Clinical Comparison Study Research Articles

Comparison of Unrelated Cord Blood Transplantation and HLA-Mismatched Unrelated Bone Marrow Transplantation for Adults with Leukemia

Recent advances in unrelated cord blood transplantation (UCBT) and high-resolution typing of human leukocyte antigen (HLA) from an unrelated donor have increased choices in alternative donor/stem cell source selection. We assessed HLA-mismatched locus-specific comparison of the outcomes of 351 single-unit UCB and 1,028 unrelated bone marrow (UBM) adult recipients 16 years old or older at the time of transplantation who received first stem cell transplantation with myeloablative conditioning for acute leukemia or myelodysplastic syndromes. With adjusted analyses, HLA 0 to 2 mismatched UCBT showed similar overall mortality (relative risk [RR] = 0.85, 95% confidence interval [CI], 0.68-1.06; P = .149) compared with that of single-HLA-DRB1-mismatched UBMT. UCBT showed inferior neutrophil recovery (RR = 0.50, 95% CI, 0.42-0.60; P < .001), lower risk of acute graft-versus-host disease (RR = 0.55, 95% CI, 0.42-0.72; P < .001), and lower risk of transplantation-related mortality (RR = 0.68, 95% CI, 0.50-0.92; P = .011) compared with single-HLA-DRB1-mismatched UBMT. No significant difference was observed for risk of relapse (RR = 1.28, 95% CI, 0.93-1.76; P = .125). HLA 0 to 2 antigen-mismatched UCBT is a reasonable second alternative donor/stem cell source with a survival outcome similar to that of single-HLA-DRB1-mismatched or other 7 of 8 UBMT.

Validating the Use of Wrist-Level Light Monitoring for In-Hospital Circadian Studies

This clinical methods comparison study describes the difference between light levels measured at the wrist (Actiwatch-L) and at the eye (Daysimeter) in a postoperative in-patient population. The mean difference between the two devices was less than 10 lux at light levels less than 5000 lux. Agreement between the devices was found to decrease as eye-level light exposure increased. Measurements at eye level of 5000 lux or more corresponded to a difference between the devices of greater than 100 lux. Agreement between the eye- and wrist-level light measurements also appears to be influenced by time of day. During the day, the measurement differences were on average 50 lux higher at eye level, whereas at night they were on average 50 lux lower. Although the wrist-level monitor was found to underestimate light exposure at higher light levels, it was well tolerated by participants in the clinical setting. In contrast, the eye-level monitor was cumbersome and uncomfortable for the patients to wear. This study provides light-exposure data on patients in real conditions in the clinical environment. The results show that wrist-level monitoring provides an adequate estimate of light exposure for in-hospital circadian studies. (Author correspondence: g.warman@auckland.ac.nz)

The optimal dose of esmolol and nicardipine for maintaining cardiovascular stability during rapid-sequence induction

Study ObjectiveTo determine the optimal dose of esmolol in combination with nicardipine in effectively blocking undesirable cardiovascular responses during rapid-sequence induction. DesignProspective, randomized clinical comparison study. SettingOperating room of a university hospital. Patients200 ASA physical status 1 and 2 patients requiring general anesthesia with endotracheal tube placement. InterventionsPatients were randomly allocated into one of 4 groups: Group E0 (no esmolol; control), Group E0.25 (esmolol 0.25 mg/kg), Group E0.5 (esmolol 0.5 mg/kg), and Group E1.0 (esmolol 1.0 mg/kg). All patients received 20 μg/kg of nicardipine, and esmolol was then given according to group allocation. Ninety seconds later, thiopental sodium 5 mg/kg and succinylcholine 1.0 mg/kg were injected. Endotracheal intubation was performed 60 seconds after injection of the anesthetic agents. MeasurementsSystolic (SBP), diastolic (DBP), and mean arterial (MAP) pressures; heart rate (HR), and rate-pressure product (RPP) were measured 30 seconds before and after intubation, and at 1, 3, 5, and 10 minutes after intubation. Rate changes using baseline values as the standard [rate changes = measured value/baseline value × 100 (%)] were calculated. Main ResultsSignificant attenuations in SBP, MAP, HR, and RPP after intubation were noted in the experimental groups as compared with the control group (P < 0.05). Rate changes in HR in Groups E0.5 and E1.0 were significantly lower than those in Group E0.25 immediately and one minute after intubation (P < 0.05). No difference in rate changes in HR were noted between the E0.5 and E1.0 groups. ConclusionsThe combination of nicardipine 20 μg/kg and esmolol 0.5 mg/kg most effectively attenuates the cardiovascular responses during rapid-sequence induction.

