Every child, every day, back to play: the PICUstars protocol - implementation of a nurse-led PICU liberation program.

BACKGROUND: As admissions to paediatric intensive care units (PICU) rise and mortality rates decline, the focus is shifting from survival to quality of survivorship. There is paucity of internationally accepted guidelines to manage complications like over-sedation, delirium, and immobility in the paediatric setting. These have a strong adverse impact on PICU recovery including healthcare costs and long-term functional disability. The A2F bundle (ABCDEF), or ICU Liberation, was developed to operationalise the multiple evidence-based guidelines addressing ICU-related complications and has been shown to improve clinical outcomes and health-care related costs in adult studies. However, there is little data on the effect of ICU Liberation bundle implementation in PICU. METHODS: PICU-STARS will be a single centre before-and-after after trial and implementation study. It is designed to evaluate if the multidimensional, nurse-led ICU Liberation model of care can be applied to the PICU and if it is successful in minimising PICU-related problems in a mixed quaternary PICU. In a prospective baseline measurement, the present practises of care in the PICU will be assessed in order to inform the adaptation and implementation of the PICU Liberation bundle. To assess feasibility, implementation outcomes, and intervention effectiveness, the implementation team will use the Consolidated Framework for Implementation Research (CIFR) and process assessment (mixed methods). The implementation process will be evaluated over time, with focus groups, interviews, questionnaires, and observations used to provide formative feedback. Over time, the barriers and enablers for successful implementation will be analysed, with recommendations based on "lessons learned." All outcomes will be reported using standard descriptive statistics and analytical techniques, with appropriate allowance for patient differentials in severity and relevant characteristics. DISCUSSION: The results will inform the fine-tune of the Liberation bundle adaptation and implementation process. The expected primary output is a detailed adaptation and implementation guideline, including clinical resources (and investment) required, to adopt PICU-STARS in other children's hospitals. PATIENT AND PUBLIC INVOLVEMENT STATEMENT: The authors thank the PICU education and Liberation Implementation team, and our patients and families for their inspiration and valuable comments on protocol drafts. Results will be made available to critical care survivors, their caregivers, relevant societies, and other researchers. TRIAL REGISTRATION: ACTRN, ACTRN382863 . Registered 19/10/2021 - Retrospectively registered. STUDY STATUS: recruiting.

Induction of labour using prostaglandin E2 as an inpatient versus balloon catheter as an outpatient: a multicentre randomised controlled trial.

OBJECTIVE: To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient. DESIGN: Randomised controlled trial. SETTING: Eight Australian maternity hospitals. POPULATION: Women with uncomplicated term singleton pregnancies undergoing IOL for low-risk indications including post-term, advanced maternal age and 'social' reasons. METHODS: Between September 2015 and October 2018, 347 women were randomised to a balloon outpatient group and 348 to a PG inpatient group. The PG group received Dinoprostone, either 2 mg gel or 10 mg controlled-release tape. The balloon group had a double-balloon catheter inserted and went home. MAIN OUTCOME MEASURES: The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidaemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported. RESULTS: There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% versus 25.8%; relative risk = 0.77, 95% CI 0.51-1.02; P = 0.070), cord arterial pH <7.10 (3.5% versus 9.2%; P = 0.072), nursery admissions (12.6% versus 15.5%; P = 0.379), neonatal antibiotic use (12.1% versus 17.6%; P = 0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% versus 31.0%;P = 0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% versus 92.3%; P = 0.045). CONCLUSIONS: Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low. TWEETABLE ABSTRACT: Multicentre trial shows outpatient induction using balloon catheter is safe and feasible for nulliparous women.

The effect of dexmedetomidine on postoperative behaviour change in children: a randomised controlled trial.

