Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN).

BACKGROUND: Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury. METHODS: A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes. DISCUSSION: The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia. TRIAL REGISTRATION: ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

An Exploratory Study of the Texture Research Investigational Platform (TRIP) to Evaluate Bone Texture Score of Distal Femur DXA Scans - A TBS-Based Approach.

Poor bone status is associated with increased complications following orthopedic surgery. Therefore, assessing site-specific skeletal status prior to or after orthopedic surgery to optimize outcomes is appealing. The trabecular bone score (TBS) approach, a surrogate for microarchitecture, was adapted to the Texture Research Investigational Platform (TRIP), which allows assessment of many skeletal sites imaged by various modalities. TRIP generates a bone texture score (TBS ORTHO), which could potentially guide surgical decision-making and offer insight into postsurgical fracture risk. As distal femur bone loss occurs following total knee arthroplasty (TKA), we hypothesized that TBS ORTHO after TKA would identify poorer texture in the operated femur compared to the nonoperated. We evaluated 30 subjects (15 M/15 F) with unilateral TKA 2-5 yr previously, mean age 67.9 yr and body mass index 30 kg/m2. Using a Lunar iDXA, lumbar spine and entire femur scans were obtained, the latter using the atypical femur fracture feature. Distal femur bone mineral density (BMD) and TBS ORTHO were obtained using manual regions of interest (ROI) at 15% and 25% of leg length from the intercondylar notch. TBS ORTHO was determined using distal femur DICOM images and TRIP v1.0 (Medimaps, France). Differences in operated vs nonoperated femur were evaluated by paired t test. As previously reported, operated leg BMD was approx 10% lower at 15% and 25% ROIs. Similarly, TBS ORTHO values in the operated leg were approx 5% lower (p < 0.05) at these same ROIs. Distal femur TBS ORTHO and BMD were largely unrelated. TBS ORTHO reproducibility at these ROIs was approx 3.5%. In conclusion, this pilot study documents the feasibility of reproducibly obtaining distal femur TBS ORTHO values. Lower values were observed in the surgical leg, consistent with the bone loss that follows TKA. Further work is indicated to refine TRIP use and evaluate whether such data provides guidance for surgical decision-making and improves periprosthetic fracture prediction.

Blood and plasma glutathione measured in healthy subjects by HPLC: relation to sex, aging, biological variables, and life habits.

We report an HPLC method for measuring the concentrations of reduced (GSH) and total (GSHt) free glutathione in human plasma and whole blood. The chromatographic step was coupled with a postcolumn derivatization reaction and fluorometric detection. The linear range was 0.81-13.02 mumol/L, and the detection limit was 0.13 mumol/L. In healthy adults (ages 18-73 years), mean concentrations were 941 +/- 155 mumol/L for GSHt and 849 +/- 63 mumol/L for GSH in blood (107 men, 94 women), and 3.39 +/- 1.04 mumol/L for GSH in plasma (66 men, 58 women). Blood GSHt but not GSH was significantly lower in children (32 boys, 32 girls: 872 +/- 157 mumol/L) than in adults. Blood GSHt and GSH appeared to be correlated positively with the number of cigarettes smoked per day and the regular practice of physical exercise, and negatively with alcohol abstinence. We observed positive correlations between blood GSHt and cholesterol and calcium concentrations, and between blood GSH and cholesterol concentration.

Treatment of ameloblastoma of the jaws.

OBJECTIVE: To evaluate treatment of ameloblastoma of the jaws and suggest a more aggressive approach for well-defined cases. SETTING: Referral center. PATIENTS: Forty-one patients were treated for ameloblastoma of the jaws. RESULTS: Seventeen patients had a local recurrence; 14 had initial curettage and three had initial resection. Seven patients had two or more recurrences. Eight patients underwent radiotherapy; two died of progressive disease. CONCLUSIONS: Ameloblastoma had a high rate of local recurrence if not adequately removed. Segmental resection for the mandible and partial maxillectomy for the maxilla should be the primary treatment; marginal resection is appropriate only for small primary tumors. For multiple recurrences, radiotherapy is effective, and surgery and radiotherapy (50 Gy postoperatively) should be used in selected cases.

[Results of the use of titanium mandibular reconstruction plates]. / Résultats de l'utilisation des plaques de reconstruction mandibulaire en titane.

The aim of this study was to assess the use of titanium mandibular reconstruction plates after cancer surgery. The medical records of 36 patients were reviewed. The mean follow-up was 22 months. All patients had primary reconstruction of the mandible with Leibinger titanium plates. Thirty patients underwent postoperative radiotherapy with the plate in the field. The mean dose was 60 Grays over 6 weeks and the overdosage into tissues was reduced to 5%. Thirty patients (83%) had retained the plate at 6 months and no sign of osteomyelitis was found in any patient. Quality of speech and deglutition were satisfactory in 63% and 94% of the patients respectively; sixty-six p. cent of them found their cosmetic appearance good or excellent. The overall success rate of the technique was 74%. This technique did not excessively prolong operating time unlike microvascular transfer. Plates are an effective method of primary reconstruction in patients with advanced cancer and uncertain long-term survival. Tolerance of plates after radiotherapy is outstanding. Speech, deglutition and facial contour are immediately restored and further bone reconstruction is feasible.

