PURPOSE: A dose-finding study to investigate the use of epidural infusions of ropivacaine for postoperative analgesia following orthopaedic surgery. METHODS: This was a randomized, double-blind study. Surgery was performed using a combination of a lumbar epidural block utilizing ropivacaine 0.5% and a standardized general anaesthetic. Postoperatively, an epidural infusion of the study solution (saline, ropivacaine 0.1%, 0.2% or 0.3%) was started at the rate of 10 ml.hr-1 and continued for 21 hr after arrival in the PACU. Analgesia was supplemented with PCA morphine (dose = 1.0 mg, lock-out = 5 min). RESULTS: Forty-four patients completed the study. The ropivacaine 0.1%, 0.2%, 0.3% groups required less morphine over the 21 hr than the saline group (P < 0.01). The VAS pain scores were also lower in the three ropivacaine groups (P < 0.001). The ropivacaine groups maintained sensory anaesthesia to pinprick when compared with saline (P < 0.05). The motor block in the 0.3% group was significantly higher than the saline group at all times (P < 0.05), and higher than the 0.1% group at eight hours (P < 0.01), while the 0.2% group had higher Bromage scores than saline at 4 and 21 hr (P < 0.05). CONCLUSIONS: The use of continuous epidural infusions of ropivacaine 0.1%, 0.2% and 0.3% at 10 ml.hr-1 improved postoperative pain relief and decreased PCA morphine requirements in patients undergoing major orthopaedic surgery. The 0.1% and 0.2% concentrations produced similar sensory anaesthesia with less motor blockade than the 0.3% concentration.

Adult↗

PubMed1996

A double-blind comparison of ropivacaine 0.5%, 0.75%, 1.0% and bupivacaine 0.5%, injected epidurally, in patients undergoing abdominal hysterectomy.

PURPOSE: Ropivacaine is a new long-acting, injectable local anaesthetic currently undergoing clinical investigation world wide. It is structurally very similar to bupivacaine, but with less potential for central nervous system or cardiac toxicity. The purpose of this double-blind study was: to investigate the dose-response relationship of increasing doses of ropivacaine on the quality of anaesthesia and the duration of both motor and sensory blockade, and to compare these results with an established local anaesthetic, bupivacaine. METHODS: One hundred and twenty five patients were randomly assigned to one of four treatment groups and 116 completed the study. Epidural anaesthesia was established using 25 ml test solution, injected over three minutes following a satisfactory test dose. Sensory onset, spread and duration, using the pin prick method, and motor scores using a modified Bromage scoring system were compared. RESULTS: A dose/response relationship was observed with increasing doses of ropivacaine for all variables tested except analgesia and muscle relaxation (P < 0.01). There were differences in: (i) motor onset (Levels 1 and 2), when ropivacaine 1.0% was compared with ropivacaine 0.75% and 0.5% (P < 0.05); (ii) in sensory duration at all levels except T6 when ropivacaine was compared with ropivacaine 0.5% (P < 0.05); (iii) differences in sensory duration at T12 and S1 when ropivacaine 1.0% was compared with bupivacaine 0.5% (P < 0.05); (iv) differences in motor duration at all levels when ropivacaine 1.0% was compared with ropivacaine 0.5% (P < 0.05). No serious adverse events were reported in this study. CONCLUSION: Increasing doses of ropivacaine were associated with an increased clinical effect. The most consistent differences occurred when ropivacaine 1.0% was compared with 0.5% and the least consistent between ropivacaine 0.5%, 0.75% and bupivacaine 0.5%. The main difference between ropivacaine 1.0% and bupivacaine was in sensory duration. No serious adverse events were reported.

Adolescent↗

PubMed1996

Bone mass and metabolism in women aged 45-55.