Children may develop changes in their behaviour following general anaesthesia. Some examples of negative behaviour include temper tantrums and nightmares, as well as sleep and eating disorders. The aim of this study was to determine whether dexmedetomidine reduces the incidence of negative behaviour change after anaesthesia for day case surgery in children aged two to seven years. Children were randomly allocated to one of three groups: a premedication group received 2 mg.kg-1 intranasal dexmedetomidine; an intra-operative group received 1 mg.kg-1 intravenous dexmedetomidine; and a control group. The primary outcome was the incidence of negative behaviour on postoperative day 3 using the Post-Hospitalisation Behaviour Questionnaire for Ambulatory Surgery (PHBQ-AS) and the Strength and Difficulties Questionnaire (SDQ). Secondary outcomes included: the incidence of negative behaviour on postoperative days 14 and 28; anxiety at induction; emergence delirium; pain; length of recovery and hospital stay; and any adverse events. The data for 247 patients were analysed. Negative behaviour change on postoperative day 3 was similar between all three groups when measured with the PHBQ-AS (47%, 44% and 51% respectively; adjusted p=0.99) and the SDQ (median scores 7.5, 6.0 and 8.0 respectively; adjusted p=0.99). The incidence of negative behaviour in the group who received dexmedetomidine intra-operatively was less at postoperative day 28 (15% compared with 36% in the dexmedetomidine premedication group and 41% in the control group, p<0.001). We conclude that dexmedetomidine does not reduce the incidence of negative behaviour on postoperative day 3 in two to seven-year olds having day case procedures.

Perinatal mortality disparities between public care and private obstetrician-led care: a propensity score analysis.

OBJECTIVE: To examine whether disparities in stillbirth, and neonatal and perinatal mortality rates, between public and private hospitals are the result of differences in population characteristics and/or clinical practices. DESIGN: Retrospective cohort study. SETTING: A metropolitan tertiary centre encompassing public and private hospitals. Women accessed care from either a private obstetrician or from public models of care - predominantly midwife-led care or care shared between midwives, general practitioners, and obstetricians. POPULATION: A total of 131 436 births during 1998-2013: 69 037 public and 62 399 private. METHODS: Propensity score matching was used to select equal-sized public and private cohorts with similar characteristics. Logistic regression analysis was then used to explore the impact of public-private differences in the use of assisted reproductive technologies, plurality, major congenital anomalies, birth method, and gestational age. MAIN OUTCOME MEASURES: Stillbirth, and neonatal and perinatal mortality rates. RESULTS: After controlling for maternal and pregnancy factors, perinatal mortality rates were higher in the public than in the private cohort (adjusted odds ratio, aOR 1.53; 95% confidence interval, 95% CI 1.29-1.80; stillbirth aOR 1.56, 95% CI 1.26-1.94; neonatal death aOR 1.48, 95% CI 1.15-1.89). These disparities reduced by 15.7, 20.5, and 19.6%, respectively, after adjusting for major congenital anomalies, birth method, and gestational age. CONCLUSIONS: Perinatal mortality occurred more often among public than private births, and this disparity was not explained by population differences. Differences in clinical practices seem to be partly responsible. The impact of differences in clinical practices on maternal and neonatal morbidity was not examined. Further research is required. TWEETABLE ABSTRACT: Private obstetrician-led care: more obstetric intervention and earlier births reduce perinatal mortality. PLAIN LANGUAGE SUMMARY: Background Babies born in Australian public hospitals tend to die more often than those born in private hospitals. Our aim was to determine whether this pattern is a result of public-private differences in care or merely linked with differences in the characteristics of the two groups. In Australian private hospitals, a private obstetrician almost always provides continuing care to each woman during pregnancy and birth. Public hospitals provide a number of care options, which usually involve midwives and/or a family doctor. Method The study population included 131 436 births (52.5% public; 47.5% private) from 1998-2013 at a single metropolitan centre with co-located public and private facilities. To isolate the effect of differences in care, we used a statistical technique called propensity score matching to select a public group and a private group with similar characteristics and equal size. This enabled us to compare 'apples with apples' when comparing public versus private perinatal death rates. Perinatal deaths include stillbirths and babies that die within 28 days of birth. Main findings After matching and after accounting for different patterns in the use of fertility treatments and multiple-birth pregnancies (such as twins), babies born in the public sector were approximately 1.5 times more likely to die than babies born in the private sector. This difference was reduced to 1.3 times more likely to die than babies born in the private sector after taking into account other factors that could skew the data, such as major congenital anomalies, birth method, and duration of pregnancy. Limitations This was a single-centre study, so the results may not apply to all settings. Despite our efforts to create highly similar public and private cohorts, some differences between the groups are likely to have remained and this may have affected the results. Implications Our findings suggest that private obstetrician-led care has a beneficial impact on perinatal deaths, despite, or possibly because of, higher obstetric intervention rates and earlier births in the private hospital. Further research is required.

