RESUMO
BACKGROUND: Local anaesthetics are commonly delivered to the epidural space by either intermittent bolus or continuous infusion. While these methods have been investigated in terms of analgesia and total dose administered, they have not been compared in terms of their effect on the spread of injectate within the epidural space. This animal study compared the spread of dye delivered to the epidural space in a porcine model by either bolus or infusion. METHODS: After ethical approval, epidural catheters were placed at three vertebral levels in seven anaesthetized pigs. Aqueous dye (1 ml) was injected into the catheter as a bolus, or as an infusion over 30 min. Animals were euthanized at the end of the study and necropsy performed immediately to quantify the extent of dye spread. RESULTS: In seven animals, 20 catheters were successfully placed in the epidural space. The mean (sd) extent of dye spread was 8.9 (2.6) cm in the infusion group compared with 15.2 (2.7) cm in the bolus group (P<0.001). Segmental spread was significantly greater in the bolus group compared with the infusion group (P<0.01). CONCLUSION: In the porcine epidural model, spread of one ml of epidural dye solution is more extensive after a single bolus compared with short term infusion.
Assuntos
Corantes/farmacocinética , Infusões Parenterais/métodos , Injeções Espinhais/métodos , Animais , Espaço Epidural , Injeções Epidurais , Modelos Animais , SuínosRESUMO
BACKGROUND: The posterior longitudinal ligament (PLL) has been found to be a reliable measure of the acoustic target window for lumbar spinal anaesthesia and a predictive tool for difficult spinals. Currently, there is limited information on the PLL in the thoracic spine and its potential use for optimizing the acoustic target window during thoracic epidural placement. This study examined the effects of changes in body position on the length of the PLL as a measure of the acoustic target window for paramedian thoracic epidural access. METHODS: We performed thoracic ultrasonography on 30 adult volunteers to measure the length of the PLL at the T9/10 interspace, in five different positions: P1, neutral; P2, thoracic and lumbar flexion; P3, as in position 2 with dorsal table tilt to 10°; P4, as in position 2 with 45° rightward shoulder rotation; and P5, as in position 2 with 45° leftward shoulder rotation. RESULTS: The mean (sd) PLL length increased significantly from 9.9 (3.9) mm in P1 to 11.7 (3.4) mm in P2, 12.9 (3.1) mm in P3, and 13.8 (4.0) mm in P4 (P<0.01, <0.01, and <0.01, respectively). The mean PLL length in P3 and P4 was also significantly longer compared with P2 (P<0.01 and 0.01, respectively). CONCLUSIONS: In volunteers, flexion with 10° dorsal table tilt and flexion with right rotation significantly increased the length of the ipsilateral PLL, compared with the standard flexed sitting position, as visualized by paramedian ultrasonography at the level of T9/10.
Assuntos
Espaço Epidural/diagnóstico por imagem , Ligamentos Longitudinais/diagnóstico por imagem , Posicionamento do Paciente , Ultrassonografia de Intervenção/métodos , Adulto , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Região Lombossacral , Masculino , Amplitude de Movimento Articular , Rotação , Tamanho da Amostra , Tórax/anatomia & histologia , Tórax/diagnóstico por imagem , TransdutoresRESUMO
PURPOSE: We explored regret in thyroid cancer patients, relating to the decision to accept or reject adjuvant radioactive iodine treatment. METHODS: We studied patients with a recent diagnosis of early stage papillary thyroid carcinoma, in whom treatment decisions on adjuvant radioactive iodine had been finalized. Participants completed a Decision Regret Scale questionnaire. We asked the participants to identify who made the final decision about radioactive iodine treatment. We explored the relationship between decision regret and a) degree of patient involvement in decision-making and b) receipt of radioactive iodine treatment. RESULTS: We included 44 individuals, more than half of whom received adjuvant radioactive iodine treatment (26/44). Decision regret was generally low (mean 22.1, standard deviation [SD] 13.0). Participants reported that the final treatment decision was made by the following: patient and doctor (52.3%, 23/44), completely the patient (27.3%, 12/44), or completely the physician (20.5%, 9/44). Decision regret significantly differed according to who made the final decision: the patient (mean 19.0, SD 11.3), patient and doctor (mean 19.5, SD 7.4), and the doctor (mean 32.9, SD 20.37) (F = 4.569; degrees of freedom = 2, 41; p = 0.016). There was no significant difference in decision regret between patients who received radioactive iodine and those who did not (mean difference -2.5; 95% confidence interval -10.6, 5.6; p = 0.540). CONCLUSION: Thyroid cancer patients who reported being involved in the final treatment decision on adjuvant radioactive iodine had less regret than those who did not.