OBJECTIVE: Changes in calcium homeostasis and bone mass around the climacteric are poorly understood. We examined relations between endocrine factors and indices of bone mass and metabolism in healthy women approaching the menopause. DESIGN: Cross-section study. PATIENTS: Sixty-eight spontaneously menstruating women aged 45-55. MEASUREMENTS: Bone density measured at lumbar spine (LS) and femoral neck (FN) using dual energy X-ray absorptiometry and distal non-dominant forearm using peripheral quantitative computed tomography. We recorded menstrual history, physical activity and dietary calcium, and measured serum calcium, phosphate, alkaline phosphatase, osteocalcin, vitamin D, fT3, T4, TSH, PTH, FSH and oestradiol (E2), and urinary pyridinoline (PYD) and deoxypyridinoline (DPD) excretion. RESULTS: Using serum FSH level as a marker of ovarian function, 63 subjects could be classified into one of three groups: group A (serum FSH < 10 U/l, n = 29), group B (10-35 U/l, n = 27) and group C (> 35 U/l, n = 7). Bone density fell with declining ovarian function at the LS, FN and forearm trabecular (but not cortical) sites. Serum PTH was lower in group A vs B (mean (SD) 2.68 (0.97) vs 3.52 (1.17) pmol/l, P < 0.05), but similar to group C (2.90 (1.09) pmol/l, P = NS). Serum phosphate was elevated in group C compared to groups A and B (1.17 (0.15) vs 1.04 (0.11) and 1.05 (0.13) mmol/l, P < 0.05), and urinary PYD (61.1 (8.0) vs 50.4 (11.6) and 43.9 (8.1) mumol/mol creatinine) and DPD (15.9 (3.9) vs 12.0 (3.6) and 11.4 (3.6) mumol/mol creatinine) excretion were also increased. There were no significant differences in vitamin D metabolites or osteocalcin. Multivariate analysis suggested serum osteocalcin was positively related to physical activity and serum 1,25-dihydroxycholecalciferol levels. Serum free T3 was positively correlated with urinary DPD excretion, and inversely related to serum PTH. In all subjects, serum PTH was related to body weight (r = 0.38, P = 0.002). CONCLUSIONS: Declining ovarian function before menopause is accompanied by reductions in bone mass and altered calcium metabolism. Free T3 may regulate bone resorption and indirectly modulate PTH release.

Amino Acids↗

PubMed1996

Tobacco control: overview.

This chapter assesses the principal components of an effective tobacco control programme in relation to efficacy, reach (i.e. numbers of smokers influenced) and cost-effectiveness. National targets for the reduction of prevalence are most likely to be achieved through the use of high reach interventions such as fiscal policy and mass communications. Restrictions on smoking at work may contribute to declines in consumption, but advice from health professionals, though effective, has limited impact owing to low reach. Measures aimed primarily at youth can delay, but not prevent, recruitment to smoking. Media publicity not only reduces smoking, but also creates a climate of opinion in favour of effective measures such as fiscal policy. In the long run, health professionals can achieve more for their patients through the media than through personal advice.

Adolescent↗

PubMed1996

Breast reduction under intravenous sedation: a review of 50 cases.

Breast reduction is a surgical procedure most commonly performed on an inpatient basis under general anesthesia. In the current climate of health care reform, we must evaluate such procedures to determine if there are alternate, less expensive, but equally safe means to perform them. Our purpose is to present our experience with 50 bilateral breast reductions performed under local anesthesia with intravenous sedation between October of 1991 and October of 1994. We have excluded bilateral reductions under 500 gm total, unilateral reductions, mastopexies, and gynecomastia procedures. Patients were sedated with intravenous Versed and fentanyl and a local solution consisting of marcaine, lidocaine, and 1:2000,000 epinephrine. Intercostal blocks were not used routinely. Monitoring and sedation were performed by nonanesthesia personnel in 49 patients. There were no complications relating to the sedation or to the local solution. All reductions were performed by the inferior pedicle technique. The average patient age was 28.0 years (20 to 67 years). The total breast tissue resected was 1372 gm (516 to 2948 gm), with 33 patients having resections greater than 1000 gm. Operative times averaged 3 hours (115 to 275 minutes). Forty-nine of the 50 patients tolerated the procedure with little or no recall. Twenty-eight patients were discharged on the same day as admission. One patient recalled some significant discomfort during parts of the procedure. All stated that they would again have the procedure performed under local anesthesia with intravenous sedation. Our conclusions are as follows: (1) Breast reduction can be performed safely and comfortably under local anesthesia with intravenous sedation. (2) Patients should be chosen on their acceptability as intravenous sedation candidates and not with regard to the amount of breast tissue removed. (3) There will be a subset of patients who can be discharged on the same day.