Behaviour of 4- to 5-year-old nondisabled ELBW children: Outcomes following group-based physiotherapy intervention.

BACKGROUND: Extreme prematurity or extremely low birth weight (ELBW) can adversely affect behaviour. Nondisabled ELBW children are at risk of behavioural problems, which may become a particular concern after commencement of formal education. This study explored the frequency of behavioural and emotional problems amongst nondisabled ELBW children at 4 to 5 years of age and whether intervention had a positive influence on behaviour. The relationship between behaviour, gender, and other areas of performance at 5 years was explored. METHODS: Fifty 4-year-old children (born <28 weeks gestation or birth weight <1,000 g) with minimal/mild motor impairment were randomly allocated to intervention (n = 24) or standard care (n = 26). Intervention was 6 group-based physiotherapy weekly sessions and home programme. Standard care was best practice advice. The Child Behavior Checklist (CBCL) for preschool children was completed at baseline and at 1-year post-baseline. Other measures at follow-up included Movement Assessment Battery for Children Second Edition, Beery Visual-Motor Integration Test 5th Edition, and Peabody Picture Vocabulary Test 4th Edition. RESULTS: The whole cohort improved on CBCL total problems score between baseline (mean 50.0, SD 11.1) and 1-year follow-up (mean 45.2, SD 10.3), p = .004. There were no significant differences between groups over time on CBCL internalizing, externalizing, or total problems scores. The intervention group showed a mean difference in total problems score of -3.8 (CI [1.5, 9.1]) between times, with standard care group values being -4.4 (CI [1.6, 7.1]). Males had higher total problems scores than females (p = .026), although still performed within the "normal" range. CBCL scores did not correlate with other scores. CONCLUSIONS: The behaviour of nondisabled ELBW children was within the "normal" range at 4 to 5 years, and both intervention and standard care may have contributed to improved behavioural outcomes. Behaviour was not related to performance in other developmental domains.

An open-label pilot study of oral vitamin C as an opioid-sparing agent in patients with chronic pain secondary to cancer.

PURPOSE: The purpose of this study is to assess the efficacy of oral Vitamin C as an opioid-sparing agent when used in conjunction with opioids and standard adjuvant therapy in the management of chronic cancer pain. METHODS: An open-label pilot study of patients ≥18 years of age with chronic pain secondary to cancer and/or its treatment and a Brief Pain Inventory average pain score of ≥3/10. In addition to opioid analgesia, patients received 1 g of vitamin C twice daily over 3 days (total daily dose of 2 g). Patients' usual medications, including breakthrough medications, were continued throughout the study period. The primary endpoint was total daily opioid use during vitamin C administration compared with that immediately prior to study. RESULTS: Thirty-four patients were enrolled in the study. Seven failed to complete the trial. Across the 17 evaluable patients, the median daily opioid consumption was 360 mg oral morphine equivalents (OME) on the days prior to vitamin C and 390 mg when administered with vitamin C. CONCLUSION: This study failed to demonstrate any clinically significant benefit from vitamin C in conjunction with opioids in cancer-related pain and does not provide support for embarking on a larger randomised trial to determine efficacy.

Induction of labour for postdates in nulliparous women with uncomplicated pregnancy - is the caesarean section rate really lower?

Induction for "post-dates" is a very common procedure and in Queensland, Australia, accounts for 35.5% of all inductions. Systematic reviews all conclude that induction of labour does not increase the risk of caesarean section (CS). However, these reviews have generally included a mixed population and have not stratified for parity. We report in a retrospective cohort study involving only nulliparous women with uncomplicated singleton pregnancy at 40° to 416 weeks that compared to spontaneous labour, incidence of CS was significantly higher in the induction group, 22.2% versus 12.1% (OR 2.06; 95% CI 1.93-2.20) at 40° to 416 weeks versus spontaneous labour at 40° to 416 weeks; and also higher at 21.0% versus 14.9% (OR 1.52; 95% CI 1.34-1.73) at 40° to 406 weeks versus spontaneous labour at 41° to 416 weeks (expectant management).

Trial for Reducing Weight Retention in New Mums: a randomised controlled trial evaluating a low intensity, postpartum weight management programme.

