Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery.

This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

[Extinction of large herbivore mammals: niche characteristics of musk ox Ovibos moschatus and reindeer Rangifer tarandus coexisting in isolation].

The extinction of large northern herbivores is a puzzle for many biologists. It is long debated whether climate change or human activity was the main factor of the extinction. The survival of the weak trophic competitors should reject the climatic hypothesis. Extant species of Pleistocene communities allow testing this explicitly. Up to date, reindeer and musk ox coexist in the Arctic territory. Their island populations provide a unique natural experiment to assess the role of competition. On Wrangel Island, their population sizes show the opposite trends and the same situation recurs on other Arctic islands--the reindeer population size decreases with the muskoxen population increasing. We have shown that the trends are defined by food-web structure. Niche overlap between species is found to .be considerable and cannot be facilitated by habitat partitioning. The number of plant species in the muskoxen diet was higher than in the reindeer. The exclusive part of the muskoxen diet was higher as well. Food webs in all of the habitat types showed the same relation. However, the changes in herbivores distribution during the Pleistocene demonstrate the opposite pattern. Therefore, the competitive advantage could not save the Palaearctic musk ox, and the extinction seems to be a result of selective overkill. Conclusively, the human activity may be considered as the main factor of the Late Pleistocene herbivore extinctions, and the musk ox reintroducing should be coupled with extensive conservational measures.

Health of adults living with a clinically significant haemoglobinopathy in New South Wales, Australia.

AIM: To comprehensively review the health needs of patients living with clinically significant haemoglobinopathies (thalassaemia and sickle-cell disease (SCD)) in New South Wales, Australia. METHODS: A survey-based health needs assessment was undertaken in outpatients cared for at five tertiary institutions in metropolitan and regional centres. Sixty-three of 121 adults (approximately 80-90% of adult patients with transfusion-requiring haemoglobinopathies in New South Wales) completed an in-house and commercial health-related quality assessment survey (SF-36v2). RESULTS: Subjects came from more than eight world regions, with those with SCD being more likely to be born outside of Australia than subjects with thalassaemia (P < 0.001, likelihood ratio 20.64) as well as more likely to have been refugees (26% vs 2%). The population contained socially disadvantaged subjects with 13 subjects (20.6%) having incomes below the Australian poverty line. Complications of thalassaemia were comparable to previous international reports although our subjects had a high rate of secondary amenorrhea (>12 months = 27%) and surgical splenectomy (55.6%). Use of hydroxyurea in SCD was less than expected with only 46.6% of subjects having prior use. Lack of universal access to magnetic resonance imaging-guided chelation (international best practice) was evident, although 65.5% had been able to access magnetic resonance imaging through clinical trial, or self-funding. CONCLUSIONS: Patients with SCD and thalassaemia experience considerable morbidity and mortality and require complex, multidisciplinary care. This study revealed both variance from international best practice and between specialist units. The results of this research may provide the impetus for the development of clinical and research networks to enable the uniform delivery of health services benchmarked against international standards.

Deep convective clouds with sustained supercooled liquid water down to -37.5 degrees C

In cirrus and orographic wave clouds, highly supercooled water has been observed in small quantities (less than 0.15 g m(-3)). This high degree of supercooling was attributed to the small droplet size and the lack of ice nuclei at the heights of these clouds. For deep convective clouds, which have much larger droplets near their tops and which take in aerosols from near the ground, no such measurements have hitherto been reported. However, satellite data suggest that highly supercooled water (down to -38 degrees C) frequently occurs in vigorous continental convective storms. Here we report in situ measurements in deep convective clouds from an aircraft, showing that most of the condensed water remains liquid down to -37.5 degrees C. The droplets reach a median volume diameter of 17 microm and amount to 1.8 gm(-3), one order of magnitude more than previously reported. At slightly colder temperatures only ice was found, suggesting homogeneous freezing. Because of the poor knowledge of mixed-phase cloud processes, the simulation of clouds using numerical models is difficult at present. Our observations will help to understand these cloud processes, such as rainfall, hail, and cloud electrification, together with their implications for the climate system.

[Peculiarities of a socio-hygienic picture of tuberculosis patients depending on the place of residence].

In the course of the study significant social factors and conditions characterizing patients with active tuberculosis were identified. Depending on the place of patient's residence the working out of a targeted complex of measures is required.

Aerosols, climate, and the hydrological cycle.