Binocular clinical comparison study of Tecnis multifocal aspheric and monofocal spherical intraocular lenses

To compare visual function in pseudophakic patients with bilateral implantation of Tecnis multifocal aspheric and conventional monofocal spherical intraocular lenses (IOL). A prospective study of 100 consecutive cases (200 eyes) was conducted. All cataract patients underwent phacoemulsification were randomized to receive multifocal aspheric IOL (Tecnis ZM900, AMO, multifocal aspheric group) or conventional spherical IOL (Akreos Adapt, Bausch & Lomb, monofocal spherical group). The following investigations were performed to assess the uncorrected and distance-corrected visual acuity of distance, intermediate and near distances, accommodative amplitude, spherical aberrations of total eye, contrast sensitivity, glare sensitivity and near stereoacuity. Patients were surveyed for visual disturbances and lifestyle visual quality. The independent-samples t test was used to compare the measure data which met normal distribution and the Mann-Whitney U test was used to compare the measure data which didn't meet. The chi-square test was applied to compare categorical variables. The uncorrected and distance-corrected bilateral visual acuity of multifocal aspheric group at 30 cm and 40 cm were 0.24 ± 0.12 and 0.22 ± 0.11 (logMAR), better than monofocal spherical group (Z = -8.261, P = 0.000; Z = -5.508, P = 0.000), but the visual acuity at other distances had no statistical difference between two groups. Patients with multifocal aspheric IOL had significantly higher accommodative amplitude than those with monofocal spherical IOL, improved about 2.3 ∼ 2.8 D (Z = -10.655, P = 0.000; Z = -2.709, P = 0.007). Mean spherical aberration of multifocal aspheric group was (0.027 ± 0.160) µm and (0.006 ± 0.083) µm, significantly lower than that of monofocal spherical group (0.269 ± 0.161) µm, (0.037 ± 0.205) µm at 5 mm and 3 mm pupil diameter (Z = -8.815, P = 0.000; Z = -2.791, P = 0.005). The difference of contrast sensitivity was not significant, but glare sensitivity was higher for monofocal spherical group than for multifocal aspheric group. Multifocal aspheric group showed statistically better uncorrected stereoacuity (72.4 ± 29.9)″ than monofocal spherical group (92.8 ± 35.7)″ (Z = -3.089, P = 0.002). The present clinical results demonstrated that Tecnis multifocal aspheric group had better near visual acuity, accommodative amplitude and near stereoacuity as compared to conventional monofocal spherical group. The aspheric design reduced spherical aberration of total eye and improved contrast sensitivity in some way.

Effect of echo spacing and readout bandwidth on basic performances of EPI‐fMRI acquisition sequences implemented on two 1.5 T MR scanner systems