BACKGROUND: Failure to return to pregnancy weight by 6 months postpartum is associated with long-term obesity, as well as adverse health outcomes. This research evaluated a postpartum weight management programme for women with a body mass index (BMI) > 25 kg m(-2) that combined behaviour change principles and a low-intensity delivery format with postpartum nutrition information. METHODS: Women were randomised at 24-28 weeks to control (supported care; SC) or intervention (enhanced care; EC) groups, stratified by BMI cohort. At 36 weeks of gestation, SC women received a 'nutrition for breastfeeding' resource and EC women received a nutrition assessment and goal-setting session about post-natal nutrition, plus a 6-month correspondence intervention requiring return of self-monitoring sheets. Weight change, anthropometry, diet, physical activity, breastfeeding, fasting glucose and insulin measures were assessed at 6 weeks and 6 months postpartum. RESULTS: Seventy-seven percent (40 EC and 41 SC) of the 105 women approached were recruited; 36 EC and 35 SC women received a programme and 66.7% and 48.6% completed the study, respectively. No significant differences were observed between any outcomes. Median [interquartile range (IQR)] weight change was EC: -1.1 (9.5) kg versus SC: -1.1 (7.5) kg (6 weeks to 6 months) and EC: +1.0 (8.7) kg versus SC: +2.3 (9) kg (prepregnancy to 6 months). Intervention women breastfed for half a month longer than control women (180 versus 164 days; P = 0.10). An average of 2.3 out of six activity sheets per participant was returned. CONCLUSIONS: Despite low intervention engagement, the high retention rate suggests this remains an area of interest to women. Future strategies must facilitate women's engagement, be individually tailored, and include features that support behaviour change to decrease women's risk of chronic health issues.

The Skin Cancer Quality of Life Impact Tool (SCQOLIT): a validated health-related quality of life questionnaire for non-metastatic skin cancers.

BACKGROUND: Quality of life (QOL) issues in patients with non-metastatic skin cancer are not satisfactorily demonstrated when using existing QOL questionnaires. OBJECTIVE: To construct and validate a 10 item disease-specific QOL questionnaire, the Skin Cancer Quality of Life Impact Tool (SCQOLIT), for use in patients following treatment of non-metastatic skin cancer. METHODS: The SCQOLIT was constructed and administered initially to 120 patients with non-metastatic skin cancer, 60 with malignant melanoma (MM) and 60 with non-melanoma skin cancer (NMSC) following treatment, then repeated in half this cohort at seven days, and the other half at three months. Data was collected on age, gender, skin cancer type and Breslow thickness. Statistical validation was undertaken. RESULTS: There were 113 valid SCQOLIT responses at initial completion (54 in the MM group, and 59 in the NMSC group). Initial SCQOLIT median scores (interquartile range [IQR], range) for the two groups were 10 (12, 0-28) MM, and 4 (5, 0-19) NMSC. Amongst the cohort readministered the SCQOLIT at three months (23 in the MM group, 25 in the NMSC group) median scores (IQR, range) were 6 (6, 0-26) MM and 3 (4, 0-20) NMSC. CONCLUSIONS: The SCQOLIT is a validated disease-specific QOL questionnaire for use in patients following treatment of non-metastatic skin cancer. Higher SCQOLIT scores are observed in MM patients than NMSC patients, but diminish with time in the MM group. Patients with persistently elevated SCQOLIT scores merit additional attention.

Associations of serum vitamin D concentrations with obstetric glucose metabolism in a subset of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study cohort.

AIMS: To assess associations between maternal serum vitamin D concentration and glucose metabolism in a cohort of pregnant women living in an Australian subtropical environment. METHODS: Cross-sectional assessment of 25-hydroxy vitamin D concentrations in 399 Hyperglycemia and Adverse Pregnancy Outcome ancillary study participants, treated at an obstetric teaching hospital in Brisbane, Australia. All patients underwent a blinded 75-g oral glucose tolerance test at 24-32 (target 28) weeks' gestation. RESULTS: The mean (± standard deviation) fasting plasma glucose was 4.5 ± 0.4 mmol/l. Mean (± standard deviation) serum 25-hydroxy vitamin D was 132.5 ± 44.0 nmol/l. A difference of one standard deviation in maternal 25-hydroxy vitamin D was inversely related to fasting glucose (fasting glucose lower by 0.047 mmol/l, P=0.012) when assessed with multiple linear regression after adjusting for confounders. Maternal 25-hydroxy vitamin D correlated with ß-cell function as estimated by the log-transformed homeostasis model assessment-ß-cell function equation (r=0.131, P=0.009), but not with the homeostasis model assessment of insulin resistance. CONCLUSIONS: An association between mid-gestational 25-hydroxy vitamin D and fasting glucose was confirmed in a largely normoglycaemic and vitamin D-replete pregnant population. The correlation between 25-hydroxy vitamin D and ß-cell function suggests that vitamin D may influence glucose metabolism through this mechanism. Intervention studies are required to determine causality and the role of vitamin D replacement in deficient individuals.

