Local infiltration analgesia with levobupivacaine compared with intrathecal morphine in total hip arthroplasty patients.

BACKGROUND: Recently, local infiltration analgesia (LIA) has been promoted for pain control after total hip arthroplasty (THA). We hypothesized that LIA would offer equal analgesic efficacy but less adverse effects, e.g., nausea and vomiting, when compared with an established regimen [intrathecal morphine (it-M)] after THA. METHODS: This randomized controlled trial comprised 60 patients undergoing THA under spinal anaesthesia. For LIA, the surgeon administered levobupivacaine, ketorolac and epinephrine at the surgical site intraoperatively. LIA patients received a LIA top-up through a wound catheter on the morning of the 1st post-operative day (POD). In group it-M, 0.1 mg morphine was given together with the spinal anaesthetic. Study parameters included pain scores, vital parameters and side effects, e.g., post-operative nausea and vomiting (PONV). Besides, levobupivacaine plasma concentrations were determined in 10 LIA patients. RESULTS: The median (25th/75th percentiles) rescue oxycodone demand differed significantly with LIA 15 (10/25) mg vs. 8.5 (1.5/15) mg with it-M (P < 0.006) during the day of surgery, but not anymore on 1st or 2nd POD. The LIA top-up had no effect. However, both analgesic regimens resulted in comparable pain scores and patient satisfaction. PONV incidence and medication did not vary significantly. LIA offered certain advantages regarding early post-operative mobilization. Maximum levobupivacaine plasma concentrations (229-580 ng/ml) remained under the toxic level. CONCLUSIONS: While LIA might enable earlier mobilization after THA, it was not associated with less nausea as compared with it-M. Less rescue oxycodone was given early after it-M, but urinary retention was more common in that group.

Psoas abscess ten years after ipsilateral nephrectomy for pyonephrosis.

Pyogenic abscess of the psoas muscle is a rare disease. The Authors report a recently observed case which developed 10 years after ipsilateral nephrectomy for pyonephrosis, reviewing the pertinent literature. The culture of the pus extracted only reproduced Proteus mirabilis. The relation between psoas abscess and nephrectomy is unclear. To make diagnosis is important to consider this condition in differential diagnosis in presence of fever and flank tenderness in a nephrectomized patient.

[Pinworm infestation of the appendix]. / Ossiuriasi appendicolare: nostra esperienza.

The Authors present 2 cases of enterobiasis of appendix observed on a total of 186 appendicectomies. Enterobius infestation is an uncommon cause of acute appendicitis. Preoperative diagnosis of pinworm infestation is almost impossible without clinical suspect. Parasites may produce symptoms which resemble acute appendicitis but parasitic infection rarely causes it. It is also important considered in the differential diagnosis cases that mimic Crohn's disease.

Chronobiology of rupture and dissection of aortic aneurysms.

A growing body of evidence suggests that the occurrence of cardiovascular events is not evenly distributed over time, but shows peculiar temporal patterns that vary with time of day, day of the week, and month (season) of the year. These patterns coincide with the temporal variation in the pathophysiologic mechanisms that trigger cardiovascular events and the physiologic changes in body rhythms. These two factors in combination contribute to the periodicity in susceptibility to acute cardiovascular events. The classic assumption of epidemiologic studies that there is a constancy in risk for disease during the various time domains has now been challenged by the emerging new concept of chronorisk. In the last two decades temporal patterns (circadian, weekly, seasonal) have been identified for several acute cardiovascular diseases, such as acute myocardial infarction, sudden death, pulmonary embolism, and stroke, with peak incidence for most in the morning and during winter. One of the most life-threatening cardiovascular emergencies, aortic aneurysm rupture or dissection, also demonstrates periodicity, characterized by a similar temporal distribution, which suggests a common pathophysiologic mechanism or triggers similar to other cardiovascular acute emergencies. We review the data on chronobiology of acute aortic rupture or dissection, and discuss various pathophysiologic mechanisms that account for this variability. It is likely that identification of consistent recurring patterns in the underlying risk mechanisms could provide potential new insights for more precise diagnosis and efficacious therapeutic intervention.