Although in EPI-fMRI analyses typical acquisition parameters (TR, TE, matrix, slice thickness, etc.) are generally employed, various readout bandwidth (BW) values are used as a function of gradients characteristics of the MR scanner. Echo spacing (ES) is another fundamental parameter of EPI-fMRI acquisition sequences but the employed ES value is not usually reported in fMRI studies. In the present work, the authors investigated the effect of ES and BW on basic performances of EPI-fMRI sequences in terms of temporal stability and overall image quality of time series acquisition. EPI-fMRI acquisitions of the same water phantom were performed using two clinical MR scanner systems (scanners A and B) with different gradient characteristics and functional designs of radiofrequency coils. For both scanners, the employed ES values ranged from 0.75 to 1.33 ms. The used BW values ranged from 125.0 to 250.0 kHz/64pixels and from 78.1 to 185.2 kHz/64pixels for scanners A and B, respectively. The temporal stability of EPI-fMRI sequence was assessed measuring the signal-to-fluctuation noise ratio (SFNR) and signal drift (DR), while the overall image quality was assessed evaluating the signal-to-noise ratio (SNR(ts)) and nonuniformity (NU(ts)) of the time series acquisition. For both scanners, no significant effect of ES and BW on signal drift was revealed. The SFNR, NU(ts) and SNR(ts) values of scanner A did not significantly vary with ES. On the other hand, the SFNR, NU(ts), and SNR(ts) values of scanner B significantly varied with ES. SFNR (5.8%) and SNR(ts) (5.9%) increased with increasing ES. SFNR (25% scanner A, 32% scanner B) and SNR(ts) (26.2% scanner A, 30.1% scanner B) values of both scanners significantly decreased with increasing BW. NU(ts) values of scanners A and B were less than 3% for all BW and ES values. Nonetheless, scanner A was characterized by a significant upward trend (3% percentage of variation) of time series nonuniformity with increasing BW while NU(ts) of scanner B significantly increased (19% percentage of variation) with increasing ES. Temporal stability (SFNR and DR) and overall image quality (NU(ts) and SNR(ts)) of EPI-fMRI time series can significantly vary with echo spacing and readout bandwidth. The specific pattern of variation may depend on the performance of each single MR scanner system in terms of gradients characteristics, EPI sequence calibrations (eddy currents, shimming, etc.), and functional design of radiofrequency coil. Our results indicate that the employment of low BW improves not only the signal-to-noise ratio of EPI-fMRI time series but also the temporal stability of functional acquisitions. The use of minimum ES values is not entirely advantageous when the MR scanner system is characterized by gradients with low performances and suboptimal EPI sequence calibration. Since differences in basic performances of MR scanner system are potential source of variability for fMRI activation, phantom measurements of SFNR, DR, NU(ts), and SNR(ts) can be executed before subjects acquisitions to monitor the stability of MR scanner performances in clinical group comparison and longitudinal studies.

Treatment of Distal Femoral Fracture by Minimally Invasive Percutaneous Plate Osteosynthesis: Comparison Between the Dynamic Condylar Screw and the Less Invasive Stabilization System

Treatment of distal femoral fractures by percutaneous plating without direct manipulation of the fracture fragments leads to good clinical outcome. Percutaneous plating has traditionally involved using a dynamic condylar screw (DCS) and the less invasive stabilization system (LISS) was reported. The biomechanical study showed that the LISS had the enhanced ability to withstand higher loads. However, there were no clinical comparison study of distal femoral fractures treated with DCS and LISS. The aim of this study was to outline any differences in clinical and radiological results between the DCS and the LISS for treating distal femoral fractures. Forty-five supracondylar or intercondylar femoral fractures were treated by minimally invasive percutaneous plating with the DCS or the LISS without bone graft. There were 26 patients with 26 fractures in the DCS group and 19 patients with 19 fractures in the LISS group. The data of the clinical and radiographic outcomes were compared between the two different fixation devices. Complete union was achieved in 41 of the 45 patients (91.1%). The success rate was 96.2% in the DCS group and 94.7% in the LISS group (p = 0.672). The mean fusion time was 19.18 weeks in the DCS group and 19.38 weeks in the LISS group (p = 0.835). The average range of motion of the knee joint was 111.65 degrees in the DCS group and 116.26 degrees in the LISS group (p = 0.334). Early implant failure only occurred in the DCS group (11.5%, p = 0.252, odds ratio = 1.826 [95% CI: 1.387-2.404]). The total complication rate was 15.4% in the DCS group and 15.8% in the LISS group (p = 0.641). The mean loss of coronal fracture fragment angle was -0.77 degrees in the DCS group and -0.19 degrees in the LISS group (p = 0.125). Minimally invasive percutaneous plating with the DCS or the LISS provides good outcome with few complications in the treatment of distal femoral fractures. Both systems minimize soft tissue trauma. LISS seems to have lower risk of early implant loosening than the DCS.

