The effect of perineural dexamethasone on duration of sciatic nerve blockade: a randomized, double-blind study.

BACKGROUND: Major hindfoot and ankle surgery is associated with severe postoperative pain, which is effectively alleviated by combined sciatic and saphenous nerve blockade. Local anaesthetics with added dexamethasone consistently prolongs the duration of pain relief compared to local anaesthetics alone. However, whether the extended duration of pain relief is due to an effect on duration of sensorimotor block per se vs. systemic absorption of the dexamethasone is still not fully elucidated. We aimed to investigate the postoperative duration of sensorimotor blockade with either dexamethasone or saline added to bupivacaine-epinephrine. METHODS: Fifty six patients scheduled for surgery were randomly assigned to a popliteal sciatic nerve block of 18 ml 0.5% bupivacaine-epinephrine with either 2 ml of 0.4% dexamethasone or 2 ml 0.9% normal saline added. Sensory and motor functions were tested every 30 min until normalized nerve functions. Primary outcome was time until complete return of sensorimotor functions. RESULTS: Mean (SD) time until return of normal sensory and motor functions was 26 (6) vs. 16 (4) hours, P < 0.001, postponing block remission by 10 (95% CI: 8-13) hours. Mean (SD) time until first opioid request was 34 (11) vs. 15 (7) hours, P < 0.001, extending first opioid request by 19 (95% CI: 13-25) hours. Total oral morphine equivalents administered 0-48 h differed significantly between the two groups by 39 (95% CI: 23-55) mg. CONCLUSIONS: Addition of 8 mg dexamethasone to 0.5% bupivacaine-epinephrine significantly prolongs the duration of sensorimotor popliteal sciatic nerve blockade, and reduces pain and opioid consumption in patients after major hind foot and ankle surgery.

Adverse childhood experiences in relation to mood and anxiety disorders in a population-based sample of active military personnel.

BACKGROUND: Although it has been posited that exposure to adverse childhood experiences (ACEs) increases vulnerability to deployment stress, previous literature in this area has demonstrated conflicting results. Using a cross-sectional population-based sample of active military personnel, the present study examined the relationship between ACEs, deployment related stressors and mood and anxiety disorders. METHOD: Data were analyzed from the 2002 Canadian Community Health Survey-Canadian Forces Supplement (CCHS-CFS; n = 8340, age 18-54 years, response rate 81%). The following ACEs were self-reported retrospectively: childhood physical abuse, childhood sexual abuse, economic deprivation, exposure to domestic violence, parental divorce/separation, parental substance abuse problems, hospitalization as a child, and apprehension by a child protection service. DSM-IV mood and anxiety disorders [major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic attacks/disorder and social phobia] were assessed using the composite international diagnostic interview (CIDI). RESULTS: Even after adjusting for the effects of deployment-related traumatic exposures (DRTEs), exposure to ACEs was significantly associated with past-year mood or anxiety disorder among men [adjusted odds ratio (aOR) 1.34, 99% confidence interval (CI) 1.03-1.73, p < 0.01] and women [aOR 1.37, 99% CI 1.00-1.89, p = 0.01]. Participants exposed to both ACEs and DRTEs had the highest prevalence of past-year mood or anxiety disorder in comparison to those who were exposed to either ACEs alone, DRTEs alone, or no exposure. CONCLUSIONS: ACEs are associated with several mood and anxiety disorders among active military personnel. Intervention strategies to prevent mental health problems should consider the utility of targeting soldiers with exposure to ACEs.

Common mental disorder diagnosis and need for treatment are not the same: findings from a population-based longitudinal survey.

