surgical group, 4 patients died and only 2 were capable of independent life. These results suggest that current medical and neurosurgical therapies remain ineffective in preventing the devastating neurologic consequences of hypertensive putaminal hemorrhage.

Magnetic resonance imaging of muscle in amyotrophic lateral sclerosis.

OBJECTIVE: To characterize leg muscle abnormalities in patients with ALS using MRI, and to correlate MRI with standard neurologic measures of motor neuron dysfunction. METHODS: Eleven ALS patients were studied twice (once at baseline and again after 4 months) and compared with eight normal control subjects. MRI data of the lower extremities were compared with tibialis anterior compound muscle action potential amplitude (CMAPa) and foot dorsiflexion maximal voluntary isometric contraction (MVIC). RESULTS: Muscle MRI was abnormal by visual inspection in six of 11 patients. The mean muscle T1 time and muscle volume were not different in patients compared with normal control subjects (p > 0.1). However, the mean T2 times were increased in the patients compared with normal control subjects (p = 0.009). T1 times did not correlate with CMAPa or MVIC. Muscle volume correlated with MVIC (r = 0.73 to 0.78, p < 0.02) but not with CMAPa (p > 0.05). There was a strong negative correlation (r < -0.8, p < or = 0.01) between muscle T2 time and MVIC and CMAPa. Also, the change in T2 relaxation time correlated with the change in CMAPa as the disease progressed (r = -0.63, p = 0.037). CONCLUSION: Of the MRI characteristics studied, T2 relaxation time was the best indicator of motor neuron dysfunction and may have a role in objective evaluation of motor neuron dysfunction.

Correction of hypocitraturia and prevention of stone formation by combined thiazide and potassium citrate therapy in thiazide-unresponsive hypercalciuric nephrolithiasis.

Thirteen patients with hypercalciuric calcium nephrolithiasis continued to form calcium stones when treated with thiazide (4.69 +/- 6.62 [mean +/- SD] stones per patient-year to 5.12 +/- 10.87 stones per patient-year), despite adequate hypocalciuric response (a reduction in urinary calcium levels from 303 +/- 119 mg per day to 193 +/- 88 mg per day, p less than 0.01). Because they had hypocitraturia (250 +/- 86 mg per day versus 643 +/- 236 mg per day in normal subjects, p less than 0.001), potassium citrate (10 to 20 meq three times per day) was added to the ongoing treatment program. During combined treatment with thiazide and potassium citrate, urinary pH significantly rose, and normal levels of urinary citrate were restored. Ten patients stopped forming new stones and all 13 had reduced stone formation rate. Thus, potassium citrate supplementation should be considered in patients requiring thiazide therapy for the control of hypercalciuric nephrolithiasis, especially if they have concurrent hypocitraturia or if it develops during thiazide therapy.

Prevention of acute cyclosporine-induced renal blood flow inhibition and improved immunosuppression with verapamil.

Pretreatment with calcium antagonists such as verapamil (VP) and isradipine prevents CsA-induced decrease in renal microcirculation in mice. Recently, in posttransplant cadaver renal transplant (CRT) recipients, we demonstrated a CsA-induced 70% reduction in renal parenchymal diastolic blood flow velocity (PDBFV). Using duplex Doppler scanning, this randomized study of forty CRT patients examines the effect of pretreatment with VP on renal blood flow velocity and posttransplant function. Patients with initially low PDBFV (less than 8.0 cm/sec) who received VP therapy prior to administration of CsA experienced prompt restoration of flow, and continued to improve during CsA administration. With CsA alone, PDBFV diminished from 8.9 +/- 2.4 (SD) to 5.3 +/- 2.7 cm/sec (P less than 0.002). Although blood CsA levels were significantly higher at 1, 4, and 7 days (68, 184, and 235 ng/ml, respectively), after CsA induction, during VP treatment than in control patients (39, 105, and 156 ng/ml, respectively) (P less than 0.001), with the same daily doses of CsA, serum creatinines at day 7 were lower during VP treatment (1.28 +/- 0.44 vs. 1.66 +/- 0.44 mg%) than in controls (P less than 0.01). When the glomerular filtration rate was less than 45 ml/min on day 1. VP-treated patients showed greater improvement in GFR at day 7 by 34.1 +/- 10.9 ml/min compared with the 18 +/- 13 ml/min in controls (P less than 0.02). Only 3 of the 22 VP patients had rejection episodes within 4 weeks, versus 10 of the 18 recipients randomized to no drug (P less than 0.005). We conclude that VP is beneficial in CRT because it improves renal blood flow characteristics and prevents CsA-induced inhibition of blood flow. VP also ameliorates CsA-induced acute nephrotoxicity, and is associated with improved immunosuppression and fewer early rejections.