[Treatment of primary bone sarcoma of the jaws]. / Traitement des sarcomes osseux primitifs des maxillaires.

Head and neck bone sarcomas are very uncommon tumors. Therefore, treatment modalities are not clearly established. The medical record of 12 patients with bone sarcoma of the jaw were reviewed. Six patients with osteosarcoma underwent primary chemotherapy followed by wide surgical resection, radiation therapy or combined radiosurgical treatment. The 2 and 5 years survivals were 66% and 40% respectively. Five patients with chondrosarcoma were treated by wide surgical resection alone or combined with postoperative radiotherapy and possibly chemotherapy. All patients were alive; the mean follow-up was 9 years. One patient had Ewing's tumor. Osteosarcoma and chondrosarcoma in head and neck patients have a high rate of local recurrences. Surgery is the mainstay of treatment. Patients with voluminous tumors and high-grade lesions should receive postoperative radiotherapy. The role of chemotherapy has not been defined.

[Treatment of primary soft tissue sarcoma of the head and neck]. / Traitement des sarcomes primitifs des tissus mous de la tête et du cou.

Soft tissue sarcomas of the head and neck account for less than 1% of all malignant neoplasms in this region. A significantly increased risk of treatment failure is associated with high histologic grade, leading to an aggressive treatment. The medical records of 17 patients with soft tissue sarcomas of the head and neck were reviewed. They were divided into two groups according to age: 13 adults and 4 children. The former underwent wide surgical excision with postoperative radiotherapy in some cases and possibly chemotherapy. The 2 and 5 years survivals were 54% and 46% respectively. The latter, with rhabdomyosarcoma, underwent multimodality treatment (chemotherapy, surgery, radiotherapy). The 2 years survival was 50%. The mainstay of treatment of soft tissue sarcomas of the head and neck in adults remains surgery. Patients with incomplete resection or high grade tumour should receive more aggressive treatment (surgery and postoperative radiotherapy). The use of systemic chemotherapy has showed no statistically significant improvement in local control or survival. However, for rhabdomyosarcoma in children, chemotherapy is an essential part of treatment.

[Titanium plates for mandibular reconstruction and radiotherapy]. / Plaques de reconstruction mandibulaire en titane et radiothérapie.

Mandibular reconstruction plates are now used after cancer surgery in particular patients. This study assesses the irradiation of Titanium mandibular reconstruction plates in terms of both dosimetry and mid-term tolerance. Twenty patients with mandibular plates underwent radiotherapy (mean dose 60 Gy). The radiation dose on the patient itself was calculated with 3-dimensional treatment planning. A clinical and radiological evaluation of tolerance was made 6 months after the end of the treatment: intraoral and cutaneous healing and possible osteomyelitis. Mid-term tolerance was very satisfactory with only two failures at 6 months. When using parallel opposing fields, the overdosage into tissues was reduced to approximately 5 p. cent; and radiotherapy has probably no effect on titanium plate tolerance.

Results of surgical treatment of T3 and T4 tumors of the oral cavity and oropharynx.

The combined use of surgery and radiotherapy is commonly accepted as the most effective treatment for locally advanced head and neck cancers. T3 and T4 tumors of the oral cavity and oropharynx often necessitate extensive local surgery. From 1981 to 1988, 199 patients with T3 and T4 tumors of the oral cavity and oropharynx were treated. One hundred seventeen patients underwent surgery plus postoperative radiotherapy; 78 had flap reconstructions. This series is extremely homogeneous because surgery was always performed by two surgeons, whereas radiotherapy was the responsibility of the same physician. The results of this study show a 96% local control rate at the end of treatment among the patients with combined treatment. The average time by which hospitalization was prolonged due to surgery was 29 days. The type and delay of recurrences and survival in relation with node involvement are also discussed. Extensive surgery in association with radiotherapy remains a reliable treatment in such patients.