Seasonal variation in onset of pulmonary embolism is independent of patients' underlying risk comorbid conditions.

As for many cardiovascular events, pulmonary embolism (PE) is not randomly distributed over time, but shows rhythmic patterns. The purpose of this study was to investigate whether such temporal pattern of occurrence varied in subgroups of patients according to different risk comorbid conditions. All cases of PE observed at the Hospital of Ferrara, Italy, from 1998 to 2001, were considered. After determination of the day of onset, the population was grouped by gender and the most common underlying risk comorbid conditions, e.g., deep vein thrombosis (DVT), neoplasms, cardiomyopathies, traumas/surgical operations, diabetes mellitus, pulmonary diseases, hypertension, cerebrovascular diseases, heart failure, hematologic diseases. For statistical analysis, chi-square test for goodness of fit and partial Fourier series were used. A total of 784 cases (mean age 71 +/- 14 years) were included. Frequency of onset was higher in winter for total population (p = 0.002), men (p = 0.004), DVT (p = 0.001), pulmonary disease (p = 0.008), cardiomyopathies (p = 0.011), and major traumas/surgical operations (p = 0.049). Chronobiologic analysis identified a winter peak for total population (p = 0.008), men (p < 0.001), DVT (p = 0.006), pulmonary diseases (p = 0.017), and hypertension (p = 0.026). This study confirms the winter peak of PE and provides evidence that it is not influenced by the underlying clinical conditions, but probably by endogenous variations.

A comparison of toxicity following two different doses of cyclophosphamide for mobilization of peripheral blood progenitor cells in 116 multiple myeloma patients.

High-dose cyclophosphamide (HDC) has been shown to be an effective regimen for collecting PBPC in multiple myeloma (MM) patients, but the optimal dose to be used remains controversial. Two historical cohorts of MM patients who received G- or GM-CSF and HDC at the dose of either 7 g/m(2) (HDC7, n = 74) or 4 g/m (HDC4, n = 42) were compared. As patients in the HDC4 group were more likely to have received G-CSF than GM-CSF (P < 10(-3)) and fewer previous alkylating agents (P = 0.004), multivariate logistic regression analysis was performed. In the HDC4 group, patients had a shorter median duration of neutropenia (P < 10(-4)), fewer RBC (P < 10(-3)) and platelet transfusions (P < 10(-3)) with fewer patients with platelets <20 x 10(9)/l (P = 0.004). Moreover, fewer febrile episodes (P < 10(-3)) and less need of intravenous antibiotics (P < 10(-3)) were found in the HDC4 group. No statistical difference was observed with regard to CD34(+) cell collection efficiency. Thus, the use of HDC at the dose of 4 g/m(2) for the collection of PBPC in MM patients decreases hematological and extrahematological toxicity with an equivalent CD34(+) cell collection efficiency.

Circadian variation in onset of acute cardiogenic pulmonary edema is independent of patients' features and underlying pathophysiological causes.

