Correlation of bupivacaine 0.5% dose and conversion from spinal anesthesia to general anesthesia in cesarean sections.

BACKGROUND: Failed spinal anesthesia for cesarean sections may require conversion to general anesthesia. The aim of this study was to determine whether the administered spinal bupivacaine dose for performing a cesarean section under spinal anesthesia was related to the conversion rate to general anesthesia. METHODS: Retrospective analysis was performed on 1252 electronic data and file of patients who underwent a cesarean section under spinal anesthesia between 2004 and 2011. RESULTS: In 15 patients, spinal anesthesia was converted into general anesthesia due to block failure. Patients in whom a bupivacaine dose of 8 mg or smaller was administered had significantly higher conversion rate (3/61 (4.9%) patients and 12/1191 (1.0%) patients, respectively; p < 0.05.). The relative risk of conversion with a 8 mg dose or lower is 4.88 (95% CI 1.41 - 16.85). CONCLUSION: This retrospective study shows that a low dose administration a bupivacaine 0.5% for spinal anesthesia in cesarean section patients elicits significantly more frequent conversion to general anesthesia.

Ultrasound-guided needle handling using a guidance positioning system in a phantom.

The SonixGPS™ needle guidance positioning system provides navigation assistance to facilitate needle handling during ultrasound-guided procedures. Each of 20 inexperienced nurse anaesthetists performed 12 different ultrasound-guided tasks in a porcine phantom. Using both in-plane and out-of-plane approaches, they inserted a needle and made contact with metal rods at depths of 2, 4 and 6 cm. We compared their performances without and with navigation as paired observations. Using the out-of-plane approach, navigation yielded shorter execution times (26 s vs 14 s, respectively; p = 0.01) and fewer needle repositionings (8 vs 3, respectively; p = 0.001). Using the in-plane approach, the needle was more visible with navigation assistance: 24% vs 52% of execution time, respectively (95% CI: 44%-12%; p = 0.0025). Better needle visibility was associated with shorter execution times and fewer needle repositionings. Combining ultrasound-guided techniques with the needle guidance positioning system may reduce tissue manipulation, thus improving patient comfort and safety.

Patient state index vs bispectral index as measures of the electroencephalographic effects of propofol.

BACKGROUND: The patient state index (PSI) and the bispectral index (BIS) quantify anaesthetic depth based on the EEG using different algorithms. We compared both indices with regard to the prediction of the depth of propofol anaesthesia. METHODS: In 17 patients, propofol was infused until burst suppression occurred and stopped thereafter until BIS recovered to values above 60. This was repeated; afterwards, patients were intubated, for subsequent surgery. Without surgical stimulus, PSI and BIS were measured simultaneously and compared with the estimated effect-site concentrations of propofol. These were derived from simultaneous pharmacokinetic and -dynamic modelling in an individual two-stage and a population-based NONMEM approach. RESULTS: A close sigmoid relationship was observed between the propofol effect-site concentration and both PSI [coefficient of determination rho(2)=0.91 (sd 0.05)] and BIS [rho(2)=0.92 (0.03)], which was significantly steeper for PSI [gamma=2.2 (0.6)] than for BIS [gamma=1.8 (0.4)], and reached significantly lower values for PSI [E(max)=0.3 (1.1)] than for BIS [E(max)=5.3 (6.7)] at maximal propofol concentrations. A significantly smaller k(e0) was obtained for PSI [0.09 (0.03) min(-1)] compared with BIS [0.10 (0.02) min(-1)]. PSI and BIS correlated significantly with each other (rho(2)=0.866) and predicted propofol effect-site concentration with a comparable probability [P(K)=0.87 (0.05) and 0.86 (0.05), respectively]. NONMEM revealed E(0)=89.3 and 92.3, E(max)=1.9 and 8.6, C(e50)=1.38 and 1.92 microg ml(-1), gamma=1.6 and 1.48, and k(e0)=0.103 and 0.131 min(-1) as typical values for PSI and BIS, respectively. CONCLUSIONS: The PSI and the BIS monitors performed equally well in predicting depth of propofol anaesthesia. However, PSI was lower than BIS by approximately 10-15 points at high propofol concentrations.

Peyote alkaloids: identification in a prehistoric specimen of lophophora from coahuila, Mexico.

Mescaline, anhalonine, lophophorine, pellotine, and anhalonidine have been identified in alkaloid extracts of a prehistoric specimen of Lophophora from a burial cave in west central Coahuila, Mexico. The specimen is associated with radiocarbon dates of A.D. 810 to 1070 and is one of the oldest materials ever submitted to alkaloid analysis.

Real-time PCR detection and quantification of fish probiotic Phaeobacter strain 27-4 and fish pathogenic Vibrio in microalgae, rotifer, Artemia and first feeding turbot (Psetta maxima) larvae.