Assuntos
Radioisótopos do Iodo/uso terapêutico , Participação do Paciente , Satisfação do Paciente , Neoplasias da Glândula Tireoide/radioterapia , Adolescente , Adulto , Tomada de Decisões , Emoções , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radioterapia Adjuvante , Inquéritos e Questionários , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia , Adulto JovemRESUMO
In patients with early stage papillary thyroid carcinoma (PTC) who have had a thyroidectomy, the decision must be made to accept or reject radioactive iodine remnant ablation (RRA). Counselling patients about this decision can be challenging, given the medical evidence uncertainties and the complexity of related information. Although physicians are the primary source of medical information for patients considering RRA, some patients have a desire for supplemental information from sources such as the internet. Yet, thyroid cancer resources on the internet are of variable quality, and some may not be applicable to the individual case. We have developed a computerized educational tool [called a decision aid (DA)], directed to patients with early stage papillary thyroid cancer, and intended as an adjunct to physician counselling, to relay evidence-based medical information on disease prognosis and the choice to accept or reject RRA. DAs are tools used to inform patients about available treatment options and have been utilized in oncologic decision-making. We tested our web-based DA in fifty patients with early stage PTC and found that it improved medical knowledge. Furthermore, participants found the technical usability of the tool acceptable. We are currently conducting a randomized controlled trial comparing the use of the DA plus usual care to usual care alone to confirm the educational benefit of the website and examine its impact on the decision-making process. In the future, DAs may play an expanded role as an adjunct to physician counselling in the care of patients with thyroid cancer.
Assuntos
Tomada de Decisões , Radioisótopos do Iodo/uso terapêutico , Educação de Pacientes como Assunto/métodos , Adolescente , Adulto , Carcinoma , Carcinoma Papilar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Software , Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/terapia , Tireoidectomia , Adulto JovemRESUMO
UNLABELLED: Using prospective data from the Canadian Multicentre Osteoporosis Study (CaMos), we compared health utilities index (HUI) scores after 5 years of follow-up among participants (50 years and older) with and without incident clinical fractures. Incident fractures had a negative impact on HUI scores over time. INTRODUCTION: This study examined change in health-related quality of life (HRQL) in those with and without incident clinical fractures as measured by the HUI. METHODS: The study cohort was 4,820 women and 1,783 men (50 years and older) from the CaMos. The HUI was administered at baseline and year 5. Participants were sub-divided into incident fracture groups (hip, rib, spine, forearm, pelvis, other) and were compared with those without these fractures. The effects of both time and fracture type on HUI scores were examined in multivariable regression analyses. RESULTS: Men and women with hip fractures, compared to those without, had lower HUI measures that ranged from -0.05 to -0.25. Both women and men with spine fractures had significant deficits on the pain attributes (-0.07 to -0.12). In women, self-care (-0.06), mobility and ambulation (-0.05) were also negatively impacted. Women with rib fractures had deficits similar to women with spine fractures, and these effects persisted over time. In men, rib fractures did not significantly affect HUI scores. Pelvic and forearm fractures did not substantially influence HUI scores. CONCLUSION: The HUI was a sensitive measure of HRQL change over time. These results will inform economic analyses evaluating osteoporosis therapies.
Assuntos
Fraturas Ósseas/reabilitação , Nível de Saúde , Qualidade de Vida , Atividades Cotidianas , Idoso , Canadá , Feminino , Traumatismos do Antebraço/etiologia , Traumatismos do Antebraço/reabilitação , Fraturas Ósseas/etiologia , Indicadores Básicos de Saúde , Fraturas do Quadril/etiologia , Fraturas do Quadril/reabilitação , Humanos , Masculino , Pessoa de Meia-Idade , Osteoporose/complicações , Ossos Pélvicos/lesões , Estudos Prospectivos , Fraturas das Costelas/etiologia , Fraturas das Costelas/reabilitação , Fraturas da Coluna Vertebral/etiologia , Fraturas da Coluna Vertebral/reabilitação , Fatores de TempoRESUMO
SUMMARY: In this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50 years or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture. Data specific to men has clinical and policy implications. INTRODUCTION: Osteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for low bone mineral density (BMD) and bone loss in healthy men age 50 years or older. MATERIALS AND METHODS: A systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL, CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained reviewers assessed articles using a priori criteria. RESULTS: Of 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis, and height/height loss. CONCLUSION: In this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary practice.