Aid to the evaluation of therapeutic studies.

Physicians are often faced with conflicting recommendations from therapeutic studies. An evaluation form is proposed to facilitate the evaluation of the quality of therapeutic studies and the resulting treatment or management recommendations in any area of medicine. Twelve major topics for evaluation include sample size determination, randomization, selection of control group(s), "blinding," and support for treatment recommendations. Emphasis is placed on study design and performance rather than data analysis. Thirty-four primary criteria based on accepted research standards are designated as most important, and examples from the literature are provided to illustrate their use. The form provides a comprehensive set of well-accepted standards of research in a format that encourages detailed, consistent, and thoughtful evaluation of therapeutic studies. The evaluation form is recommended as a tool for physicians who wish to develop and exercise skill in evaluating therapeutic studies.

The effect of acetazolamide on regional cerebral blood flow in normal human subjects as measured by single-photon emission computed tomography.

Regional cerebral blood flow (rCBF) was evaluated in 15 normal, healthy volunteer control subjects before and after the administration of 1 g acetazolamide (ACZ) using a rotating four-detector single-photon emission computed tomograph (SPECT). ACZ, a carbonic anhydrase inhibitor, is a cerebral vasodilator. RCBF values in mL/minute/100 g were derived within eight cortical regions of interest (ROI), and from the whole slice as an expression of whole brain blood flow (WBF). ROI/WBF ratios were established for each ROI in each of the 15 subjects for both pre-ACZ and post-ACZ studies. ACZ produced a 30% +/- 17% increase in WBF. Studies were done in random order, with nine subjects undergoing the post-ACZ study first, and six the pre-ACZ, or baseline, study first. Statistical analysis showed no significant difference in any ROI that might be caused by sequence of test procedures. Ratios were then examined to determine whether rCBF elevation was proportionate in all ROI in all subjects. No significant difference was found in any ROI except for the left parietal, for which marginally significant change was identified. Subjects also were examined for possible age and sex differences in ACZ response, and no differences were found.

The effect of acetazolamide on regional cerebral blood flow in patients with Alzheimer's disease or stroke as measured by single-photon emission computed tomography.

Regional cerebral blood flow (rCBF) was assessed in 35 patients with possible or probable Alzheimer's disease (AD) and in 16 patients known to have had at least one stroke. Patients were evaluated before and after the administration of 1 g acetazolamide (ACZ) by means of a rotating four-detector single-photon emission computed tomograph (SPECT) and inhaled Xe-133. RCBF values in mL/minute/100 g were derived from eight cortical regions of interest (ROI), and from the whole transverse section as a measure of whole brain flow (WBF). ROI/WBF ratios were calculated for each ROI in paired determinations done before and 15 minutes after the administration of ACZ. Results were compared with those previously obtained in a study of 15 normal, healthy volunteer subjects. ROI/WBF ratios greater than 2 standard deviations (SD) below the mean for a given ROI in the normal group were regarded as probably abnormal, whereas ratios greater than 4 SD below the mean were considered definitely abnormal. After ACZ administration, the number of ROI greater than 2 SD below the normal mean decreased significantly in the AD group and was unchanged in the stroke patients. However, the number of ROI/WBF ratios greater than 4 SD below the normal mean fell in the AD group and rose in the stroke group, with the difference in behavior highly statistically significant. Thus, the response of low-flow areas to ACZ differs in AD and in stroke, which could be of ultimate diagnostic significance.

Clinical measures of gestational age in normal pregnancies.