Human activities are releasing tiny particles (aerosols) into the atmosphere. These human-made aerosols enhance scattering and absorption of solar radiation. They also produce brighter clouds that are less efficient at releasing precipitation. These in turn lead to large reductions in the amount of solar irradiance reaching Earth's surface, a corresponding increase in solar heating of the atmosphere, changes in the atmospheric temperature structure, suppression of rainfall, and less efficient removal of pollutants. These aerosol effects can lead to a weaker hydrological cycle, which connects directly to availability and quality of fresh water, a major environmental issue of the 21st century.

Adjustment disorder as an admission diagnosis.

OBJECTIVE: The authors' goal was to study subtyping, demographic variables, suicidality, diagnostic stability, and 2-year rehospitalization outcome for inpatients given the admission diagnosis of adjustment disorder at their institution. METHOD: They reviewed the charts of 54 adolescent and 102 adult inpatients given the diagnosis of adjustment disorder at admission and compared them with the charts of 156 matched comparison subjects given other admission diagnoses. RESULTS: Adolescents and adults with adjustment disorder had significantly shorter index hospitalizations and more presenting suicidality than the comparison subjects. Adults but not adolescents with adjustment disorder had significantly fewer psychiatric readmissions and fewer rehospitalization days 2 years after discharge than comparison subjects, and more adults with adjustment disorder had diagnoses of comorbid substance use disorder. Forty percent of the patients admitted with the diagnosis of adjustment disorder were discharged with different diagnoses. Only 18% of the inpatients with adjustment disorder who were rehospitalized were given that diagnosis at readmission. CONCLUSIONS: Adjustment disorder diagnoses were associated with suicidality, shorter lengths of stay, and, in adults, more substance use disorders and fewer rehospitalizations.

Shakespeare and sleep disorders.

Shakespeare was a consummate dramatist and profound observer of human behavior. He vividly described many clinical disorders, including those of sleep. His characters suffered from somnambulism, sleep apnea, insomnia, and nightmares. Sleep, to Shakespeare, was a blessing denied to many of his protagonists.

Retrocardiac pneumomediastinum: radiographic finding and clinical implications.

Fourteen neonates with posterior mediastinal air collections (retrocardiac pneumomediastinum) are described. In the majority of the infants (13 of 14), the mediastinal air developed as a complication of assisted ventilation. It is suggested that the retrocardiac pneumomediastinum represents air trapped in a potential space in the mediastinum posterior to the heart and not within the pulmonary ligament. The collections have a variable shape and size and rarely may produce a tension phenomenon elevating the posterior, inferior portion of the heart off of the diaphragm. There was a strong association of retrocardiac pneumomediastinum with other manifestations of extraalveolar air, including pulmonary interstitial emphysema (13 of 14 infants), pneumothorax (10 of 14 infants), dissection of air into the soft tissues of the neck (10 of 14 infants), and pneumoperitoneum (5 of 14 infants).

Visitation to a neonatal intensive care unit.

Preterm newborns may experience extended periods of hospitalization which disrupt the normal early contact between the newborn and its family. Variations in the frequency of visits to 164 preterm neonates in a neonatal intensive care unit were examined in relation to infant and family status variables and compliance with follow-up appointments at 3 months postterm. The mean number of visitors decreased from day 2 to day 12 of hospitalization and then remained stable through day 21. There was a corresponding increase in the number of days with no visitors through day 12, and then stabilization. Neonates who had intraventricular hemorrhages, whose parents did not live together, and who were not firstborn had the most days with no visitors. While the mother was hospitalized herself, her condition was the only variable related to percentage of no-visitor days. The sicker the mother, the more likely the newborn had no visitors. The greater the number of days with no visitors, the poorer the likelihood that the infant was brought to a 3-month follow-up clinic appointment.

A case of autoimmune thyroiditis presenting as menstrual related mood disorder.

A case of autoimmune thyroiditis presenting as menstrual related mood disorder (MRMD) is described. The symptoms of the patient's prospectively confirmed MRMD remitted following thyroid hormone supplementation. Although most patients with prospectively confirmed MRMD are not clinically hypothyroid or hyperthyroid, the importance of routine thyroid function tests in the initial evaluation of MRMD is underscored by the successful treatment of this patient with thyroid hormone replacement.

Effects of pentafraction and hetastarch plasma expansion on lung and soft tissue transvascular fluid filtration.