Does an objective system-based approach improve assessment of perioperative risk in children? A preliminary evaluation of the 'NARCO'.

BACKGROUND: This study evaluated whether an objective tool would provide a more reliable and valid assessment of perioperative risk compared with the ASA-physical status (ASA-PS) in children. METHODS: A system-based risk assessment tool was developed using these categories: Neurological, Airway, Respiratory, Cardiovascular, and Other (NARCO) with a subcomponent grading surgical severity (SS). Anaesthesiologists reviewed the preoperative assessments and assigned NARCO, SS, and ASA-PS scores independently. Perioperative outcomes were recorded by trained observers. Validity and reliability of the tools were evaluated. RESULTS: NARCO correlated with ASA-PS (ρ=0.664; P<0.01) supporting its criterion validity. Inter-rater reliability of the measures was supported (intraclass correlation coefficients 0.71-0.96; κ 0.43-0.87) except for the Airway category. Measures of exact agreement were slightly better for NARCO compared with ASA-PS. NARCO, SS, and ASA-PS scores correlated significantly with perioperative escalation of care, adverse events (AE), hospital length of stay, and admission status. Correlations between NARCO and ASA-PS and outcomes improved when SS was factored into their coding. There were significant, but low, correlations between all measures and mortality. The odds of having escalation of care, AE, and mortality were 5-47 times greater among children with higher risk scores. CONCLUSIONS: Findings suggest that all measures of outcome have acceptable to excellent reliability with a slight improvement in agreement for the NARCO compared with the ASA-PS. This study supports the validity of both the NARCO and the ASA-PS in predicting perioperative risk in children with a slight improvement in correlations when combined with the SS score.

DNA markers for nervous system diseases.

Recombinant DNA technology has provided a vast new source of DNA markers displaying heritable sequence variation in humans. These markers can be used in family studies to identify the chromosomal location of defective genes causing nervous system disorders. The discovery of a DNA marker linked to Huntington's disease has opened new avenues of research into this disorder and may ultimately permit cloning and characterization of the defective gene.

A Randomised Controlled Trial to Delay or Prevent Type 2 Diabetes after Gestational Diabetes: Walking for Exercise and Nutrition to Prevent Diabetes for You.

Aims. To develop a program to support behaviour changes for women with a history of Gestational Diabetes Mellitus (GDM) and a Body Mass Index (BMI) > 25 kg/m(2) to delay or prevent Type 2 Diabetes Mellitus. Methods. Women diagnosed with GDM in the previous 6 to 24 months and BMI > 25 kg/m(2) were randomized to an intervention (I) (n = 16) or a control (C) (n = 15) group. The intervention was a pedometer program combined with nutrition coaching, with the primary outcome increased weight loss in the intervention group. Secondary outcomes included decreased waist and hip measurements, improved insulin sensitivity and body composition, increased physical activity, and improved self-efficacy in eating behaviours. Results. Median (IQR) results were as follows: weight: I -2.5 (2.3) kg versus C +0.2 (1.6) kg (P = 0.009), waist: I -3.6 (4.5) cm versus C -0.1 (3.6) cm (P = 0.07), and hip: I -5.0 (3.3) cm versus C -0.2 (2.6) cm (P = 0.002). There was clinical improvement in physical activity and eating behaviours and no significant changes in glucose metabolism or body composition. Conclusion. A pedometer program and nutrition coaching proved effective in supporting weight loss, waist circumference, physical activity, and eating behaviours in women with previous GDM.

Early tracheostomy for primary airway management in the surgical critical care setting.