BACKGROUND: Controversy exists regarding whether people in the community who meet criteria for a non-psychotic mental disorder diagnosis are necessarily in need of treatment. Some have argued that these individuals require treatment and that policy makers need to develop outreach programs for them, whereas others have argued that the current epidemiologic studies may be diagnosing symptoms of distress that in many cases are self-limiting and likely to remit without treatment. All prior studies that have addressed this issue have been cross-sectional. We examined the longitudinal outcomes of individuals with depressive, anxiety and substance use (DAS) disorder(s) who had not previously received any treatment. Method Data came from a nationally representative US sample. A total of 34 653 non-institutionalized adults (age ≥20 years) were interviewed at two time points, 3 years apart. DAS disorders, mental health service use and quality of life (QoL) were assessed at both time points. RESULTS: Individuals with a DAS disorder who had not previously received any treatment were significantly more likely than those who had been previously treated to have remission of their index disorder(s) without subsequent treatment, to be free of co-morbid disorder(s) and not to have attempted suicide during the 3-year follow-up period (50.7% v. 33.0% respectively, p < 0.05). At wave 2, multiple linear regression demonstrated that people with a remission of their baseline DAS disorder(s) had levels of functioning similar to those without a DAS disorder. CONCLUSIONS: Individuals with an untreated DAS disorder at baseline have a substantial likelihood of remission without any subsequent intervention.

A low proportion of malnourished patients receive nutrition treatment - results from nutritionDay.

NutritionDay is a yearly point-prevalence study of malnutrition in hospitals from more than 50 countries. The aim of the present study was to quantify the frequency of malnutrition and the proportion of malnourished patients receiving nutritional treatment in two university hospitals in Norway using data from nutritionDay. All units at Oslo University Hospital (OUH) and University Hospital of Northern Norway (UNN) were invited to participate in nutritionDay 2014, and 28 out of 85 eligible units agreed to take part. Malnutrition was diagnosed based on body mass index (BMI), weight reduction and food intake in the previous week, according to national guidelines and ESPEN criteria. Data from 488 patients were available, representing 90.1% of occupied beds in participating units. Thirty percent of the patients were diagnosed malnourished when national criteria were used, and only 41% of these patients received nutritional treatment. The estimated malnutrition rate was 11% when the ESPEN consensus criteria were used. Data on weight or height were frequently missing in the patient records, and BMI could only be calculated in two-thirds of the patients. The frequency of low BMI (<18.5 kg/m2) was only 5%. Involuntary weight loss was present in 37% of the patients, and 60% had eaten less than normal in the previous week. Oncology units had the highest frequency of patients with low BMI, and the highest weight loss and overall malnutrition rate. Surgery and geriatric units had the highest rate of patients with low food intake. In this study, nearly 60% of the malnourished patients did not receive any nutritional treatment, and this indicates a potential for improved nutritional care and cost savings. Low food intake and weight loss were frequent at these two Norwegian hospitals, and in line with previous reports from nutritionDay in other countries.

Fat-soluble vitamins in breast-fed preterm and term infants.

OBJECTIVE: To examine the supply and status of fat-soluble vitamins in very low birth weight (VLBW) infants compared to a reference group of normal birth weight (NBW) infants. DESIGN: A longitudinal study of VLBW infants in the early neonatal period. Blood samples were drawn at 1 week of age and at discharge from hospital. Plasma was analyzed for the fat-soluble vitamins: retinol, 25-OH-vitamin D, alpha-tocopherol and phylloquinone (vitamin K(1)) using high-performance liquid chromatography. SUBJECTS: A total of 40 VLBW infants were included in the study. A reference group of 33 NBW infants was randomly selected from one of our previous studies. RESULTS: The VLBW infants received fortified human milk, and daily oral vitamin supplement (Multibionta). In VLBW infants, plasma retinol concentrations decreased and plasma 25-OH-vitamin D increased during the study period. VLBW infants had significantly lower plasma retinol (0.3 vs 0.7 mu M) and higher plasma 25-OH-vitamin D (166 vs 25 nM) at discharge compared to NBW infants. Plasma phylloquinone concentration in VLBW infants was very high (53 ng/ml) at one week of age, especially in the youngest infants (192 ng/ml), but decreased rapidly during the study period resulting in low/normal plasma concentrations (0.9 ng/ml) at discharge. CONCLUSIONS: We observed alterations in plasma concentration of retinol and 25-OH-vitamin D in VLBW infants in the early neonatal period, resulting in marked differences between VLBW at discharge and NBW. Further trials are needed to evaluate whether changes in vitamin supplementation may improve clinical outcome in VLBW infants.

Growth energetics and metabolic fluxes in continuous cultures of Penicillium chrysogenum.