Adult↗

PubMed1996

Using economics to prioritize research: a case study of randomized trials for the prevention of hip fractures due to osteoporosis.

OBJECTIVES: To assess the role of economics, in combination with clinical judgement, for setting research priorities, using osteoporosis prevention (and, as a result, hip fracture prevention) as an example. METHODS: Modelling the cost and effectiveness of each of six potential interventions to prevent hip fractures over the 5-year length of a randomized trial (vitamin D injection; thiazide diuretics; hormone replacement therapy; oral calcium and vitamin D; calcium alone; calcitonin). Drug costs were derived from the Monthly Index of Medical Specialties (MIMS); averted fracture costs and estimates of effectiveness were derived from published sources. RESULTS: Vitamin D injection proved to be the most potentially cost-effective treatment with a cost-effectiveness ratio of 584 Pounds. If averted costs are included, this leads to a saving of 9,176,496 Pounds per 100,000 women treated. By contrast, the most expensive therapy was calcitonin (marginal cost-effectiveness ratio of 433,548 Pounds). This suggests that priority should be given to trials assessing the effectiveness of vitamin D injections. CONCLUSIONS: Relatively simple economic modelling exercises can inform research priorities and could help optimize the use of scarce research resources.

Benzothiadiazines↗

PubMed1996

Infectious mononucleosis and Hodgkin's disease--a similar seasonality.

The presentation of Hodgkin's disease and acute infectious mononucleosis (glandular fever) due to Epstein-Barr virus, have similar seasonal features with the peak incidence around March. The extent of seasonal variation is also similar. Seasonality of Hodgkin's disease is most obvious and also significant in adult age groups below the age of 40. Amongst those over 40 years, seasonality was no longer present in the 40-59 but returned over age 60. Seasonal similarity does not prove a relationship. However two speculations are made on possible mechanisms. Firstly glandular fever may accelerate presentation in young adults, destined to present with HD. Secondly the Epstein-Barr virus may have an inherent seasonal behaviour whether causing acute infectious mononucleosis or when latent and playing a role in the aetiology of Hodgkin's disease.

Adolescent↗

PubMed1996

Informed consent: an evolution from battery/medical negligence to potential invasion of physician privacy.

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Confidentiality↗

PubMed1995

Sexual behaviour of men. Survey shows unprotected sex is a common behaviour in bisexual men.

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Adolescent↗

PubMed1995

The climacteric, osteoporosis and hormone replacement; views of women aged 45-49.

We report climacteric symptoms among women aged 45-49, and their attitudes towards HRT and osteoporosis prevention. Semi-structured questionnaires were administered to 481 women attending for bone density screening after random invitation. We recorded social class, menopausal status, history of HRT exposure and climacteric symptoms, awareness of HRT and osteoporosis, and potential willingness to consider HRT before and after bone densitometry. In total, 294 (61%) were from non-manual social classes; 338 (70%) were premenopausal, 68 (14%) postmenopausal and 75 (16%) uncertain; 101 (21%) were current/previous HRT users. Three or more climacteric symptoms were experienced by 189 (56%) of premenopausal women, compared to 64 (94%) of postmenopausal women. Most women had heard of HRT (96%) and osteoporosis (84%), usually from women's magazines or friends. HRT was usually prescribed for climacteric symptoms and, in one case, for osteoporosis prevention. Side effects were reported with most HRT preparations and affected 38% of all users. Of the 380 (79%) women who had never taken HRT, half had concerns about such treatment, and few wanted it at the menopause. However, 364 (96%) said they would consider HRT if their bone scan suggested increased osteoporosis risk. In conclusion, women around the menopause experience considerable climacteric morbidity, but are often anxious about HRT use. Better health education might improve HRT uptake, while long-term compliance might be enhanced by disclosure of fracture risk.