BACKGROUND: The present study aimed to confirm the existence of a circadian pattern in the onset of acute pulmonary edema (APE) and to verify whether sex, age, preexisting diseases, and clinical causes determining the event may influence it. SUBJECTS AND METHODS: The study considered all consecutive cases of APE observed at the St. Anna General Hospital of Ferrara, Italy, during a 7-year period from January 1, 1992, to December 31, 1998. The sample population was divided into subgroups by sex, age (<75 and > or =75 years), presence or absence of diabetes and hypertension, clinical causes determining the event (i.e., acute myocardial infarction (AMI), pulmonary embolism, arrhythmias). The most important associated or concomitant diseases were also considered (i.e., coronary heart disease and angina, previous myocardial infarction, chronic cardiac failure, dilatative cardiopathy, chronic atrial fibrillation, valvular disease, chronic obstructive pulmonary disease, chronic cor pulmonale, malignancy, chronic renal failure). Time of symptom onset of each event was recorded accurately, then tabulated into 24 increments of 1h (e.g., 06:00 to 06:59 was reported as 6 A.M.). For statistical chronobiological analysis, partial Fourier series were used. RESULTS: During the 7-year period, 1321 consecutive cases of APE in 1014 different subjects were observed. The majority of events occurred at night, and statistical analysis showed a 24h rhythmicity both in the total sample population and in all considered subgroups, with the only exception being patients with pulmonary embolism and arrhythmias, for which the small number of cases made the study of rhythms in APE impossible. CONCLUSIONS: The nighttime preference in the occurrence of APE appears to be quite independent of all demographic features or underlying pathophysiological causes.

The association of low serum cholesterol with depression and suicidal behaviours: new hypotheses for the missing link.

Several observational studies indicate that reduction of serum cholesterol levels is related to an increase in violent deaths and suicide but the nature of this possible relationship remains unclear. Many confounding factors, e.g. poor health, depression and loss of appetite may play a role in the apparent relationship between serum cholesterol levels and suicide. Two separate phenomena should be considered: lowering total cholesterol and low total cholesterol. This review considers the evidence from epidemiological studies on serum cholesterol lowering and psychiatric disturbances. The available evidence does not seem to substantiate the view that large-scale intervention to reduce cholesterol concentrations could lead to more violent and aggressive behaviour, and generally greater unhappiness. In recent trials using statin treatment, there were slightly fewer deaths from accidents and suicide in the treated group compared with the placebo group. We believe that clinicians should not be deterred from prescribing cholesterol-lowering drugs, to reduce the risk of death from coronary heart disease, when they are indicated.

Seasonal variation in the occurrence of nontraumatic rupture of thoracic aorta.

Research has identified circadian and seasonal patterns for several acute cardiovascular diseases. In order to investigate the possible existence of a seasonal variation in the onset of acute nontraumatic ruptures of thoracic aorta, this study considered all patients referred to the emergency department of St Anna Hospital of Ferrara, Italy, from January 1985 to December 1996. In the considered period, 85 patients (52 males, 33 females) of nontraumatic ruptures of thoracic aorta were observed. Cosinor analysis and partial Fourier series with up to 4 harmonics were applied to monthly data, and the best-fitting curves for circannual rhythmicity were calculated. A higher winter occurrence with a significant peak in January was found for the total population and the male subgroup. Although the underlying factors are not fully known, such patterns strictly resemble that of arterial blood pressure. Emergency doctors can put to practical use the recognition of a clearly identified chronorisk for aortic rupture, increasing alertness, and providing the most effective antihypertensive protection at the specific vulnerable periods.

Sokolow-Lyon voltage criteria in sickle cell patients.

The electrocardiogram remains the most commonly used method of cardiac assessment in developing countries. To determine the prevalence of electrocardiographic left ventricular hypertrophy (LVH) and the clinical significance of Sokolow-Lyon voltage criteria in sickle cell patients, echocardiographic and ECG findings were studied in 112 patients (71 with haemoglobin SS disease and 41 with haemoglobin SC disease). Electrocardiographic left ventricular hypertrophy (ECGLVH) defined as Sokolow-Lyon voltage > or = 35 mm was detected in 39 (55%) SS patients and 11 (27%) SC patients. This prevalence was higher in men than in women. There were statistically significant trends for increasing prevalence of ECGLVH with height (p < 0.007 in SS, and p < 0.01 in SC, patients) and with left ventricular internal dimension (p < 0.05 in SS, and p < 0.01 in SC, patients). But no significant trend was found with increasing posterior wall (PWT) or interventricular septal thickness (IVST). Sensitivity of Sokolow-Lyon criteria for detection of echocardiographic left ventricular hypertrophy was 63% and 33% in SS and SC patients, respectively, and specificity was 51% and 74%, respectively. Sokolow-Lyon voltage correlated with left ventricular mass in SS and SC patients (r = 0.44, p < 0.01 and r = 0.32, p < 0.05) and with left ventricular internal dimension (r = 0.2, p < 0.01 and r = 0.32, p < 0.05) but not significantly with PWT and IVST. We conclude that, in sickle cell patients, the electrocardiographic LVH mainly indicates the existence of an eccentric echocardiographic LVH with increase of left ventricular internal dimension.