Continuous cultures of the penicillin producing fungus Penicillium chrysogenum have been analyzed with respect to the macromolecular composition of the mycelium. All cultivations were carried out using a chemically defined medium with glucose as the growth limiting component. Biomass was harvested at steady state and analyzed for proteins, lipids, RNA, DNA, and carbohydrates. Carbohydrates present in the cell wall, i.e., glucans and chitin, and carbohydrates serving as storage materials, i.e., glycogen, were measured. It was observed that the levels of DNA and lipids are relative constant, whereas the proteins and stable RNA levels increase with the specific growth rate and the total amount of carbohydrates decreases with the specific growth rate. Glycogen is only present in small amounts, decreasing with the specific growth rate. As an average the measured macromolecules account for 77 +/- 2% (w/w) of the biomass. On the basis of estimations of the metabolic costs for biosynthesis and polymerization of the different macromolecules the total ATP and NADPH requirements for cell biosynthesis from glucose and inorganic salts, i.e., YxATP,growth and YxNADPH, have been quantified. The biosynthesis of 1 g biomass was calculated to require 39.9 mmol of ATP and 7.5 mmol of NADPH when cytosolic acetyl-CoA is formed from citrate by citrate lyase and oxaloacetate is recycled back into the TCA cycle. Other pathways of acetyl-CoA biosynthesis have been considered. The calculations show that the different biosynthetic routes for generating cytosolic acetyl-CoA have a significant influence on the theoretical value of ATP and NADPH requirements for cell biosynthesis. Combining a detailed stoichiometric model for growth and product formation of P. chrysogenum with experimental data on the macromolecular composition of P. chrysogenum and precise measurements of substrate uptake and product formation the intracellular flux distribution was calculated for different cultivation conditions.

Continuous cultivation of Penicillium chrysogenum. Growth on glucose and penicillin production.

A series of constant-mass, continuous cultivations of the penicillin producing mold Penicillium chrysogenum was carried out using a chemically defined medium with glucose as the growth-limiting component. The stoichiometry for growth of P. chrysogenum on glucose was characterized in terms of mass-yield and maintenance coefficients. Saturation kinetics with respect to glucose was used to describe the glucose consumption rate at steady-state conditions. Transient data indicate that the maximum rate of glucose consumption at a particular set of operating conditions is correlated to the metabolic 'capacity' of the mold as reflected by its intracellular RNA content. A progressive loss in the penicillin productivity in glucose limited chemostat cultures was correlated to the formation of two mutants. The two mutants were characterized by their sporulation when grown as surface cultures and by Southern dot-tests for delta-(L-alpha-aminoadipyl)-L-cysteinyl-D-valine synthetase (ACVS), isopenicillin-N synthase (IPNS) and acyl-CoA:6-APA acyltransferase (AT). The loss of penicillin productivity was caused by an increasing fraction of mutants which had lost the genes encoding for all three enzymes needed in the penicillin synthesizing pathway.

Diet and vitamin D status among pregnant Pakistani women in Oslo.

OBJECTIVES: In the present study the diet and the nutritional status of pregnant Pakistani immigrant women have been compared with a group of Norwegian women. DESIGN: A cross-sectional survey of women in the 18th week of pregnancy. SETTING: Women referred to routine ultrasound examination at Aker and Ullevål Hospitals in Norway. SUBJECTS: All (58) healthy women of Pakistani origin referred from October of 1991 to January of 1992 were included, of whom 38 (66%) participated. Forty-five Norwegian women were randomly included in the same period and 38 (84%) of these women participated. RESULTS: The serum levels of 25-hydroxyvitamin D3 were significantly lower in the Pakistanis compared with the Norwegians (median 19 nmol/l vs 55 nmol/l, P < 0.001) and 83% of the Pakistani women had 25-hydroxyvitamin D3 levels below the reference value (< 30 nmol/l). The Pakistanis had higher levels of serum parathyroid hormone (median 2.6 vs 1.6 pmol/l, P < 0.001). The Pakistanis also had a lower dietary intake of vitamin D than that of the Norwegians (median 2.2 vs 3.3 micrograms/day, P < 0.05), and a lower total intake, including supplements (median 2.9 vs 7.0 micrograms/day, P < 0.001). Among the Pakistanis a correlation was found between the dietary intake of margarine, the main source of vitamin D in the diet, and the concentration of 25-hydroxyvitamin D3 in serum, r = 0.48 (P = 0.01). In general, the Pakistanis avoided any direct sunshine exposure, and no relation between outdoor activity and serum level of 25-hydroxyvitamin D3 was found. The Pakistani women had a lower intake of calcium than the Norwegians (median 793 vs 1134 mg/day, P < 0.001). CONCLUSION: This study has shown that Pakistani women living in Oslo are at great risk of developing vitamin D deficiency during pregnancy. The main reasons for this are avoidance of sun exposure, a low dietary intake of vitamin D, and no or little use of supplementation.

