A randomized, single-blind, prospective trial of auricular 'battlefield' acupuncture for the reduction of postoperative tonsillectomy pain in adults.

AIM: The purpose of this randomized, single-blind trial was to evaluate the efficacy of battlefield acupuncture in reducing postoperative pain and opioid consumption after adult tonsillectomy. METHODS: Adult participants undergoing a tonsillectomy were randomized to either receive auricular 'battlefield' acupuncture or not. Groups were compared using the Wilcox rank sum test, Fisher's exact test and a generalized estimating equations model for post-discharge pain scores. RESULTS: Statistically significant difference was not noted for morphine equivalent opioid use, nor was there any difference noted in the pain scores between the control group and treatment group. CONCLUSION: Acupuncture is cheap, safe and effective in many settings. Peri-operative battlefield auricular acupuncture did not reduce postoperative pain or opioid consumption in this study.

Bone mineral density loss after combat-related lower extremity amputation.

OBJECTIVES: Determine the incidence, severity, and associated risk factors for the development of low bone mineral density (BMD) after combat-related lower extremity amputation. DESIGN: Retrospective case-control comparison. SETTING: Tertiary care military treatment facility. PATIENTS/PARTICIPANTS: One hundred fifty-six lower extremity amputees, representing 182 amputations (121 unilateral, 35 bilateral). INTERVENTION: All patients underwent dual energy x-ray absorptiometry scanning during the treatment period. MAIN OUTCOME MEASUREMENTS: The Z score was the main outcome measure. We identified all patients with low BMD (Z < -1.0) and conducted multivariate analysis to identify significant risk factors for low BMD development. RESULTS: The observed rate of low BMD was 42%. The average Z score was -0.6 ± 1.1 among unilateral amputations and -1.2 ± 1.0 among bilateral amputations (P = 0.005). Risk factors for the development of low BMD were prolonged time to first ambulation [odds ratio (OR) = 1.39; 95% confidence interval (CI): 1.003-1.93; P = 0.048], prolonged time to dual energy x-ray absorptiometry (OR = 1.10; 95% CI: 1.02-1.18; P = 0.009), and more proximal amputation level (OR = 7.27; 95% CI: 3.21-16.49; P < 0.001). Among unilateral amputees, we detected a significant difference in the BMD of the intact and amputated limbs (-1.0; 95% CI: -1.1 to -0.8; P < 0.001). CONCLUSIONS: Proximal amputation level and delayed ambulation demonstrated a significant relationship with low BMD after traumatic and trauma-related amputation. We conclude that transfemoral amputees are at greater risk of BMD loss and that disuse atrophy is a primary factor in the development of low BMD. Prevention should focus on early and aggressive weight bearing rehabilitation and assessing levels and appropriately supplementing calcium and vitamin D.

Double-blinded, placebo-controlled, prospective randomized trial evaluating the efficacy of paravertebral block with and without continuous paravertebral block analgesia in outpatient breast cancer surgery.

BACKGROUND: Paravertebral block (PVB) is an effective alternative to general anesthesia for breast cancer surgery. Continuous paravertebral block (CPVB) anesthesia may extend postoperative analgesia at home and improve quality of early postoperative recovery of breast cancer patients. PURPOSE: This double-blinded randomized trial was conducted to compare degree of pain, nausea, mood, level of symptom distress, and time to return to normal daily activity between PVB and PVB + CPVB in patients undergoing outpatient breast cancer surgery. PATIENTS AND METHODS: Between July 2003 and April 2008 we randomly assigned 94 (73 evaluable) patients in a 1:1:1 ratio with early breast cancer to single injection PVB followed by CPVB infusion of 0.1% or 0.2% ropivacaine vs placebo (saline) for 48 hours postoperatively for unilateral breast cancer surgery without reconstruction. The primary study endpoint was the degree of pain, nausea, mood state, level of symptom distress, and recovery time. RESULTS: Of the 468 patients assessed for eligibility, 94 consented and 21 with incomplete data or follow-up were excluded, leaving 73 subjects for analysis. There was no clinically significant difference in degree of postoperative pain, nausea, mood state, level of symptom distress, or return to normal activity among the three study groups. CONCLUSION: The current study does not support the routine use of continuous paravertebral catheter anesthesia in patients undergoing operative treatment for breast cancer.

A randomized controlled trial of local heat therapy versus intravenous sodium stibogluconate for the treatment of cutaneous Leishmania major infection.

BACKGROUND: Cutaneous Leishmania major has affected many travelers including military personnel in Iraq and Afghanistan. Optimal treatment for this localized infection has not been defined, but interestingly the parasite is thermosensitive. METHODOLOGY/PRINCIPAL FINDINGS: Participants with parasitologically confirmed L. major infection were randomized to receive intravenous sodium stibogluconate (SSG) 20mg/kg/day for ten doses or localized ThermoMed (TM) device heat treatment (applied at 50 degrees C for 30 seconds) in one session. Those with facial lesions, infection with other species of Leishmania, or more than 20 lesions were excluded. Primary outcome was complete re-epithelialization or visual healing at two months without relapse over 12 months. Fifty-four/56 enrolled participants received intervention, 27 SSG and 27 TM. In an intent to treat analysis the per subject efficacy at two months with 12 months follow-up was 54% SSG and 48% TM (p = 0.78), and the per lesion efficacy was 59% SSG and 73% TM (p = 0.053). Reversible abdominal pain/pancreatitis, arthralgias, myalgias, headache, fatigue, mild cytopenias, and elevated transaminases were more commonly present in the SSG treated participants, whereas blistering, oozing, and erythema were more common in the TM arm. CONCLUSIONS/SIGNIFICANCE: Skin lesions due to L. major treated with heat delivered by the ThermoMed device healed at a similar rate and with less associated systemic toxicity than lesions treated with intravenous SSG. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT 00884377.