Seasonal variations in the incidence of cranial nerve paralysis.

The aim of the study was to verify whether there is a seasonal pattern in the occurrence of cranial nerve paralysis. All patients admitted to the Emergency Department of St Anna Hospital, Ferrara, Italy, from 1 January 1991 to 31 December 1997, were reviewed. Cranial nerve paralysis was diagnosed in 126 cases: the oculomotor nerve accounted for 46 cases, the trochlear nerve for 14, and the abducens nerve for 66. The frequencies of cases involving the oculomotor nerve and of all cases were significantly higher in winter than in the other seasons. Compared with other 2-month periods, the highest number of total cases occurred in November to December. Chronobiological analysis of the data for individual months showed a rhythmic 12-month pattern for the total population, with a weakly significant peak in January.

Sokolow-Lyon voltage criteria in sickle cell patients

The electrocardiogram remains the most commonly used method of cardiac assessment in developing countries. To determine the prevalence of electrocardiographic left ventricular hypertrophy (LVH) and the clinical significance of Sokolow-Lyon voltage criteria in sickle cell patients, echocardiographic and ECG findings were studied in 112 patients (71 with haemoglobin SS disease and 41 with haemoglobin SC disease). Electrocardiographic left ventricular hypertrophy (ECGLVH) defined as Sokolow-Lyon voltage greater than or equal to 35 mm was detected in 39 (55 percent) SS patients and 11 (27 percent) SC patients. This prevalence was higher in men than in women. There were statistically significant trends for increasing prevalence of ECGLVH with height (p<0.007 in SS, and p<0.01 in SC patients). But no significant trend was found with increasing posterior wall (PWT) or interventricular septal thickness (IVST). Sensitivity of Sokolow-Lyon criteria for detection of echocardiographic left ventricular hypertrophy was 63 percent and 33 percent in SS and SC patients, respectively, and specificity was 51 percent and 74 percent, respectively. Sokolow-Lyon voltage correlated with left ventricular mass in SS and SC patients (r = 0.44, p < 0.01 and r = 0.32, p < 0.05) and with left ventricular internal dimension (r = 0.2, p < 0.01 and r = 0.32, p < 0.05) but not significantly with PWT and IVST. We conclude that, in sickle cell patients, the electrocardiographic LVH mainly indicates the existence of an eccentric echocardiographic LVH with increase of left ventricular internal dimension.(AU)

Sokolow-Lyon voltage criteria in sickle cell patients

The electrocardiogram remains the most commonly used method of cardiac assessment in developing countries. To determine the prevalence of electrocardiographic left ventricular hypertrophy (LVH) and the clinical significance of Sokolow-Lyon voltage criteria in sickle cell patients, echocardiographic and ECG findings were studied in 112 patients (71 with haemoglobin SS disease and 41 with haemoglobin SC disease). Electrocardiographic left ventricular hypertrophy (ECGLVH) defined as Sokolow-Lyon voltage > or = 35 mm was detected in 39 (55) SS patients and 11 (27) SC patients. This prevalence was higher in men than in women. There were statistically significant trends for increasing prevalence of ECGLVH with height (p < 0.007 in SS, and p < 0.01 in SC, patients) and with left ventricular internal dimension (p < 0.05 in SS, and p < 0.01 in SC, patients). But no significant trend was found with increasing posterior wall (PWT) or interventricular septal thickness (IVST). Sensitivity of Sokolow-Lyon criteria for detection of echocardiographic left ventricular hypertrophy was 63and 33in SS and SC patients, respectively, and specificity was 51and 74, respectively. Sokolow-Lyon voltage correlated with left ventricular mass in SS and SC patients (r = 0.44, p < 0.01 and r = 0.32, p < 0.05) and with left ventricular internal dimension (r = 0.2, p < 0.01 and r = 0.32, p < 0.05) but not significantly with PWT and IVST. We conclude that, in sickle cell patients, the electrocardiographic LVH mainly indicates the existence of an eccentric echocardiographic LVH with increase of left ventricular internal dimension.