AIMS: To develop a SYBR Green quantitative real-time PCR protocol enabling detection and quantification of a fish probiotic and two turbot pathogenic Vibrio spp. in microcosms. METHODS AND RESULTS: Phaeobacter 27-4, Vibrio anguillarum 90-11-287 and Vibrio splendidus DMC-1 were quantified as pure and mixed cultures and in presence of microalgae (Isochrysis galbana), rotifers (Brachionus plicatilis), Artemia nauplii or turbot (Psetta maxima) larvae by real-time PCR based on primers directed at genetic loci coding for antagonistic and virulence-related functions respectively. The optimized protocol was used to study bioencapsulation and maintenance of the probiont and pathogens in rotifers and for the detection and quantification of Phaeobacter and V. anguillarum in turbot larvae fed rotifers loaded with the different bacteria in a challenge trial. CONCLUSIONS: Our real-time PCR protocol is reproducible and specific. The method requires separate standard curve for each host organism and can be used to detect and quantify probiotic Phaeobacter and pathogenic Vibrio bioencapsulated in rotifers and in turbot larvae. SIGNIFICANCE AND IMPACT OF THE STUDY: Our method allows monitoring and quantification of a turbot larvae probiotic bacteria and turbot pathogenic vibrios in in vivo trials and will be useful tools for detecting the bacteria in industrial rearing units.

Soft tissue landmark for ultrasound identification of the sciatic nerve in the infragluteal region: the tendon of the long head of the biceps femoris muscle.

BACKGROUND AND OBJECTIVES: The sciatic nerve block represents one of the more difficult ultrasound-guided nerve blocks. Easy and reliable internal ultrasound landmarks would be helpful for localization of the sciatic nerve. Earlier, during ultrasound-guided posterior approaches to the infragluteal sciatic nerve, the authors recognized a hyperechoic structure at the medial border of the long head of biceps femoris muscle (BFL). The present study was performed to determine whether this is a potential internal landmark to identify the infragluteal sciatic nerve. METHODS: The depth and the thickness of this hyperechoic structure, its relationship with the sciatic nerve and the ultrasound visibility of both were recorded in the proximal upper leg of 21 adult volunteers using a linear ultrasound probe in the range of 7-13 MHz. The findings were verified by an anatomical study in two cadavers. RESULTS: The hyperechoic structure at the medial border of the BFL extended in a dorsoventral direction between 1.4+/-0.6 cm (mean+/-SD) and 2.8+/-0.8 cm deep from the surface, with a width of 2.2+/-0.9 mm. Between 2.6+/-0.9 and 10.0+/-1.5 cm distal to the subgluteal fold, the sciatic nerve was consistently identified directly at the ventral end of the hyperechoic structure in all volunteers. The anatomical study revealed that this hyperechoic structure corresponds to tendinous fibres inside and at the medial border of the BFL. CONCLUSION: The hyperechoic BFL tendon might be a reliable soft tissue landmark for ultrasound localization of the infragluteal sciatic nerve.

[Target-controlled infusion. Clinical relevance and special features when using pharmacokinetic models]. / "Target-controlled infusion". Klinische Relevanz und Besonderheiten im Umgang mit pharmakokinetischen Modellen.

Since its commercial introduction in 1996, target-controlled infusion (TCI) has become an established technique for administration of intravenous anaesthetics. Modern TCI systems, however, are characterized by an increasing number of additional options and features, such as the choice between different pharmacokinetic models and modes of application, which may confuse the less experienced user. This review describes the differences between pharmacokinetic models, modes of application and the effect of covariates as well as the consequences for dosing. The aim is to explicate for the user of modern TCI systems the underlying scientific concepts and the relevance for clinical practice.

Visualization of the course of the sciatic nerve in adult volunteers by ultrasonography.

BACKGROUND: The sciatic nerve block by the posterior approaches represents one of the more difficult ultrasound-guided nerve blocks. Our clinical experiences with these blocks indicated a point slightly distal to the subgluteal fold as an advantageous position to allow good ultrasonic visibility. In this study, we systematically scanned the sciatic nerve from the subgluteal fold to the popliteal crease, to determine an optimal point for ultrasonographic visualization. METHODS: After institutional approval and written informed consent, we recruited 15 volunteers to visualize the sciatic nerve from the subgluteal fold to the popliteal crease using a linear ultrasound probe in the range of 7-13 MHz. The ultrasonographic visibility of the sciatic nerve, nerve diameter (width and thickness), and skin-to-nerve distance at 20 equidistant points between the subgluteal fold and the popliteal crease were recorded. RESULTS: The sciatic nerve could be successfully visualized in cross-section as a hyperechoic structure on ultrasound in all volunteers. In the course from subgluteal to the popliteal area, the shape of the sciatic nerve changed from flat to round, while the skin-nerve distance varied with the smallest skin-nerve distances at the popliteal crease and at 5.4 cm (on average) distal to the subgluteal fold. The best ultrasonographic visibility scores were found between 7.2 and 10.8 cm (on average) distal to the gluteal fold. CONCLUSION: Between 5.4 and 10.8 cm from the subgluteal fold seems to be the best area to scan the sciatic nerve in terms of superficial nerve position and good ultrasonic visibility.