Lymphocyte apoptosis after major abdominal surgery is not influenced by anesthetic technique: a comparative study of general anesthesia versus combined general and epidural analgesia

Study Objective To examine the influence of abdominal colectomy with combined general anesthesia and epidural analgesia versus general anesthesia on apoptosis of circulating lymphocytes. Design Prospective, randomized, clinical comparison study. Setting Tertiary-care general hospital. Patients 40 ASA physical status I and II patients undergoing elective open colectomy for nonmetastatic colon carcinoma. Interventions Patients were randomly allocated to two groups to receiver either general anesthesia alone (Group G) or general anesthesia combined with epidural analgesia (Group C). Group C comprised 21 patients while 19 patients constituted Group G. All patients underwent median longitudinal laparotomy. Measurements Blood samples were collected preoperatively and 24 hours postoperatively for measurement of lymphocyte apoptosis, serum cortisol, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Main Results There were no differences between the two groups in age, weight, or duration of surgery. No significant alterations in total lymphocyte counts, as well as in lymphocyte subpopulations (early apoptotic, late apoptotic, viable, and necrotic), were observed between the general and combined anesthesia groups. Cortisol, ESR, and CRP were significantly increased postoperatively in both groups. Group C presented with lower serum cortisol levels postoperatively than Group G (b = −5.38, CI95%: −8.72 to −2.05, P = 0.002). Conclusions Epidural block could not suppress postoperative lymphocyte apoptosis, increases in cortisol, CRP, or ESR compared with general anesthesia.

Salivary paracetamol: evaluation of a colorimetric method in assessing deliberate self-poisoning

In the laboratory evaluation of suspected paracetamol poisoning, a non-invasive sample type that avoids venepuncture would be an attractive alternative to plasma, particularly in the paediatric setting. Salivary paracetamol measurement has not previously been evaluated in the published medical literature in the setting of deliberate self-poisoning (DSP). In-house validation experiments (recovery, stability and lower limit-of-detection) were performed on pooled saliva samples using a Roche Acetaminophen assay on a Roche/Hitachi 917 analyser. A clinical study of comparison of paired saliva and plasma samples was also conducted involving adult patients presenting with DSP of paracetamol, the results of which were published previously. The validation experiments using pooled saliva samples showed: (i) mean recovery (paracetamol concentration 37.5-525 mg/L) 100.01% (+/-0.02 SD); (ii) precision of repeated assay over 24-h period CV <4%; (iii) lower limit-of-detection 0.9 mg/L. The clinical study of 21 patients with mean plasma paracetamol concentration of 48 mg/L (range 0-130) and mean saliva concentration 62 mg/L (range 0-183) showed good correlation between saliva and plasma concentrations (r(2) = 0.91). The Roche Hitachi 917 Acetaminophen assay is suitable for the measurement of paracetamol in saliva. Further studies comparing plasma and saliva samples from patients with DSP and plasma paracetamol concentrations in the hepatotoxic range are warranted. If salivary samples are suitable for risk-stratifying patients with paracetamol DSP, venepuncture may be avoided, which would be attractive, especially in the paediatric setting.

Indications for Minimally Invasive Disk and Vertebral Procedures

Objective. This article reviews some of the interesting advances that have taken place in the treatment of chronic lower back discogenic pain and leg pain associated with disk protrusion. Indications, including patient-selection criteria, of selected minimally invasive procedures are discussed. Design. Comprehensive review. Results. Several nonsurgical approaches to discogenic pain are described, including minimally invasive annular heating procedures like Intradiscal Electrothermal Therapy (Smith and Nephews, London, UK), DiscTrode (Radionics Inc., Burlington, MA) and Intradiscal Biacuplasty (Baylis Medical Inc., Montreal, Canada). Careful selection of the patients may significantly improve the success rates of these procedures. Significant advances in treatment of predominantly leg pain caused by contained disk protrusion are also described. A few percutaneous minimally invasive modalities of discectomy or disk decompression have become therapeutic alternatives to open surgical procedures and may produce similar clinical improvements. In addition, patients may rapidly return to their baseline functional capacity. Unfortunately, there are no good clinical comparison studies or even individual prospective controlled studies to confirm such a claim. Kyphoplasty and vertebroplasty are established as minimally invasive, interventional techniques that decrease pain and improve function in patients with fractured vertebrae due to osteoporosis and other osseous lesions such as metastases, multiple myeloma, and hemangiomas. Conclusions. Several percutaneous minimally invasive disk and vertebral procedures for the treatment of back and neck pain were introduced recently. Sufficient clinical evidence to accept these new treatment modalities is still lacking and will probably require years to accumulate.