Circadian variation in the onset of acute critical limb ischemia.

Research has identified a circadian rhythm for several acute thrombotic cardiovascular and cerebrovascular diseases. We investigated the possible existence of a circadian variation in the onset of acute critical limb ischemia. Out of a consecutive series of 198 cases, precise determination (within 30 minutes) of the time of symptom onset was possible in 156 (78.8%). Partial Fourier series were applied to hourly data and the best-fitting curves for circadian rhythmicity were calculated. Both in the total population and in subgroups by gender and location of ischemia, a highly significant circadian pattern of occurrence was demonstrated with peak in the morning (approximately 0800) and nocturnal minimum around midnight. This study is the first demonstration of the circadian pattern of acute arterial occlusion of the limbs, in agreement with several studies showing a circadian pattern to the time of onset of acute myocardial infarction and other unfavorable acute events related to thrombosis. This opens up the potential for therapeutic implications, suggesting the need to adjust the dose of drugs based on the time of day. Further studies dealing with circadian variation in the efficacy of thrombolytic agents are so needed.

Response at three months is a good predictive factor for newly diagnosed chronic myeloid leukemia patients treated by recombinant interferon-alpha.

In a single institution, we have used recombinant interferon- (IFN-) to treat 116 newly diagnosed Philadelphia-positive (Ph+) chronic myeloid leukemia (CML) patients and analyzed the predictive factors for response and survival. The patients whose median age was 50.3 years (range, 9 to 70) were administered IFN- (5 million units/m2/d) subcutaneously. The IFN- dose was subsequently adjusted to maintain the white blood cell and platelet counts between 1.5 and 5 x 10(9)/L, 50 and 100 x 10(9)/L, respectively. At diagnosis, the Sokal score was used to classify the patients into three groups: low (n = 57), intermediate (n = 42), and high risk (n = 16). A complete hematological response (CHR) was achieved in 93 cases (80.2%). Of the 116 patients, 113 were available for cytogenetic evaluation. Fifty patients (43%) achieved a major cytogenetic response (MCR) (=65% marrow Ph- cells), 37 of them having a complete cytogenetic response (CCR). The estimated 5-year survival of the 116 patients was 68% +/- 11% (95% confidence interval [CI]) with a median follow-up of 42 months (range, 3 to 114) and 85% +/- 11% (95% CI) with a median follow-up of 30.9 (range, 3 to 111) when patients were censored at the time of transplantation. Event-free survival at 5 years (adding death and transplant as event) was 46% +/- 11% (95% CI). Using proportional hazards regression to study time-dependent variables, we confirmed that the most significant factor associated with survival was the cytogenetic response (MCR or CCR) (P <.0001). This factor was independent compared with the Sokal score and baseline variables used to calculate the Sokal score. Moreover, using either univariate or multivariate analysis, the achievement of CHR within 3 months was strongly correlated with MCR (P <.0001). Minimum cytogenetic response (mCR, ie, at least 5% of Ph- metaphases) at 3 months was also a significant predictive factor for MCR (P <.0001). These results show that IFN- can induce a high rate of hematological and cytogenetic response when administered in doses leading to myelosuppression. Factors such as the achievement of CHR and mCR within 3 months could be useful to identify early those patients who will not respond to IFN- and who need alternative treatments such as stem cell transplantation.