Bone Density↗

PubMed1995

Reduced genetic load revealed by slow inbreeding in Drosophila melanogaster.

The rate of decline in reproductive fitness in populations of Drosophila melanogaster inbred at an initial rate of approximately 1% per generation has been investigated under both competitive and noncompetitive conditions. Breeding population size was variable in the inbred lines with an estimated harmonic mean of 66.7 +/- 2.2. Of the 60 lines maintained without reserves, 75% survived a period of 210 generations of slow inbreeding and were then rapidly inbred by full-sib mating to near-homozygosity. The initial rate of inbreeding was estimated to be 0.96 +/- 0.16% per generation, corresponding to an effective population size of approximately 50. However, the rate of inbreeding declined significantly with time to average only 0.52 +/- 0.08% per generation over the 210 generation period, most likely due to associative overdominance built up by genetic sampling and selection in the small populations. The total inbreeding depression in fitness was estimated to be 87 +/- 3% for competitive ability and 27 +/- 5% for fitness under uncrowded conditions, corresponding to rates of decline of 2.0 +/- 0.3 and 0.32 +/- 0.07%, respectively, per 1% increase in the inbreeding coefficient. The frequency of lethal second chromosomes in the resultant near-homozygous lines was of the order of 5%, lethal free second chromosomes showed a mean viability under both crowded and uncrowded conditions of approximately 95%, and their population cage fitness was 60% that of Cy/+ heterozygotes. It can be concluded that homozygous genotypes from which deleterious genes of major effect have been eliminated during slow inbreeding may show far less depression in reproductive fitness than suggested by earlier studies of wild chromosome homozygotes. The loss in fitness due to homozygosity throughout the entire genome may be as little as 85-90% under competitive conditions, and 25-30% in an optimal environment.

Animals↗

PubMed1995

Changes in bone mass and metabolism after surgery for primary hyperparathyroidism.

BACKGROUND AND OBJECTIVE: Bone mass is often reduced in patients with primary hyperparathyroidism (pHPT) and is usually partially reversible after parathyroidectomy. However, site specific and overall skeletal benefits of surgery in mild asymptomatic pHPT remain uncertain. DESIGN: Cross-sectional and longitudinal studies. PATIENTS: Fourteen patients (12 women and 2 men) with pHPT. MEASUREMENTS: Baseline bone mass was assessed at the lumbar spine, left hip and whole body using dual-energy X-ray absorptiometry, and at the left os calcis using broad-band ultrasound attenuation. Changes in bone mass, serum intact PTH and osteocalcin, and urinary pyridinium cross-link excretion were recorded in 10 patients followed for 6 months after surgery. RESULTS: (1) Cross-sectional study: Baseline measurements at the lumbar spine and hip were inversely related to both the serum PTH concentration and the weight of the parathyroid gland removed at surgery. (2) Longitudinal study: Six months after adenectomy, bone mass had increased significantly at the femoral neck, greater trochanter, whole body and os calcis, but not at the lumbar spine or Ward's area. Serum PTH, osteocalcin and pyridinium cross-link excretion all fell significantly after surgery. The percentage increment in whole body bone mineral content at 6 months was proportional to the baseline PTH. CONCLUSION: In primary hyperparathyroidism, preoperative reductions and post-operative gains in bone mass are proportional to the initial serum PTH concentration. Mild primary hyperparathyroidism probably does not cause appreciable bone loss at clinically relevant fracture sites such as the spine and hip, and in such cases the overall skeletal benefits of surgery are likely to be negligible.

Aged↗

PubMed1995

Photo quiz.

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Adult↗

PubMed1994

Effect of health publicity on prevalence of smoking.

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Health Promotion↗