Evidence of long distance airborne transmission of Aujeszky's disease (pseudorabies) virus.

Aujeszky's disease has been the subject of an eradication campaign in Denmark since 1980. A detailed knowledge of the virus strains present in the country was provided by restriction fragment analyses of older clinical isolates, and of isolates from all the virologically confirmed outbreaks since 1985. The introduction of foreign strains into southern border areas was demonstrated during the winters of 1984/85, 1986/87 and 1987/88. An epizootic during the winter of 1987/88 was shown to correlate with an unusual predominance of southerly winds. Both conventional and specific pathogen free herds became infected. A herd level case-control analysis of the outbreaks during the winter of 1987/88 revealed that there was a positive correlation between the risk of infection and the size of the herd. The observations support the hypothesis of airborne transmission of the disease.

Further evidence of long distance airborne transmission of Aujeszky's disease (pseudorabies) virus.

In spite of the eradication of Aujeszky's disease in Denmark a single outbreak was recorded in December 1988 and another severe epizootic took place during the winter and spring of 1989/90. The epizootic occurred in nearly the same areas as the preceding epizootic during the winter of 1987/88. Identification of the strains of virus involved eliminated the possibility that the latest epizootic was due to the persistence of virus in the pig population. Furthermore, as during the preceding epizootic, initial recordings of the new strains were found to coincide with periods with southerly winds. It was concluded from circumstantial evidence that the concurrent introductions of virus to several farms played a major role during the epizootic.

[Orthopedic ambulatory surgery. A study of patient satisfaction]. / Ortopaedkirurgisk endagskirurgi. Patienttilfredshedsundersøgelse.

One hundred and eighty-two patients who underwent ambulatory orthopaedic surgery received a questionnaire, 168 (92%) answered. Fourteen patients (7.7%) had to stay in hospital for one to three nights. One hundred and forty-seven (87.5%) found it acceptable to be discharged the same day, and 145 (86.3%) would prefer ambulatory to stationary treatment in case of new surgery.

[Diagnosis and treatment of injuries to the lateral ligaments of the ankle joint]. / Diagnose og behandling af laterale ligamentlaesioner i fodleddet.

Injury to the lateral ligaments of the ankle joint is one of commonest injuries seen in the casualty department. The diagnostic routines and treatment vary considerably from one hospital to another. The methods for precise diagnosis and treatment are reviewed and discussed and the main emphasis is placed on major prospective investigations. The authors suggest that the diagnosis should be made on the basis of the clinical examination and that, regardless of the degree of ligamental injury, treatment should consist of adhesive strapping. Primary identification of patients with prolonged symptoms is an unsolved problem since the degree of ligamental injury is not a reliable predictor.

[Indication for radiological examination in acute ankle distorsion]. / Indikation for røntgenundersøgelse ved akut ankeldistorsion.

Inversion injuries of the ankle are a common cause of presentation to accident and emergency units. They impose a major load on radiological services. A prospective study was carried out to test the hypothesis that a thorough physical examination can eliminate the need for a large number of radiographs obtained in patients with acute ankle trauma. Two hundred and one patients were seen in the emergency department for acute ankle trauma. All patients were assessed clinically, then examined radiographically. Sensitivity and specificity of various clinical signs were calculated. Swelling, focal bony tenderness on the lateral malleollus, and decreased ability to bear weight were found to be the most important predictors, especially if present simultaneously. According to this material bimalleolar distance ratio cannot be used as predictor.