BACKGROUND: Hetastarch and pentafraction are high molecular weight starch solutions designed to augment plasma oncotic pressure. Although clinical utilization of hetastarch has been limited by reported coagulation abnormalities, pentafraction is a newer derivative that appears to have few adverse hemostatic effects. We examined the ability of pentafraction to modulate lung and soft tissue transvascular fluid filtration under hypoproteinemic conditions compared with hetastarch and Ringer's lactate (LR). METHODS: Awake, protein-depleted sheep (n = 19) were prepared with lung and soft tissue lymph fistulas, and comparable infusions of 5% pentafraction (n = 6), 6% hetastarch (n = 6), or LR (n = 7) were administered. Plasma and lymph samples were collected during 24-hour period to determine changes in protein concentrations, plasma-to-lymph oncotic gradients, and lung (QL) and soft tissue (QS) lymph flows. RESULTS: QL and QS rose nearly twofold after protein depletion alone. LR infusion increased QL and QS to 8.7 +/- 1.7 and 3.1 +/- 0.6 times normoproteinemic baseline, respectively (p < 0.05). In contrast, hetastarch and pentafraction infusion limited the increase in QL to 4.2 +/- 1.1 and 4.0 +/- 0.8 times normoproteinemic baseline, respectively (p < 0.05 versus LR) and did not significantly increase QS. Hetastarch and pentafraction infusions increase plasma oncotic pressure by nearly 6 mm Hg, which significantly widened the plasma-to-lymph oncotic pressure gradients above preinfusion baseline by 4.7 +/- 0.7 and 3.4 +/- 0.4 mm Hg in lung and 4.6 +/- 0.7 and 3.2 +/- 0.4 mm Hg in soft tissue, respectively (p < 0.05). CONCLUSIONS: Both hetastarch and pentafraction limit transvascular fluid filtration under hypoproteinemic conditions by augmenting plasma oncotic pressure and the plasma-to-lymph oncotic pressure gradient. Because of fewer adverse hemostatic effects pentafraction may be an improvement over current therapies in critical care fluid management.

Pulmonary and systemic fluid filtration after continuous versus bolus interleukin-2 infusion.

Interleukin-2 has been widely investigated as adjuvant therapy for advanced cancer and is administered by either bolus or continuous infusion. We compared the effects of bolus and continuous interleukin-2 infusion on pulmonary (QL) and systemic microvascular fluid filtration in 11 adult sheep prepared with chronic lung and soft-tissue lymph fistulas. Interleukin-2 was administered as a bolus infusion (100,000 units/kg) every 8 hours for 3 days or as a continuous infusion at the same dose for 3 days. No significant changes in pulmonary hydrostatic pressures or pulmonary vascular resistance were noted after either bolus or continuous interleukin-2 infusion. However, significantly decreased (p less than or equal to 0.05) systemic vascular resistances were observed in both groups. QL increased steadily throughout the infusion period in both groups, peaking at three times baseline on the third infusion day. The plasma/interstitial protein clearance (QL X lymph/plasma protein ratio) rose similarly in both groups, indicating increased barrier permeability. Increased lymphocyte clearance into lung lymph occurred by day 3 but was not associated with lymphocytic sequestration in the lung interstitium. We conclude that pulmonary and systemic microvascular fluid and protein flux exhibit similar changes after bolus or continuous interleukin-2 infusion. These changes are associated with increased clearance of lymphocytes into lung lymph that are not sequestered in the pulmonary interstitium after infusions of shorter duration.

Subsequent pregnancies in previously infertile women with endometriosis.

Sixty-eight previously infertile patients with endometriosis who had delivered a child tried to conceive again. Fifty-two of them were successful, 28 within 1 year, and 16 were not. The ability to conceive a second child was uniformly good regardless of the stage of the previous disease, the method of treatment, the duration of the initial sterility, or the age of the patient. Patients with endometriosis and infertility who deliver should be reassured concerning their chances of completing their families.

Reproductive problems in the DES-exposed female.

The records of 25 diethylstilbestrol-exposed women under treatment for reproductive dysfunction were reviewed. A tendency toward pregnancy wastage (5 of 10 patients), ectopic pregnancy (2 of 8 patients), cervical factor infertility (15 of 20 patients), hysterographic abnormalities (15 of 19 patients), and ovulatory dysfunction (10 of 25 patients) was noted. With the exceptions of ovulation induction and cervical cerclage, no means of treatment can be recommended.

Diagnosis of luteal phase inadequacy.

Plasma progesterone concentrations drawn at the time of endometrial biopsy in 26 infertility patients with histologically documented luteal phase inadequacy were compared with those of 26 infertility patients with normal biopsies. Although as a group the former patients had lower progesterone values and shorter cycles, there was considerable overlap. Therefore, although plasma progesterone determinations and temperature charts are useful in the detection of ovulation and in the interpretation of the biopsy results, a properly obtained endometrial biopsy is essential for the diagnosis of luteal phase inadequacy.