A needle guidance device compared to free hand technique in an ultrasound-guided interventional task using a phantom.

In this in vitro study, a needle guidance device and a 'free hand' technique for ultrasound guided needle insertion were compared in a simulated ultrasound-guided interventional task using a porcine phantom. Residents inexperienced in using ultrasonography were asked to insert a needle, using an in-plane techniques, and to make contact with metal rods at a depth of 2 and 4 cm in the phantom. The transducer made angles of 90 degrees, 60 degrees and 45 degrees with the surface of the phantom. The times to perform the procedures were significantly shorter and the needle visualisation was significantly better when using the needle guidance device. The residents ranked their satisfaction with the needle-guidance device significantly better than the 'free-hand' technique. This device may be beneficial when performing ultrasound guided peripheral nerve blocks, especially by inexperienced operators.

Mitochondrial genetics in a natural population of the plant pathogen armillaria.

Transmission and propagation of mitochondrial genotypes in fungi have not been previously investigated in the field. This study examined the distribution of nuclear and mitochondrial genotypes in a natural, local population of the fungal (Basidiomycetes) root-rot pathogen, Armillaria. Six vegetative clones, ranging in size up to 635 m, were identified on the basis of mating-type alleles. Mitochondrial DNA (mtDNA) restriction fragment patterns indicated that each vegetative clone has one, unique mtDNA type. However, as in other basidiomycetous fungi, biparental transmission of mitochondria following laboratory matings of sexually compatible haploid isolates of Armillaria resulted in a uniformly diploid mycelium that was a mosaic for both parental mitochondrial types. Therefore, either matings between monosporous, haploid isolates are uncommon in nature, or when mating does occur, cytoplasmic markers of one partner predominate during subsequent vegetative growth.

Should health systems agencies be involved in environmental health planning?

Public Law 93-641 provides health systems agencies (HSAs) with a broad planning preview which has enabled a number of agencies to address environmental health issues in their health systems plans. Opponents of HSA involvement in environmental health planning charge that these activities overextend agency resources, duplicate efforts of other government agencies and involve HSAs in "issues of public policy." Closer examination of these charges finds them lacking in validity. The planning activities of health systems agencies are cooperative in nature, drawing upon the planning efforts of other institutions and agencies. It is illogical to exclude environmental concerns from general health planning in light of the impact of the environment upon health. Charges that issues of public policy are inappropriate topics for health planning are seen as attempts to avoid scrutiny of inconsistant legislative policies. Cooperative planning between health systems agencies and environmental health agencies is considered both desirable and essential for the development of effective health planning.

Effect of human corticotropin-releasing hormone on gonadotropin secretion in cycling and postmenopausal women.

OBJECTIVE: To test the hypothesis that corticotropin-releasing hormone (CRH) is linked to stress-associated reproductive dysfunction in the human by determining if the administration of human corticotropin-releasing hormone (hCRH) results in an inhibition of gonadotropin secretion. DESIGN: Twenty-four-hour prospective study with frequent (every 10 minutes) blood sampling. SETTING: University Clinical Research Center. INTERVENTIONS: Sequential 8-hour infusions of normal saline, hCRH (1 to 5 micrograms/kg per hour), and hCRH plus naloxone (2 mg/h). SUBJECTS: Four normal cycling women and four postmenopausal women. MAIN OUTCOME MEASURES: Plasma luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), and adrenal and ovarian steroids. RESULTS: In response to hCRH, a prompt and sustained rise in cortisol (F) was noted in both normal cycling women and postmenopausal women. No inhibition of LH or FSH was noted during either the hCRH or hCRH plus naloxone infusion in either group of women. Unexpectedly, elevations in the mean LH peak amplitude and the transverse mean LH concentration were noted in the postmenopausal women during the infusion of hCRH as compared with saline. The infusion of hCRH had no apparent effect on concentrations of PRL, FSH, and gonadal and adrenal steroids (except for F). CONCLUSIONS: Under these conditions, intravenously administered hCRH has no inhibitory effect on gonadotropin secretion in either premenopausal or postmenopausal women. The mechanism by which stress exerts its deleterious effect on reproductive function in the human remains unknown.