Study of IVF success with pituitary suppression prior to follistim/hMG stimulation in ganirelix cycles using oral contraceptives and estrace

It has been noted that higher LH levels prior to the onset of ovarian stimulation increase androgen levels which may suppress stimulation of a secondary cohort of follicles. FSH increases prior to stimulation prematurely stimulates the lead follicles so that the net effect is greater asynchrony of the follicles. It was hypothesized that by suppressing FSH and LH prior to ovarian stimulation with OCP followed by four days of Estrace would allow for better synchronization of follicles leading to retrieval of more mature oocytes which would result in equivalent numbers and pregnancy rates as that associated in Leuprolide cycles. IRB approved, randomized prospective clinical comparison study of two stimulation protocols in a private ART center. 40 pts undergoing ovarian stimulation for IVF were equally divided to OCP, Lupron, Follistim/hMG, protocol (Group A) and OCP, Estrace, Follistim, hMG, Ganirelix protocol (Group B). One pt dropped out from Group A and one from group B. Only women <35 and with both FSH on day 3 < 10 and total antral follicle count >10 were included in study. Pregnancy was defined as ultrasound evidence of a gestational sac. A two tailed t test was performed. There was no statistical difference between groups A and B with respect to age, BMI, diagnosis and incidence of ICSI, day 3 E2, FSH, number of embryos transferred (A = 2.1, B = 2.0) or Follistim/hMG/hCG dose determinants. There was no statistical difference though there was an impressive trend for the Group B Ganirelix patients to use less gonadotropins, more hMG, and have more eggs retrieved with a higher fertilization rate and number cryopreserved. The E2 on the day of hCG had a 7 correlation for the two groups, however the LH on the day of hCG was significantly lower in Group B, P<0.01. Three Group B patients had no fresh transfer due to hyperstimulation. 12/16 (75%) Group B pts and 7/19 (36.8%) Group A pts were pregnant from fresh cycle, P<0.05). Adding pregnancies from the frozen embryo transfers, 12/19 (63.2%) Group A pts and 15/19 (78.9%) Group B pts were pregnant. This difference was not statistically different. Suppression with OCP and Estrace prior to Follistim/hMG stimulation achieved an equivalent pregnancy rate to that of OCP, Lupron protocols utilizing fewer injections and gonadotropins with a trend towards achieving more embryos.

Fecal pyruvate kinase: A potential new marker for intestinal inflammation in children with inflammatory bowel disease

Objective. Inflammatory bowel disease (IBD) in children creates diagnostic and clinical challenges. Clinical data, endoscopic appearance and the histopathological assessment of biopsies are essential for diagnosis. However, new methods are required for non-invasive follow-up. Recently, we demonstrated that the dimeric isoform of pyruvate kinase (PK) detected in stool might serve as a potential non-invasive screening tool in inflamed pouch mucosa. The aim of this study was to investigate whether this test could be used to detect intestinal inflammation in pediatric IBD patients. Material and methods. Fecal PK immunoreactivity was assessed in 75 patients with proven ulcerative colitis (UC) and 32 with Crohn's disease (CD). Pediatric Crohn Disease Activity Index (PCDAI) and Truelove-Witts scores were determined in CD and UC patients, respectively. Thirty-five healthy subjects (HS) served as a control group. Results. Increased PK levels were documented in 94.1% and 100% active CD patients with a cut-off level of 5 U/g and a cut-off level of 4 U/g, respectively, and in 94.3% of active UC patients regardless of cut-off level. Enzyme immunoreactivity was significantly higher in all IBD patients than in HS. Abnormal PK results were documented in 71.7% of all IBD patients (65.3% and 84.4 for UC and CD patients, respectively). Enzyme levels in UC remission were significantly lower than in the active phase. Enzyme immunoreactivity significantly correlated to both scoring systems. Conclusions. The measurement of stool PK could be a potentially useful marker of IBD activity in children. However, its clinical value demands further studies for comparison with other tests.