Perinatal outcome after multifetal reduction to twins compared with nonreduced multiple gestations.

The outcomes of twins resulting from multifetal reduction were analyzed to examine whether the outcome was improved over that of triplet and quadruplet pregnancies and similar to that of twin pregnancies not involving multifetal reduction. Maternal and perinatal outcomes were examined retrospectively in 62 infertile women who conceived multiple gestations with ovulation induction. The mean gestational age at birth of quadruplets was significantly less than that of twins reduced from quadruplets (24.8 versus 31.0 weeks; P less than .001), and there was appreciable neonatal mortality in the nonreduced quadruplets (62%). In twins selectively reduced from triplets as compared with nonreduced triplets, the mean gestational age at birth, though statistically significant, differed by an average of only 1.7 weeks (34.8 versus 33.1 weeks; P less than .05), and the mean gestational birth weight differed only by 380 g (2305 versus 1924.7 g; P less than .05). Triplets required a longer average stay in the neonatal intensive care unit than did twins resulting from multifetal triplet reduction (20.7 versus 8 days; P less than .001). Although five sets of triplets (20%) were born before 32 weeks, there were only two neonatal deaths, with the remainder of the 58 infants eventually discharged home. The mean gestational age of twins selectively reduced from triplets or quadruplets was significantly less than that for nonreduced twins (32.6 versus 35.3 weeks; P less than .001), and the groups differed by 1605 g in mean birth weight (1841.8 versus 2447.5 g; P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

A phase I/II study of intensive dose escalation of cytarabine in combination with idarubicin and etoposide in induction and consolidation treatment of adult acute myeloid leukemia. Australian Leukaemia Study Group (ALSG).

To determine the safety and efficacy of the combination of idarubicin, cytarabine and etoposide ("ICE") for induction and consolidation treatment of acute myeloid leukemia (AML), and of dose-intensification of cytarabine in this setting, 54 previously untreated patients in three cohorts were studied by sequential dose escalation of cytarabine, in combination with standard doses of idarubicin and etoposide. Cytarabine was given to Cohort 1 at the conventional dosage of 100 mg/m2 per day by continuous infusion for 7 days in induction and 5 days in consolidation; to Cohort 2 at high-dose (HiDAC) (3 g/m2 intravenously twice daily on days 1, 3, 5 and 7) during induction with conventional dosage during consolidation; to Cohort 3 HiDAC was given for both induction and consolidation. In addition, Cohort 3 patients received lenograstim (Granocyte; rHuG-CSF) after both induction and consolidation courses. We found that there was no significant difference between the three cohorts in hematological toxicity in induction, but that HiDAC was associated with a greater incidence of gastro-intestinal toxicities. There was no difference in induction mortality between the three cohorts, which was 11% overall. Consolidation with HiDAC led to a significant increase in hematological toxicity. Overall, the complete remission (CR) rate was 80% with no significant difference between the three regimens. The estimated disease free survival at 3 years was 28%, 67% and 54% respectively for Cohorts 1, 2 and 3 with an estimated overall survival of 38%, 63% and 47%. We conclude that cytarabine dosage can be escalated safely in combination with idarubicin and etoposide in both induction and consolidation. The combination is effective for induction treatment of AML and its side-effects appear similar to those of standard regimens. Whether its use offers long-term benefits compared with standard regimens is the subject of ongoing controlled randomized studies.

Abdominal myomectomy for otherwise unexplained infertility.

Twenty-three patients with otherwise unexplained infertility underwent abdominal myomectomy for the removal of subserous or intramural myomata. None were submucosal in location. Fifteen of these patients (65.2%) conceived. There were 18 term births in 13 patients. All but 1 patient conceived within the first year. The age of the patient, duration of infertility, size and number of the fibroids, hysterosalpingography, or presence of menorrhagia did not necessarily predict success.

Endometrial biopsy in the cycle of conception.

The pregnancy outcome of 18 infertile patients inadvertently biopsied during the cycle of conception is reviewed. Fourteen patients delivered term infants, one a premature infant; one patient aborted during the first trimester, and two patients were lost to follow-up. The pregnancy outcome was better than that frequently quoted for infertile patients. A comparison of the present series with those previously reported is made and the author's technique for endometrial biopsy is discussed. The average duration of gestation is calculated using the endometrial biopsy.