Molecular epidemiology of coagulase-negative staphylococcal bacteraemia in a newborn intensive care unit.

We isolated 55 coagulase-negative staphylococci (CoNS) over two separate 12-month periods (26 in 1993 and 29 in 1996) from the blood of neonates in a neonatal intensive case unit (NICU) in Melbourne, Australia and compared them by pulse-field gel electrophoresis profile (PFGE), random amplification of polymorphic DNA (RAPD) and antibiogram. The most common species were Staphylococcus epidermidis, S. haemolyticus and S. warneri. The majority of such isolates were resistant to penicillin and to either or both of methicillin and gentamicin. During 1993, there was an increase in the number of CoNS bloodstream infections compared with previous years. S. epidermidis was the most common isolate, with 88% assessed as clinically relevant. Using the three typing systems, we identified one likely epidemic clone of S. epidermidis, the isolates of which were resistant to penicillin, gentamicin and erythromycin and possessed the mecA gene. There was complete correlation between the detection of mecA and the phenotypic expression of resistance when zone diameters in the disc diffusion assay were interpreted according to the latest NCCLS guidelines (1999). Profiles of the remaining 1993 isolates were generally heterogeneous, suggesting independent acquisition with some evidence of cross-infection. The predominant bloodstream isolates in 1996 were heterogeneous multi-resistant strains of S. epidermidis, S. haemolyticus and S. warneri, about half of which were assessed as clinically relevant. These data support the view that CoNS are significant nosocomial pathogens in NICU and that resistant clones may be transmitted between babies. Molecular epidemiological tools are helpful for understanding transmission patterns and sources of infection, and are useful for measuring outcomes of intervention strategies implemented to reduce nosocomial CoNS sepsis. PFGE was found to be more discriminatory than RAPD, but the latter provides results in a more timely manner.

The house officer and the dying patient: attitudes, experiences, and needs.

A survey of house staff who care for dying patients was conducted at a large medical center and demonstrated that house officers are aware of their discomfort in dealing with dying patients and their families but believe they do not avoid them. They strongly agreed with the use of the "no code' designation and believed the quality of life was the most important factor in making that decision. The house officer who has concerns about a dying patient is most likely to talk with another house officer. The survey highlights the needs of house staff for experienced resource people and informal programs dealing with the care of dying patients.

Gynostemma pentaphyllum: identification of major sapogenins and differentiation from Panax species.

Four main dammarane-type aglycones of gypenosides, extracted from the aerial parts of Gynostemma pentaphyllum were identified by gas chromatography-mass spectrometry. By detecting these aglycones as well as the aglycones of ginsenosides, a difference in sapogenin composition between Gynostemma pentaphyllum and Panax species was observed, which can be used in the differentiation of these plant drugs.

Adhatoda vasica: a critical review of ethnopharmacological and toxicological data.

Adhatoda vasica (L.) Nees is a well-known plant drug in Ayurvedic and Unani medicine. It has been used for the treatment of various diseases and disorders, particularly for the respiratory tract ailments. During the last 20 years, several scientific reports on oxytocic and abortifacient effects of vasicine and alkaloid derived from the plant have appeared. This leads to questions concerning the safety of A. vasica as a herbal medicine. In this article, the major data on traditional uses as well as ethnopharmacological and toxicological studies, both published and unpublished, are reviewed and commented upon. The data have been evaluated from the point of view of correctness, reliability, relevance and importance for the overall evaluation of the safety of A. vasica.

Was opium known in 18th dynasty ancient Egypt? An examination of materials from the tomb of the chief royal architect Kha.

Examination by microscopy, thin-layer chromatography, gas-liquid chromatography alone and combined with mass spectrometry, and radioimmunoassay methods of materials from the tomb of the ancient Egyptian chief royal architect Kha, who is believed to have died about 1405 BC, has shown that there is no morphine--and hence no opium--present. This finding casts doubt on the results of an earlier analysis. Tropane alkaloids are likewise absent. The significance of the present findings for the history of the opium poppy, Papaver somniferum L., in the eastern Mediterranean region is discussed. Evidence (chemical, botanical, artefactual, and linguistic) for the supposed presence of the opium poppy and opium in Egypt in the Late Bronze Age is briefly reviewed. These considerations and the negative outcome of the present analyses mean that the earlier reported finding can no longer be accepted as evidence.

A response to history: a review of one medical school's efforts to graduate minority physicians.

The number of minority physician graduates depends upon both the recruitment and retention of physician manpower. Numbers cannot be increased until the problems of recruiting and retaining minority students are minimized. This paper describes the process by which one medical school initiated changes to overcome barriers to recruiting, admitting, and graduating more minority students for medical practice.