Effect of 2 anesthetic techniques on the postoperative proinflammatory and anti-inflammatory cytokine response and cellular immune function to minor surgery

Study Objective The aim of this study was to investigate the influence of 2 established anesthetic techniques: total intravenous anesthesia and balanced inhalation anesthesia (BAL) on the perioperative-induced changes of peripheral blood mononuclear cells (PBMCs), changes in lymphocyte subsets, and the balance of proinflammatory and anti-inflammatory cytokines. Design This is a prospective, randomized, clinical comparison study. Settings This study was set at a university hospital. Patients This study involved 50 patients with American Society of Anesthesiologists physical status I who were scheduled for elective minimal invasive partial diskectomy. Interventions There was no intervention involved in this study. Measurements Changes in differential counts, lymphocyte subsets, and proliferation rates were determined before surgery and in the early postoperative period. Plasma concentrations of proinflammatory cytokines (IL-2, IL-6, IL-12, interferon γ) and anti-inflammatory cytokines (IL-10, IL-1RA, transforming growth factor β), and plasma concentrations of cortisol, epinephrine, and norepinephrine were measured before, during, and after surgery. Main Results Absolute number of CD3 +, CD4 +, and CD8 +, and expression of HLA-DR and activation marker CD25 +, CD26 +, and CD69 + decreased more in response to surgery after BAL. Changes in distribution of T-lymphocyte cells seem to be in part related to severe postoperative pain. Plasma concentration of IL-6 significantly increased during and after surgery with BAL without relation to pain. Conclusion Anesthetic management may have varying influences on the postoperative immune response. Surgery-induced inflammatory response and alteration in cell-mediated immunity seem to be more pronounced after BAL. These effects were attributed to the enhanced stress response after BAL.

The usefulness of the modified laryngoscopic blade for training novice laryngoscopists

Study Objective The objective of this study was to evaluate the effectiveness of a modified Macintosh blade for reducing the chances of directly contacting the teeth and providing a satisfactory laryngoscopic view during laryngoscopies by novice laryngoscopists. Design This is a prospective clinical comparison study. Setting The study took place at an operating room of a university hospital. Patients Seventy-two patients with American Society of Anesthesiologists physical statuses I and II, aged 16 to 64 years, who were scheduled for elective surgery requiring general anesthesia with endotracheal tube placement participated in this study. Interventions Laryngoscopy was performed twice on each patient, once with a regular Macintosh no. 3 blade and once with a blade in which the flange was partially removed. Measurements As an indirect parameter for anticipating potential dental injury during laryngoscopy, the perpendicular distance from the tip of the maxillary central incisor to the flange of each blade (the blade-tooth distance) was measured when a novice laryngoscopist lifted up the laryngoscope and visualized the glottis. We compared the blade-tooth distances, the chances of directly contacting the tooth, laryngoscopic views, and the subjective feeling of difficulty in handling the laryngoscope between the 2 blades. Main Results Blade-tooth distance varied significantly between the 2 blades: the median/interquartile range was 1.2/2.3 mm vs 3.0/4.3 mm for the regular Macintosh no. 3 and the modified blade, respectively ( P < .01). The modified blade was associated with decreased chances of directly contacting the teeth ( P < .05). In addition, the modified blade provided a better laryngoscopic view than did the regular blade ( P < .01). Most novice laryngoscopists felt that laryngoscopy with the modified blade was significantly easier than that with the regular Macintosh blade ( P < .01). Conclusions The modified Macintosh blade used in this study proved to be a useful device for training novice laryngoscopists with respect to procedure effectiveness and patient safety.