Assuntos
Osteoporose/etiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Densidade Óssea , Fraturas Ósseas/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Atividade Motora/fisiologia , Projetos de Pesquisa , Fatores de Risco , Fumar/efeitos adversos , Redução de Peso/fisiologiaRESUMO
Background: Medullary thyroid carcinoma (mtc) is a rare malignancy of the thyroid gland, and raising awareness of the recommended diagnostic workup and pathologic characteristics of this malignancy is therefore important. Methods: We reviewed the current clinical practice guidelines and recent literature on mtc, and here, we summarize the recommendations for its diagnosis and workup. We also provide an overview of the pathology of mtc. Results: A neuroendocrine tumour, mtc arises from parafollicular cells ("C cells"), which secrete calcitonin. As part of the multiple endocrine neoplasia (men) type 2 syndromes, mtc can occur sporadically or in a hereditary form. This usually poorly delineated and infiltrative tumour is composed of solid nests of discohesive cells within a fibrous stroma that might also contain amyloid. Suspicious nodules on thyroid ultrasonography should be assessed with fine-needle aspiration (fna). If a diagnosis of mtc is made on fna, patients require baseline measurements of serum calcitonin and carcinoembryonic antigen. Calcitonin levels greater than 500 pg/mL or clinical suspicion for metastatic disease dictate the need for further imaging studies. All patients should undergo dna analysis for RET mutations to diagnose men type 2 syndromes, and if positive, they should be assessed for possible pheochromocytoma and hyperparathyroidism. Summary: Although the initial diagnosis of a suspicious thyroid nodule is the same for differentiated thyroid carcinoma and mtc, the remainder of the workup and diagnosis for mtc is distinct.
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Carcinoma Neuroendócrino/diagnóstico , Neoplasias da Glândula Tireoide/diagnóstico , Calcitonina/sangue , Antígeno Carcinoembrionário/sangue , Carcinoma Neuroendócrino/sangue , Carcinoma Neuroendócrino/genética , Carcinoma Neuroendócrino/patologia , Mutação em Linhagem Germinativa , Humanos , Guias de Prática Clínica como Assunto , Proteínas Proto-Oncogênicas c-ret/genética , Neoplasias da Glândula Tireoide/sangue , Neoplasias da Glândula Tireoide/genética , Neoplasias da Glândula Tireoide/patologiaAssuntos
Bloqueio Nervoso/métodos , Vértebras Torácicas/diagnóstico por imagem , Ultrassonografia de Intervenção/instrumentação , Idoso , Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Sistemas Computacionais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrostomia Percutânea , RopivacainaRESUMO
Introduction Surgically inserted rectus sheath catheters (RSCs) are used increasingly for analgesia after cystectomy and other abdominal surgery. Currently, there is little information on the optimal positioning of RSCs to allow maximal spread of local anaesthetic. This study sought to assess the spread of dye injected via RSCs and to highlight the extent of its coverage in a fresh unembalmed cadaveric cystectomy model in order to confirm the nerve endings that are likely to be anaesthetised with RSCs. Methods Four cadavers underwent lower midline incision with limited bladder mobilisation. A RSC was inserted into the eight hemiabdomens. The RSCs were positioned either anterior (n=5) or posterior to the rectus muscle (n=3). Dye was injected down the RSCs to evaluate spread. The eight hemiabdomens were dissected anatomically to determine the surface area of dye spread and nerve root involvement. Results The mean surface area of dye spread with anteriorly placed RSCs was 30.6cm2 anterior and 25.9cm2 posterior to the rectus muscle. The mean surface area of dye spread with posteriorly placed RSCs was 11.3cm2 anterior and 37.3cm2 posterior to the rectus muscle. The mean number of nerve roots stained with anteriorly and posteriorly placed RSCs was 3.8 and 2.7 respectively. Subcutaneous spread of dye was seen with one anterior RSC insertion. Peritoneal spread was seen with one anteriorly positioned RSC. Conclusions This study has demonstrated efficient nerve root infiltration with anteriorly and posteriorly positioned RSCs. It appears that dye spreads between the fibres of the rectus muscle rather than out laterally to the nerve roots when spreading from its initial compartment.
Assuntos
Catéteres , Cistectomia/instrumentação , Cistectomia/métodos , Reto do Abdome/cirurgia , Idoso de 80 Anos ou mais , Cadáver , Corantes , Feminino , Humanos , Masculino , Modelos BiológicosRESUMO
Some hypothyroid patients receiving levothyroxine replacement therapy complain of depressive symptoms despite normal TSH measurements. It is not known whether adding T(3) can reverse such symptoms. We randomized 40 individuals with depressive symptoms who were taking a stable dose of levothyroxine for treatment of hypothyroidism (excluding those who underwent thyroidectomy or radioactive iodine ablation of the thyroid) to receive T(4) plus placebo or the combination of T(4) plus T(3) in a double-blind manner for 15 wk. Participants receiving combination therapy had their prestudy dose of T(4) dropped by 50%, and T(3) was started at a dose of 12.5 micro g, twice daily. T(4) and T(3) doses were adjusted to keep goal TSH concentrations within the normal range. Compared with the group taking T(4) alone, the group taking both T(4) plus T(3) did not report any improvement in self-rated mood and well-being scores that included all subscales of the Symptom Check-List-90, the Comprehensive Epidemiological Screen for Depression, and the Multiple Outcome Study (P > 0.05 for all indexes). In conclusion, the current data do not support the routine use of combined T(3) and T(4) therapy in hypothyroid patients with depressive symptoms.