Narcolepsy presenting as REM sleep behaviour disorder.

REM sleep behaviour disorder (RBD) is a neurological condition well known to be associated with the synucleinopathies in middle-aged patients. However, there is much less data concerning its development, evolution, and association with other disorders in younger patients. We report two patients aged less than 33 years who presented with clinical and polysomnographical features of RBD, both of whom proved to have previously undiagnosed narcolepsy. Whilst the association of narcolepsy with RBD has been previously recognised, this is the first report of narcoleptic patients presenting with RBD. Narcolepsy should be included in the differential diagnosis of young patients presenting with abnormal behaviour during sleep compatible with RBD.

The impact of race on outcomes of autologous transplantation in patients with multiple myeloma.

Multiple myeloma is the most common hematologic malignancy in African-Americans, with twice the mortality of Caucasians according to population based data. In the pretransplantation era, comparable conventional therapy has resulted in similar outcomes between African-Americans and Caucasians. However, there has been limited data on outcomes after high dose chemotherapy with autologous stem cell transplantation (ASCT). A retrospective analysis of Caucasian (n = 55) and African-American (n = 36) myeloma patients who underwent ASCT in an equal access health care system in the Department of Defense was performed. Presenting demographic variables, pre/post ASCT characteristics, overall mortality and relapse rates after ASCT were obtained. Progression-free survival (PFS) and overall survival (OS) were calculated by Kaplan-Meier, and compared via log-rank testing. The median age at diagnosis for African-Americans = 52 years, Caucasians = 56 years (P = 0.009). There were no differences in presenting ISS stage, hemoglobin, calcium, or creatinine. African-Americans presented with higher CRP levels (P = 0.005), and a trend for less skeletal involvement (P = 0.10). Response to induction and ASCT was similar. Median PFS was 60.5 months (95% CI: 31.3-89.8 months) for African-Americans, 43.7 months (95% CI: 33.9-53.5 months) for Caucasians, HR of 1.3 (95% CI: 0.7-2.4), P = 0.46. Median OS was 95.2 months (95% CI: N/A) for African-Americans, 68.5 months (95% CI: 14.2-122.9 months) for Caucasians, HR of 1.4 (95% CI: 0.7-2.9), P = 0.41. In a cohort of myeloma patients who received autologous transplantation in an equal access health care system, there was comparable survival between African-Americans and Caucasians, suggesting that the historical increased mortality for African-Americans may be due to inequalities in access to care.

The effect of fourth-generation fluoroquinolones gatifloxacin and moxifloxacin on epithelial healing following photorefractive keratectomy.

PURPOSE: To compare the rate of epithelial healing following photorefractive keratectomy (PRK) with two commercially available fourth-generation fluoroquinolones, gatifloxacin (Zymar, Allergan, Irvine, California) and moxifloxacin (Vigamox, Alcon Laboratories, Fort Worth, Texas). DESIGN: Double-masked, randomized, prospective trial. METHODS: Thirty-five subjects received gatifloxacin in one eye and moxifloxacin in the fellow eye following PRK with a 9.0-mm epithelial defect. Patients were examined daily after surgery until the epithelium had healed completely in both eyes. Beginning on post-operative day 3, photos were taken and used to confirm epithelial healing or measure the area of residual epithelial defects. Healing times and defect sizes were compared using the Wilcoxon signed-ranks test. RESULTS: Both eyes healed on the same day in 18 of the 35 subjects (51.4%). In 13 of 35 (37.1%) subjects, the moxifloxacin-treated eye healed first, compared with only four of 35 (11.4%) subjects whose gatifloxacin-treated eye healed first. All six of the eyes that took 2 days longer than their fellow eye to heal were gatifloxacin-treated. Median healing time for both groups was 4 days (moxifloxacin range: 3 to 7 days; gatifloxacin range: 3 to 9 days; P = .01), but only 69% of gatifloxacin-treated eyes had healed by day 4 compared with 80% of the moxifloxacin-treated eyes. Overall, on each post-operative day, defect sizes were greater for the gatifloxacin-treated eyes. This difference was statistically significant on day 4 (P = .027). CONCLUSIONS: Eyes treated with moxifloxacin healed faster and had smaller defects compared with those treated with gatifloxacin. This provides another factor to consider in selecting antibiotic prophylaxis for corneal refractive surgery.

A sleep disorders centre in the United Kingdom.

The demographic features of 296 patients who consulted a sleep disorders centre in the United Kingdom were reviewed. Diagnosis after a sleep study was mainly that of sleep-related breathing disorders; however, various other sleep disorders were also diagnosed. Considering that most sleep disorders are diagnosed only after sleep investigations, it should be emphasized that such a facility should be well prepared in undertaking not only polysomnography but also various sleep investigations, including multiple sleep latency testing and actigraphy. In addition, several treatment options, including sleep hygiene, light therapy, and behavioural therapy, should be available. Therefore, a sleep disorders centre needs to be operated by sleep specialists.