Gamma-glutamyltransferase: nucleotide sequence of the human pancreatic cDNA. Evidence for a ubiquitous gamma-glutamyltransferase polypeptide in human tissues.

gamma-Glutamyltransferase (GGT, EC 2.3.2.2) is an enzyme involved in glutathione metabolism and drug and xenobiotic detoxification. Using human hepatoma Hep G2 GGT cDNA as probe, we isolated a cDNA from a human pancreatic cDNA library. Analysis of the nucleotide sequences revealed a 2244-bp insert that includes an open reading frame of 1710 bp, encoding a protein identical to the Hep G2 and human placenta GGTs. Similarly, the 5' untranslated region, though shorter, is highly homologous to that of Hep G2 cDNA. These data suggest strongly that the same gene encodes human GGT in the placenta, Hep G2 and the pancreas. We further studied the distribution of the corresponding mRNA, called type I mRNA, in different human tissues. Using a highly sensitive method associating reverse transcription with specific amplification by polymerase chain reaction, cDNA was synthesized from total RNA isolated from the tissues and GGT specific fragments were amplified. We observed the presence of a specific cDNA fragment corresponding to the type I mRNA in the human tissues and cells tested, providing the evidence for a ubiquitous expression of this GGT mRNA in human tissues.

Modified approach for ethmoid and anterior skull base surgery.

The use of combined craniofacial resection is well established for tumors of the ethmoid bone and the anterior aspect of the base of the skull. Mobilization of the medial fronto-orbital ridge improves the transbasal approach and can be performed with a monobloc bone flap. We describe an en bloc bifrontal craniotomy including the supraorbital ridges and the nasal bones. This provides a wider angle of approach to the anterior aspect of the base of the skull than any other method and avoids retraction of the frontal lobes. This type of bone flap procedure can be performed after a wide periosteal dissection in the coronal area of the scalp alone, without facial skin incision.

[Complementary tests in the evaluation of velar insufficiency]. / Les examens complémentaires dans le bilan de l'insuffisance vélaire.

In order to assess the degree of velar deficiency as accurately as possible, three tests can be made: a nasofibroscopy, X-rays, and notably xeroradiography, a radiography made under brightness amplification. This check-up indicates the course of action to be undertaken: orthophonic rehabilitation followed, depending on the results, by a surgical operation. These tests are incorporated into a pluridisciplinary treatment.

Approach to the pterygomaxillary space and posterior part of the tongue by lateral stair-step mandibulotomy.

Fifteen patients underwent surgery for retromandibular parotid, pharyngeal, or posterior tongue tumors. Surgical approach to the pterygomaxillary fossa, parapharyngeal space, and posterior tongue was performed by external cervical incision and lateral stair-step mandibulotomy. After resection of the tumors, the mandibular segments were replaced and secured with miniplates. The plates were removed after six weeks whenever postoperative radiation therapy was planned. By reflecting the ascending ramus, this method provides excellent exposure of the concerned areas. It makes unnecessary both incision of the lower lip and intermaxillary fixation with arch bars, thus allowing a quick resumption of oral feeding. A review of 15 patients demonstrated satisfactory results for mandibular function and morphologic appearance, with minimal complications.

[Craniofacial injuries and osteomeningeal ruptures. When should the anterior fossa be approached?]. / Traumatismes cranio-faciaux et brèches ostéo-méningées. Quand faut-il aborder l'étage antérieur?

A retrospective analysis was carried out of 142 cases of craniofacial traumas divided into 5 types according to the Fain classification. The incidence of cerebrospinal fistula of fronto-basal skull is very high in types III and IV traumas (60% of the cases). It is less important in type II2 traumas representing severe naso-orbital lesions (40% of the cases). It is only of 20% in type II1 traumas (Lefort II and III). Uncontrollable rhinorrhea and late meningitis are mainly due to types II and IV traumas. From these findings surgical indications and technique of the approach of the fronto basal skull are discussed.

Nutrición del anciano y protesis dentales / Nutrition of the aged and dental prosthesis

El anciano tiene una fisiología diferente de la del adulto; ha perdido una parte de sus reservas y de su capacidad de adaptación, es más vulnerable a la agresión del medio y la reducción de su plasticidade le vuelve frágil. La asistencia a ancianos expuestos al riesgo de malnutrición o desnutrición en principio debe ser preventiva. Las alteraciones nutricionales en el anciano con frecuencia se encuentran ligadas a deficiencias bucodentales, como parodontopatías, desdentación y prótesis defectuosas; por esta causa el geriatra debe establecer una estrecha colaboración con el estomatólogo con el fin de encontrar un tratamiento adecuado para el paciente anciano con desequilibrio nutricional. Además, las enfermedades agudas exponen al anciano a una desnutrición rápida, por lo que es necesario evaluar el estado de nutrición anterior del paciente y proporcionarle en forma precoz los medios fisiológicos y la realimentación adecuados para corregir las anomalías observadas

[The amount of maxillofacial risk in playing rugby]. / Part du risque maxillo-facial dans la pratique du rugby.

123 cases of maxillo-facial injuries due to rugby and treated in the Department of Maxillo-Facial Surgery at the University Teachers Hospital (C.H.U.) of Bordeaux between 1981 and 1984 are analyzed. The high rate of injuries decreases considerably if accidents caused by intentional brutality are excluded. This then approaches the rate for other team sports. Rugby is not basically a violent sport but can be made so by the unfairness of certain players. It would be most advisable to educate players along these lines.