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Depressão/tratamento farmacológico , Hipotireoidismo/tratamento farmacológico , Tiroxina/administração & dosagem , Tri-Iodotironina/administração & dosagem , Adulto , Afeto/efeitos dos fármacos , Depressão/etiologia , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Hipotireoidismo/complicações , Hipotireoidismo/psicologia , Masculino , Pessoa de Meia-Idade , Glândula Tireoide/efeitos dos fármacos , Glândula Tireoide/fisiologia , Tiroxina/sangue , Resultado do Tratamento , Tri-Iodotironina/sangueRESUMO
We describe four cases of symptomatic pneumocranium, a rare, potentially life-threatening complication of transsphenoidal pituitary surgery. Symptomatic pneumocranium manifested as impaired mental status, headaches, and grand mal seizures, early in the postoperative course after transsphenoidal pituitary surgery. Furthermore, a Cushing response, including systemic hypertension and bradycardia (secondary to intracranial hypertension) was seen, which has not been previously described in association with symptomatic pneumocranium. We describe a previously unreported risk factor for tension pneumocranium, untreated obstructive sleep apnea. Other factors predisposing to tension pneumocranium in our patients included: cerebrospinal fluid leaks, postoperative positive-pressure mask ventilation, large pituitary tumors, and intraoperative lumbar drainage catheters. Surgical drainage of the pneumocranium and repair of any coexistent cerebrospinal fluid leak markedly improved neurologic status. Symptomatic pneumocranium occurring early in the postoperative course after transsphenoidal pituitary surgery is rare, but prompt recognition and treatment of this condition can be life-saving.
Assuntos
Procedimentos Neurocirúrgicos/efeitos adversos , Hipófise/cirurgia , Pneumocefalia/etiologia , Complicações Pós-Operatórias , Adenoma/cirurgia , Adulto , Idoso , Craniofaringioma/cirurgia , Síndrome de Cushing/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/cirurgia , Pneumocefalia/diagnóstico , Pneumocefalia/cirurgia , Tomografia Computadorizada por Raios XAssuntos
Doença da Artéria Coronariana/complicações , Hipotireoidismo/complicações , Doença da Artéria Coronariana/prevenção & controle , Feminino , Terapia de Reposição Hormonal , Humanos , Hipotireoidismo/tratamento farmacológico , Pessoa de Meia-Idade , Projetos de Pesquisa/normas , Hormônios Tireóideos/uso terapêuticoAssuntos
Tosse/etiologia , Epistaxe/etiologia , Cefaleia/etiologia , Síndrome da Veia Cava Superior/complicações , Síndrome da Veia Cava Superior/diagnóstico , Diagnóstico Diferencial , Humanos , Neoplasias Pulmonares/diagnóstico , Masculino , Pessoa de Meia-Idade , Síndrome da Veia Cava Superior/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
UNLABELLED: We examined osteoporosis diagnosis/treatment in 2,187 community dwelling men age 50+. After five years in the study, 90% of men with fragility fractures remained undiagnosed and untreated for osteoporosis. The need to treat fragility fractures is well established in guidelines, and these numbers represent an important care gap. INTRODUCTION: Whether physicians in the community are recognizing and appropriately treating osteoporosis and fragility fractures in men remains unknown. We examined the rate of diagnosis and treatment in community dwelling men participating in the Canadian Multicentre Osteoporosis Study (CaMos). METHODS: Between February 1996 and September 2002, 2,187 participants were recruited from nine sites across Canada and prospectively followed. Information on osteoporosis diagnosis, fractures, medications were collected annually by a detailed questionnaire. DXA examination of lumbar spine (L1-4) and hip were conducted at baseline and year five. RESULTS: Diagnosis and treatment in men with clinical fragility fractures was low: at baseline and year five only 2.3% and 10.3% of men with a clinical fracture reported an osteoporosis diagnosis, respectively. At year five, 90% of men with a clinical fragility fracture were untreated. Hip fractures were the most commonly treated (37.5% by year five). A diagnosis of osteoporosis resulted in greater treatment: 67% of participants with diagnosed osteoporosis were treated with a bisphosphonate and 87% were taking calcium and/or vitamin D (year five). CONCLUSIONS: In this population-based study, both a diagnostic and therapeutic gap existed between knowledge and practice related to fragility fractures and osteoporosis in men aged >or=50 years.