[Vitamin D deficiency among pregnant women from Pakistan. How best to prevent it?]. / Vitamin D-mangel blant gravide fra Pakistan. Hvordan best forebygge?

Vitamin D deficiency is common among pregnant Pakistani women now living in Norway. This study was carried out to evaluate a health programme consisting of free samples of vitamin D (10 micrograms/day) combined with information about vitamin D deficiency. 38 pregnant women were included in the 18th week of pregnancy (study group) and blood samples were taken both at inclusion and after delivery. In addition, 18 other Pakistani women (control group) were included after giving birth at the same hospitals during the same period. 83% (30/36) of the pregnant women (study group) were vitamin D deficient (calcidiol < 30 nmol/l) at inclusion. Only 33% (11/33) of the women took more vitamin D than 5 micrograms/day. 19 of the women agreed to having a new blood sample taken after delivery, and 56% (10/18) of these women were still vitamin D deficient. 76% (13/17) of the women in the control group were vitamin D deficient at delivery. In conclusion the study demonstrates that it can be difficult to prevent vitamin D deficiency in the Norwegian immigrant population just by providing information and free samples of vitamin D.

Redirection of pyruvate catabolism in Lactococcus lactis by selection of mutants with additional growth requirements.

Based on requirements for acetate or lipoic acid for aerobic (but not anaerobic) growth, Lactococcus lactis subsp. lactis mutants with impaired pyruvate catabolism were isolated following classical mutagenesis. Strains with defects in one or two of the enzymes, pyruvate formate-lyase (PFL), lactate dehydrogenase (LDH) and the pyruvate dehydrogenase complex (PDHC) were obtained. Growth and product formation of these strains were characterized. A PFL-defective strain (requiring acetate for anaerobic growth) displayed a two-fold increase in specific lactate production compared with the corresponding wild-type strain when grown anaerobically. LDH defective strains directed 91-96% of the pyruvate towards alpha-acetolactate, acetoin and diacetyl production when grown aerobically in the presence of acetate and absence of lipoic acid (a similar characteristic was observed in an LDH and PDHC defective strain in the presence of both acetate and lipoic acid) and more than 65% towards formate, acetate and ethanol production under anaerobic conditions. Another strain with defective PFL and LDH was strictly aerobic. However, a variant with strongly enhanced diacetyl reductase activities (NADH/NAD+ dependent diacetyl reductase, acetoin reductase and butanediol dehydrogenase activities) was selected from this strain under anaerobic conditions by supplementing the medium with acetoin. This strain is strictly aerobic, unless supplied with acetoin.

Modelling of the protonophoric uncoupling by phenoxyacetic acid of the plasma membrane potential of Penicillium chrysogenum.

Physiological effects of phenoxyacetic acid, the penicillin V side-chain precursor, on steady-state continuous cultures of Penicillium chrysogenum have been studied both theoretically and experimentally. Theoretical calculations show that at an extracellular pH of 6.50, phenoxyacetic acid has negligible influence on the growth energetics due to protonophoric uncoupling of membrane potentials by passive diffusive uptake. On the other hand, when the extracellular pH is lowered to 5.00, a severe maintenance-related uncoupling effect of phenoxyacetic acid is calculated. These findings were confirmed experimentally by steady-state continuous cultivations with a high-yielding penicillin strain of P. chrysogenum performed on a chemically defined and glucose-limited medium at pH 6.50 and pH 5.00, both with and without phenoxyacetic acid present. The yield and maintenance coefficients were determined from steady-state measurements of the specific uptake rates of glucose and oxygen and the specific production rate of carbon dioxide as functions of the specific growth rate. Combining these data with a simple stoichiometric model for the primary metabolism of P. chrysogenum allows quantitative information to be extracted on the growth energetics in terms of ATP spent in maintenance- and growth-related processes, i.e. mATP and YxATP. The increased maintenance-related ATP consumption when adding phenoxyacetic acid at pH 5.00 agrees with the theoretical calculations on the uncoupling effect of phenoxyacetic acid. When YxATP is compared with earlier reported values for the theoretical ATP requirement for biosynthesis of P. chrysogenum, i.e. YxATP, growth, it is found that YxATP,growth is only 40-50% of YxATP, which stresses that a large amount of ATP is wasted in turnover of macromolecules, leaks, and futile cycles.