Obstetric findings in 89 healthy women were evaluated prospectively by one obstetrician unaware of menstrual history. With weekly examinations, fetal heart tones were audible by fetoscope at 17.1 +/- 1.1 weeks' gestation (mean +/- SD) and the fundus reached the umbilicus at 16.6 +/- 0.9 weeks. At 20 to 31 weeks, fundal height in centimeters equaled weeks' gestation (confidence interval: +/- 3 weeks). The accuracy of predicting delivery date from combined findings (SD: 11.4 days) approached that from reliable menstrual history (SD: 10.2 days). Gestational age at delivery minus the pediatric Dubowitz estimate was 0.4 +/- 1.7 weeks. Gestational age may be overestimated by up to six weeks by assuming that the fundus reaches the umbilicus or that fetal heart tones appear at 20 weeks. However, carefully derived obstetric estimates potentially may be more reliable than pediatric estimates.

A paired controlled study of vaginal and abdominal delivery of the low birth weight breech fetus.

In a paired, controlled, retrospective study, 44 low birth weight breech fetuses delivered vaginally were compared with 44 breech fetuses delivered by cesarean section. Seven deaths occurred in the vaginal delivery group, compared with only 1 in the abdominal delivery group. Asphyxia, trauma, and intracranial hemorrhage were also found more frequently among vaginally delivered fetuses. The authors conclude that for the low birth weight breech fetus, delivery by cesarean section is preferable.

Proposed cutoff values to define bladder outlet obstruction in women.

OBJECTIVES: There is no accepted urodynamic definition of outlet obstruction in women. Currently, the diagnosis is made on the basis of history and radiographic and endoscopic findings. The goal of this study is to design a pressure-flow nomogram (PdetQmax/Qmax) and define cut-off values for obstruction. METHODS: Two groups were studied prospectively in an open study: 124 control and 35 clinically obstructed patients. All had a complete history, physical examination, normal neurologic evaluation, cystoscopy, voiding cystography, and urodynamics-with-pressure-flow study. Pressure-flow plot and receiver operator characteristic curves (ROCs) were constructed to determine optimal cut-off values to predict obstruction for peak flow rate (Qmax) and detrusor pressure at maximal flow (PdetQmax). RESULTS: The etiology of obstruction was previous anti-incontinence surgery (n = 13), large cystocele (n = 11), urethral stricture (n = 6), and other (n = 5). On the basis of ROC curves, using cut-off values of Qmax of 15 mL/s or less and 12 mL/s or less, sensitivity was 85.7% and 71.4%, and specificity 78.2% and 90.3%, respectively. Using cut-off values of PdetQmax of more than 25 and more than 30 cm H2O, sensitivity was 74.3% and 71.4%, and specificity 79.8% and 88.7%, respectively. Using a combined cut-off value of Qmax of 1 5 mL/s or less and PdetQmax of more than 20 cm H2O, sensitivity was 74.3% and specificity was 91.1%. CONCLUSIONS: Based on this prospective, controlled study, preliminary cut-off values were obtained for refining the definition of outlet obstruction in women.

The effects of etomidate on cerebral metabolism and blood flow in a canine model for hypoperfusion.

The effects of etomidate, a nonbarbiturate cerebral metabolic depressant, on cerebral metabolism and blood flow were studied in 29 dogs during cerebral hypoperfusion. Three groups of animals were studied during a 45-minute normotensive and a 30-minute hypotensive period: 10 control animals without etomidate, 11 animals receiving a 0.1-mg/kg etomidate bolus followed by an infusion of 0.05 mg/kg/min etomidate (low-dose group), and eight animals receiving doses of etomidate sufficient to suppress electroencephalographic bursts (high-dose group). The mean arterial pressure fell to similar levels (p less than 0.05) during hypotension in all three groups (40 +/- 5, 38 +/- 3, and 27 +/- 6 mm Hg, respectively). The mean cerebral oxygen extraction fraction rose (p less than 0.05) from 0.23 +/- 0.02 to 0.55 +/- 0.08 in the five control animals tested and from 0.33 +/- 0.02 to 0.53 +/- 0.02 in the seven animals tested in the low-dose group, but did not increase (p greater than 0.05) in the four animals tested in the high-dose group (0.24 +/- 0.03 to 0.23 +/- 0.05). Mean cerebral blood flow levels decreased in all groups during hypotension (p less than 0.05): 42 +/- 3 to 21 +/- 4 ml/100 gm/min (52% +/- 12% decrease) in the five animals tested in the control group, 60 +/- 8 to 24 +/- 6 ml/100 gm/min (56% +/- 13% decrease) in the four animals tested in the low-dose group, and 55 +/- 8 to 22 +/- 3 ml/100 gm/min (60% +/- 4% decrease) in the four animals tested in the high-dose group. In summary, the cerebral oxygen extraction fraction increased in the control animals and low-dose recipients during hypotension, suggesting the presence of threatened cerebral tissue. In contrast, the cerebral oxygen extraction did not change during hypotension when high-dose etomidate was administered. It is concluded that high-dose etomidate may preserve the cerebral metabolic state during hypotension in the present model.