Predicting recovery from deep neuromuscular block by rocuronium in the elderly

Study objective To determine the influence of aging on the relationship between posttetanic count (PTC) and train-of-four (TOF) response during intense neuromuscular blockade caused by rocuronium. Design Prospective, observational, clinical comparison study. Setting Operating room of a university hospital. Patients 42 ASA physical status I and II patients, 20 of whom were elderly (ages 65 to 80 yrs) and 22 younger control patients (ages 18 to 40 yrs), who were scheduled for elective orthopedic surgery and ear, nose, and throat surgery with a planned duration of 2 hours. Interventions Neuromuscular blockade was evaluated with accelerometry of the thumb, using posttetanic twitch (PTT) and TOF stimulation of the ulnar nerve, in patients who received rocuronium 1 mg·kg −1. Measurements and main results The first responses to posttetanic nerve stimulation were seen at mean times of 38.5 and 35.2 minutes after the injection of rocuronium in the elderly and in the young, respectively (NS). The average interval between the appearance of a posttetanic response and the first response to TOF stimulation (T1) was longer in the elderly than the young (22.3 ± 8.1 (SD) vs.14.8 ± 4.2 min, p < 0.05). There was a significant correlation between PTC and the time to first response to TOF nerve stimulation both in the elderly and in the young (r = –0.73, p < 0.0001 and r = –0.87, p < 0.0001, respectively). Conclusions Posttetanic twitch stimulation is a useful method of monitoring intense neuromuscular blockade caused by rocuronium in both age groups. The interval between the earliest appearance of a posttetanic response and the first response to TOF stimulation (T1) is greater in the elderly than in the young.

The use of quantitative ultrasonometry in patients with glucocorticoid-induced osteoporosis.

There is a great need to introduce methods to determine bone fragility in outpatient settings for chronically GC-treated patients which are easy to use, reasonably inexpensive, precise and have a high sensitivity and specificity to detect patients at risk for fractures. DXA and QUS have both been shown to predict hip fracture rates independently in prospective studies in postmenopausal women. No such studies have been done for patients under GC treatment yet. Most studies investigated patients with established GCO and only one large study has investigated patients with risk factors such as intermittent GC intake and compared DXA and QUS. No studies have been done using QCT. All studies show that QUS is equally potent in detecting patients at risk compared to DXA. There is good evidence that phalangeal QUS is highly dependent on structural changes of trabecular bone. Phalangeal QUS might thus have the advantage of detecting GC-induced structural deterioration earlier then calcaneal devices, however no clinical comparison studies have been conducted. The best would be to do longitudinal studies to see which device and site best predicts bone loss, however this requires large patient numbers and patients at risk are usually in different departments due to the difference in underlying diseases.

Evaluation of the new ImmuliteTurbo cTnI assay and the original Immulite cTnI assay

Objectives : An analytical and clinical evaluation of cTnI on the ImmuliteTurbo system with 15 min assay time compared to 45 min with the original Immulite assay is presented. Methods and Design : Detection limit, functional sensitivity, AMI decision limit, assay linearity, influence of sample material (serum, heparin, citrate and EDTA plasma), interference, analytical and clinical method comparison studies were performed. Results : Functional sensitivity (at CV 20%) was 0.35 compared to 0.23 mug/L for the original assay. AMI decision limit (99th percentile of a reference control group) was 0.48 mug/L for both assays. In patients with acute coronary syndromes, chronic renal failure or pulmonary embolism the assays showed concordant results in 87.2-96.5%. Differing results were only found around the cut-off level and were attributed to assay imprecision. Conclusion : The new assay is sensitive for the determination of cTnI, shows comparable results to the original assay version and is easy to perform within 15 min.

Study of the safe threshold of apneic period in children during anesthesia induction