During a 12-month period, 264 patients with multiple injuries who required mechanical ventilation were admitted to the surgical intensive care unit. One hundred twenty patients (46%) were disengaged from the ventilator, and 38 patients (14%) died. Of the remaining 106 patients (40%) 51 patients (group I) were to receive tracheostomy within 1 to 7 days, and 55 patients (group II) underwent late (8 or more days after admission) tracheostomy. Multiple variables in four categories (admission, operative, ventilatory, and outcome) were analyzed prospectively to define the impact that early tracheostomy had on duration of mechanical ventilation, intensive care stay, and hospital stay. Morbidity and mortality rates of the procedures were assessed. Early tracheostomy, in a homogeneous group of critically ill patients, is associated with a significant decrease in duration of mechanical ventilation, as well as shorter intensive care unit and hospital stays, compared with translaryngeal endotracheal intubation. There were no deaths attributable to tracheostomy, and overall morbidity of the procedures was 4%. We conclude that early tracheostomy has an overall risk equivalent to that of endotracheal intubation. Furthermore, early tracheostomy shortens days on the ventilator and intensive care unit and hospital days and should be considered for patients in the intensive care unit at risk for more than 7 days of intubation.

Can patients with minor head injuries be safely discharged home?

To identify all patients with serious intracranial injury, current treatment strategies include admission and/or computed tomographic evaluation of all patients with head injuries. However, the majority of patients with head injuries who are awake do not require subsequent intervention. A review of 407 consecutive patients with head injuries treated at an adult regional trauma center identified 310 patients with Glasgow Coma Scores of 15 in the emergency department, all of whom were admitted. Five patients with Glasgow Coma Scores of 15 required intervention for intracranial abnormality. All five patients had skull fractures and/or neurologic deficits. Based on this and other studies, criteria for discharge from the emergency department are a Glasgow Coma Score of 15, no deficit except amnesia, no signs of intoxication, and no evidence of basilar fracture on clinical examination or linear fracture on screening skull roentgenography. Safe discharge without universal computed tomographic evaluation or admission is possible and cost-efficient.

Balloon test occlusion of the internal carotid artery with hypotensive challenge.

PURPOSE: To evaluate the usefulness of provocative testing with hypotensive challenge during balloon test occlusion of the internal carotid artery before carotid sacrifice and to correlate tolerance of balloon test occlusion with clinical outcome after carotid artery sacrifice. METHODS: Forty-seven consecutive cases of balloon test occlusions performed at our institution during the past 4 years were retrospectively reviewed. Occlusion was performed under normotensive conditions with distal perfusion of heparinized saline for 20 minutes, or until a deficit was perceived. If 20 minutes of normotension was tolerated, hypotension was induced to two thirds of mean arterial pressure for 20 minutes, or until a deficit was perceived. RESULTS: Of 47 patients, 4 (9%) had deficits at normotension. Of the remaining 43 patients, 9 (21%) had deficits at hypotension. One patient with a positive hypotensive test occlusion underwent carotid artery sacrifice after extracranial-intracranial bypass without sequelae. In one of the 19 patients who clinically tolerated test occlusion with hypotension and had carotid sacrifice (surgical ligation of the intracranial carotid artery), a mild embolic stroke developed, probably from the giant carotid wall aneurysm. This patient fully recovered; MR imaging showed mild changes consistent with emboli distal to the aneurysm. Symptomatic complications were noted in 2 (4%) patients, and asymptomatic arterial dissections were noted in 3 (6%) patients. CONCLUSION: Balloon test occlusion with hypotensive challenge is safe, economical, and greatly increases the sensitivity of balloon test occlusion. The predictive value of a negative test is high. However, to determine the test's specificity compared with quantitative imaging, controlled trials will be necessary.

Thrombolysis of the cervical internal carotid artery before balloon angioplasty and stent placement: report of two cases.

The application of endovascular techniques to the treatment of cervical carotid artery bifurcation atherosclerosis has been delayed because of the fear of causing embolic events while traversing the diseased portion of the artery with an angioplasty balloon catheter. Symptomatic carotid arteries often contain fresh or partially digested intraluminal thrombus. Before we cross certain carotid bifurcation lesions with angioplasty catheters, we deliver 100,000 to 200,000 units of urokinase in an attempt to digest loose thrombus. We have witnessed changes in the angiographic appearance of the diseased portion of the vessel after urokinase treatment, such as widening of the lumen, that suggest clot lysis. We present two patients who had symptomatic internal carotid artery stenosis. Angiography showed irregular narrowing of the internal carotid artery origin. One patient was selected for angioplasty instead of carotid endarterectomy because of severe cardiac risk factors. The other patient had major angiographic risk factors manifested by poor collateral circulation. The angiographic findings and history of transient ischemic attacks led us to suspect the presence of soft, loose plaque debris or thrombus in both cases. Therefore, we performed thrombolysis with urokinase before angioplasty. Repeat angiography showed widening of the arterial lumen and smoothing of the plaque profile. Subsequent angioplasty and stent placement were uneventful. Intraarterial thrombolysis can produce a change in the angiographic appearance of symptomatic atherosclerotic lesions of the cervical carotid artery bifurcation. Digestion of intralesional thrombus may provide a safer environment for deployment of endovascular remodeling devices by decreasing the likelihood of embolic phenomena. We believe thrombolysis should be done before angioplasty in select patients.