Effects of medial meniscectomy in patients older than forty years.

Forty-nine of the sixty-five consecutive patients who were more than forty years old when medial meniscectomy was performed returned for follow-up evaluation one to twelve years postoperatively. Pain was present in 62.2 per cent of the patients with so-called degenerative tears and in 75 per cent of those with so-called traumatic tears. The medial joint space was significantly thinner in the patients with degenerative tears than in those with traumatic tears. The roentgenographic findings of osteoarthritis were significantly more severe on the side operated on. The femorotibial angle was always in relatively more varus angulation on the involved side (mean, 5.3 degrees) than on the uninvolved side.

Do weighted nasoenteric feeding tubes facilitate duodenal intubations?

A widely held assumption is that postpyloric intubations occur more often with weighted than with unweighted nasally inserted feeding tubes. This randomized, prospective study compared the frequency of duodenal intubations using weighted and unweighted nasoenteric feeding tubes. One hundred sixteen patients had either weighted (61 patients) or unweighted (55 patients) 10F silicone elastomer feeding tubes inserted nasally 85 cm. Tubes were placed with wire stylets. Tube positions were verified radiographically within 4 hr after insertions. Radiographs were repeated daily for 3 days or until duodenal intubation occurred. Successful duodenal intubations were achieved in 35 patients (57%) with weighted feeding tubes and in 37 patients (67%) with unweighted feeding tubes. This difference was not significant. Weighted nasoenteric feeding tubes offer no advantage over unweighted tubes in achieving duodenal intubations.

Microvascular invasion in cancer of the oral cavity and oropharynx.

The presence of squamous cell carcinoma within capillaries and/or venules in the immediate vicinity of primary lesions of the oral cavity and oropharynx may be related to regional lymph node metastasis. To evaluate this possibility, we have reviewed the clinical and histopathologic features of 43 consecutive cases of previously untreated T2 or greater squamous cell carcinoma of these sites managed with simultaneous surgical treatment of the primary neoplasm and the neck. The incidence of histologically proved cervical metastasis for all lesions with vascular invasion compared with those without vascular involvement was highly significant. No statistical correlation was found for the clinical stage of neck disease or for the other pathologic features of the primary tumor, ie, size, appearance, differentiation, depth of invasion, periphery of lesion, inflammatory infiltrate, and perineural invasion, when compared with the histopathologic status of regional lymph nodes.

Conservation of the hypopharyngeal mucous membrane in total laryngectomy.

Dysphagia secondary to partial pharyngeal stenosis after total laryngectomy is most likely attributable to the size of the reconstructed lumen. To reduce the incidence of this postoperative complication, we have utilized a modification of total laryngectomy that conserves the hypopharyngeal mucous membrane. The results of this surgical procedure are now reported in the context of two similar, contemporaneous groups of patients who underwent either standard wide-field laryngectomy or hypopharyngeal mucosa conservation laryngectomy. Statistical analysis showed no difference between groups in cancer control (P = .80) or survival (P = .65); whereas the group treated with hypopharyngeal conservation laryngectomy had significantly less pharyngeal stenosis as measured by dysphagia and need for dilatation (P = .011).