Citrate can partially replace carbon dioxide required for growth of Lactococcus lactis subsp. lactis biovar diacetylactis.

Lactococcus lactis subsp. lactis biovar diacetylactis was grown as batch cultures on a chemically defined medium. No growth was observed when the cultures were sparged with pure nitrogen (1.3 l l-1 min-1) whereas the cultures displayed exponential growth in the presence of minute amounts of carbon dioxide (0.035 mol-% of the inlet gas). However, in the former case, the addition of citrate restored growth. This suggested that oxaloacetate required for aspartate biosynthesis can be formed by the carboxylation of pyruvate or by citrate catabolism. When the cultures were heavily sparged with nitrogen (2.6 l l-1 min-1), no growth was observed even in the presence of citrate. This indicated that growth in these conditions was repressed by the absence of carbon dioxide required in some other biosynthetic reaction than in the carboxylation of pyruvate leading to oxaloacetate/aspartate biosynthesis.

Nutrient intake among two-year-old children on cows' milk-restricted diets.

UNLABELLED: Approximately 2-3% of young children develop allergy or intolerance to cows' milk. The only available treatment is elimination of milk from the diet. However, as milk is an important source of nutrients in childhood, a milk-free diet may not adequately meet the child's nutritional needs. A dietary survey was conducted to assess the nutrient intake of children on cows' milk-restricted diets. A population-based sample of families with young children (31-37 mo) with adverse reaction to cows' milk and/or eggs was contacted, of which 75% agreed to complete a dietary intake assessment. Dietary intake was assessed using a 4-d weighed recording. The nutrient intake in a group of children on cows' milk protein-free (n = 16) and cows' milk reduced (n = 8) diets were compared to a group of cows' milk consumers (n = 10). There were significant differences in nutrient intake of children on milk-free diets and children consuming milk. Children on milk-free diets had significantly lower intake of energy, fat, protein, calcium, riboflavin and niacin. Use of milk substitutes improved the nutritional content of the cows' milk-free diets; however, the recommendations for riboflavin and calcium were still not met. CONCLUSION: The results reveal a risk for malnutrition in children on cows' milk-free diets, unless precautions are taken to replace the valuable nutrients from milk in the diet. Parents of children on milk-free diets need advice about food choices in order to reduce the risk of low intake of energy, fat and protein. Supplements with calcium, vitamin D and riboflavin are indicated.

Iron deficiency among pregnant Pakistanis in Norway and the content of phytic acid in their diet.

BACKGROUND: To test the hypothesis that iron deficiency is more common among pregnant Pakistani than pregnant Norwegian women in Oslo; and to determine whether differences in the diet can explain some of the differences in stored iron. METHODS: A cross sectional study in the 18th week of pregnancy. Thirty-eight Pakistani women and 38 Norwegian women referred to routine ultrasound examination at Aker and Ullevål Hospitals in Oslo participated. Analysis was undertaken of phytate (inositol hexaphosphate) and its degradation products in bread and chapatti. RESULTS: Twenty-six (68%) of the Pakistani and six (17%) of the Norwegian women had ferritin levels below 12 micrograms/l and a highly significant difference in serum ferritin was found between the groups (p < 0.001). Only one of the Pakistani and seven of the Norwegian women were supplemented with iron and there were no significant differences in the dietary intake of hem iron, non-hem iron, organic fiber, tea, ascorbic acid, meat or cereals. The content of inositol hexaphosphate (phytate) and inositol pentaphosphate, well known inhibitors of iron absorption, were measured in bread and chapatti and the estimated dietary intake was much higher in the Pakistani group, mean (95% CI) was 1175 mumol/day (933-1417) and 507 mumol/day (417-597) respectively, p < 0.001. CONCLUSIONS: Iron deficiency seems to be far more common among pregnant Pakistanis in Norway than among pregnant Norwegians. We speculate that the main reasons for this are a combination of a higher parity and a less common use of iron supplementation in pregnancy in the Pakistani group, and a higher content of phytate in the Pakistani diet.