Lumbar discectomy: use of an epidural morphine sponge for postoperative pain control.

A technique for extended ambulatory epidural pain control after lumbar discectomy is described; preliminary results with 45 patients are reported; and alternative methods of narcotic analgesia are reviewed. In this technique, an absorbable gelatin sponge (Gelfoam, Upjohn Co., Kalamazoo, MI) is contoured to the laminotomy defect, placed in methylprednisolone acetate (40-80 mg), and then injected with 2 to 4 mg of preservative-free morphine (a small needle was used to fill the sponge). The sponge is placed over the defect before closure. A review of office and hospital records was conducted. The series consisted of 33 men and 12 women (mean age, 39 yr; range, 24-57 yr); records showed narcotic use in 34 patients (parenteral in 3) and work-related injuries in 14 patients. Thirty-three patients were ambulatory postoperatively on the day of surgery; all were ambulatory by postoperative day (POD) 1. On the day of surgery, 18 patients did not require any postoperative analgesics; on POD 1, 22 patients did not require analgesics. Six patients received parenteral narcotics; four received one dose only, and two had two or more doses. Thirty-one patients were discharged from the hospital on POD 1, and 10 were discharged POD 2. The other patients were discharged from the hospital on POD 3 (three patients) or POD 4 (one patient). When they were discharged, all patients received a limited supply of acetaminophen with codeine for pain control at home. After discharge, phone follow-up (at 1 week) and office follow-ups (at 3-5 weeks) revealed only one patient with more than mild discomfort. Three patients required one-time bladder catheterization, and one patient had presumed discitis 1 month postoperatively. In a control group who had undergone surgery 3 months previously, the average day of discharge had been POD 3.07; no control patient had been discharged on POD 1, and only 20% had been discharged on POD 2. This method provides effective, safe, and extended analgesia after lumbar discectomy.

Microvascular surgical anatomy of the vertebrobasilar junction.

OBJECTIVE: We examined the pertinent microvascular anatomy of 28 formalin-fixed brains to develop anatomic guidelines for aneurysm surgery in the region of the vertebrobasilar junction. METHODS: Using a surgical microscope, the outer diameters were observed for the following main arteries: vertebral, basilar, posteroinferior cerebellar, and anteroinferior cerebellar. The number of lower brain stem perforating arteries was examined in relation to their course. The distance between the arteries and their perforators was measured with respect to anatomic landmarks. RESULTS: The anatomy of the main arteries was characteristically variable, whereas the anatomy of the perforators was constant, particularly in terms of their numbers and points of penetration into the brain substance. The four major points of entry were the lateral medullary area just caudal to the posterior olivary sulcus, the posterior olivary sulcus, the small lateral fossa at the superior olivary groove, and the foramen cecum. Each of these areas coincides with the origin of common vertebrobasilar aneurysms. CONCLUSION: The anatomy of the main arteries was variable. In contrast, the perforators penetrated the adjoining brain stem at specific locations, regardless of the caliber of the main artery. Despite a small vertebral artery or its major branches, perforators penetrating the brain are significant and may effect the outcome of aneurysm surgery or endovascular procedures.

Occlusion of an "accessory" distal anterior cerebral artery during treatment of anterior communicating artery aneurysms. Report of two cases.

Two cases are presented in which clip occlusion of a third distal anterior cerebral artery segment occurred during treatment of anterior communicating artery aneurysms. Case histories, angiograms, operative descriptions, and postmortem findings are presented. The incidence of this anomalous vessel is reviewed. Preoperative and intraoperative vigilance in determining the presence of this anomaly prior to clip placement is emphasized.