Study Objectives: (1) To investigate changes in arterial oxygen saturation via pulse oximeter (SpO 2) during apnea and after reinstitution of manual ventilation at SpO 2 of 95% or 90% following rapid sequence induction of anesthesia in children after 2-minute preoxygenation; (2) to determine whether the setting of a safe threshold of apneic period to an SpO 2 of 95% is appropriate in children during anesthetic induction; and (3) to evaluate the influences of age, body weight, and height on the time from the start of apnea to SpO 2 of 95%. Design: A clinical study of random design and comparison among groups. Setting: Operating room of a plastic surgery hospital of the Chinese Academy of Medical Sciences and Peking Union Medical College. Patients: 152 infants and children, ASA physical status I, aged 3 months to 12 years, scheduled for elective plastic surgery. Interventions: Patients were divided into three age groups: Group 1-infants 3 months to 1 year (n = 39); Group 2-children 1 to 3 years (n = 41); and Group 3-children 3 to 12 years (n = 72). Patients in each age group were randomly allocated again to Subgroups A and B. After a 2-minute preoxygenation, anesthesia was induced with thiopental 5 mg/kg, fentanyl 5 μg/kg, and suxamethonium 1.5 mg/kg. Patients were manually ventilated when SpO 2 decreased to 90% in Subgroups A and 95% in Subgroups B, respectively, during apnea. Measurements and Main Results: SpO 2 was measured continuously with a Datex pulse oximeter applied to the right index finger. During apnea, the times for SpO 2 to decrease to 99% (T 99) and 95% (T 95) in all children, and 90% (T 90) in Subgroups A were recorded. The time for SpO 2 to decrease from 95% to 90% (T 95 − 90) in Subgroups A was also measured. After reinstitution of manual ventilation, the time when SpO 2 continued to decrease (T 1) and the time from the end of apnea to recovery of SpO 2 baseline (T 2) were determined. In addition, the lowest value of SpO 2 after apnea was also recorded. The results showed that younger children were more susceptible than older children to the risk of hypoxemia during apnea. There were significant differences in T 99, T 95, T 90, and T 95 − 90 between the three age groups. T 1 and T 2 were significantly longer in Group 3 than in Groups 1 and 2. There were significant differences in the lowest values of SpO 2 following apnea among the three Subgroups A and between Subgroups A and B of each age group. During apnea, heart rate decreased gradually as SpO 2 decreased, showing a significant decrease at SpO 2 of 95%. Bradycardia was found in three children in Subgroups A. The apnea time to SpO 2 of 95% correlated well with age, weight, and height by linear regression analysis. Conclusions: The safe threshold of an apneic period setting to an SpO 2 of 95% was appropriate in children during anesthesia induction. Despite the same duration of preoxygenation, younger children were more susceptible than older ones to the risk of hypoxemia during apnea. The apnea time to Sp0 2 of 95% correlated with age, body weight, and height using linear regression analysis.

Conservative management of incontinence

This review evaluates the main conservative treatments (general measures, physiotherapy, electrostimulation, mechanical devices, and bladder retraining) with particular emphasis on their effectiveness in the management of urinary incontinence. This is difficult because of the paucity of clinical comparison studies using objective end points, and further work needs to be done to establish more clearly the effectiveness of these measures. However, because the therapies are of low risk, relatively low cost and are reversible, they should be included in the counselling of all incontinent patients regarding treatment options.

Improved imaging of bone with scan equalization radiography.

Use of scan equalization radiography (SER) for imaging bone in the head, face, neck, and shoulder was evaluated in a clinical comparison study with conventional radiographs of randomly selected patients. Two hundred nine pairs of normal and abnormal SER images and conventional radiographs were compared by four radiologists in a side-by-side viewing situation. The radiologists compared the visibility of specific anatomic features and rated the SER images as better than, equal to, or worse than the conventional radiographs. In the evaluation of the images of the cervical spine, the radiologists much preferred the SER images 63% of the time because of slight improvement in bone detail and marked improvement in detail of the soft tissues. In the evaluation of the images of the shoulder, the radiologists preferred the SER image 58% of the time and preferred the conventional radiograph only 5% of the time (p less than .05). In the evaluation of the images of the skull, face, and mandible, the radiologists preferred the SER images 62% of the time and the conventional images 4% of the time (p less than .05). The superior image quality with the SER technique was recognized by all radiologists in the study and was the overwhelmingly preferred way of imaging the shoulder, neck, head, and face.

外部潅流方式ｈｏｌｌｏｗ ｆｉｂｅｒ型人工肺ＨＦ‐５０００およびＭＡＸＭＡ肺の臨床的比較検討

外部潅流方式ｈｏｌｌｏｗ ｆｉｂｅｒ型人工肺ＨＦ‐５０００およびＭＡＸＭＡ肺の臨床的比較検討