Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis

The purpose of this study was to determine the anesthetic efficacy of a supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in teeth diagnosed with irreversible pulpitis. Fifty-one patients with symptomatic, vital maxillary, and mandibular posterior teeth diagnosed with irreversible pulpitis received conventional infiltrations or inferior alveolar nerve blocks. Pulp testing was used to determine pulpal anesthesia after "clinically successful" injections. Patients who were positive to the pulp tests, or were negative to the pulp tests but felt pain during endodontic access, received an intraosseous injection using 1.8 ml of 2% lidocaine with 1:100,000 epinephrine. The results demonstrated that 42% of the patients who tested negative to the pulp tests reported pain during treatment and required supplemental anesthesia. Eighty-one percent of the mandibular teeth and 12% of maxillary teeth required an intraosseous injection due to failure to gain pulpal anesthesia. Overall, the Stabident intraosseous injection was found to be 88% successful in gaining total pulpal anesthesia for endodontic therapy. We concluded that, for posterior teeth diagnosed with irreversible pulpitis, the supplemental intraosseous injection of 2% lidocaine (1:100,000 epinephrine) was successful when conventional techniques failed.     

Evaluation of local anesthesia techniques for small incision cataract surgery

PURPOSE: To evaluate the surgical experiences and patient preference with 3 local anesthesia techniques for small incision cataract surgery. SETTING: Department of Ophthalmology, Hj?rring Hospital, Denmark. METHODS: This prospective, randomized study included 66 patients having simultaneous bilateral cataract surgery. There were 3 test groups, each containing 2 of the following local anesthesia techniques: retro/peribulbar (RBA), sub-Tenon's (STA), or topical (TA). Each patient served as his or her own control. No medical sedation was used. Patient response to each anesthesia technique was evaluated by the surgeon based on surgical difficulties, a nurse using hand-holding tension and verbal interaction, and a visual analog pain score. Patients were also asked which of the 2 techniques they preferred and their reasons. RESULTS: No local anesthesia techniques interfered with surgery. The order of a positive pain/discomfort response during surgery was TA > STA > RBA. Significantly more pain occurred with application of RBA than with STA or TA. No postoperative pain was recorded with any method. Fifty-six percent of patients said they preferred 1 technique over the other; 16% of patients having STA would not do so again, 19% would not have TA again, and 40% would not have RBA again. The main reasons for preferring STA and TA were fear of or pain from a retrobulbar injection. The main reasons for preferring RBA were less awareness, anxiety, and surgical pain. Immediate visual recovery seemed to be of minor importance in patients' choice of an anesthesia technique. CONCLUSION: Although less discomfort/pain occurred during surgery with RBA, patients preferred STA and TA primarily because of the inconvenience or pain of the retrobulbar injection. Although medical sedation was not used in this study, the pain/discomfort ratio from surgery was not greater than in studies using intravenous sedation, indicating that the use of medical sedation should be re-evaluated.     

A comparison of the effect of different occlusal forms in mandibular implant overdentures

STATEMENT OF PROBLEM: Posterior tooth form selection for implant overdentures is made according to personal preference and experience using the concepts of conventional complete denture prosthodontics. PURPOSE: This study (1) compared the masticatory efficiency of three occlusal forms, 0 degrees, 30 degrees, and lingual contact (lingualized occlusion), in subjects with mandibular implant overdentures, and (2) determined their effects on the implant supporting tissues. MATERIAL AND METHODS: Eight patients who had four root form implants in the mandibular symphysis area connected with a Hader bar were selected. Maxillary and mandibular dentures were constructed for each patient with interchangeable posterior segments and the three occlusal forms were tested. The masticatory efficiency for each posterior tooth form was assessed with objective food tests and a subjective patient preference questionnaire. Periodic evaluation of implant-supporting tissues also was performed. RESULTS: Reliability analysis showed that all R1 coefficients were > or =0.80 (<0.001), indicating high subject consistency between multiple chewing efficiency trials. MANOVA analysis indicated a significant difference in chewing efficiency among the three occlusal forms (p < 0.001). The 0 degree occlusal form was associated with a significantly higher number of chewing strokes compared with 30 degrees or lingualized occlusal forms. The different occlusal forms were not found to have a clinically detrimental effect on the peri-implant soft or hard tissues. CONCLUSION: Chewing efficiency tests and patient preference ratings showed that 30 degree teeth and lingual contact provided better chewing efficiency than 0 degree teeth. None of the tested occlusal forms showed any clinical or radiographic detrimental effect on the implant-supporting tissues.     

Interactive MR imaging-guided biopsy and aspiration with a modified clinical C-arm system

OBJECTIVE: This investigation was performed to test the hypotheses that interactive guidance of MR image acquisition during needle-directed procedures using a clinical 0.2-T C-arm open MR imaging system integrated with a frameless optically linked stereotaxy system is feasible, and that procedure times can be sufficiently short to be well tolerated by the patient. SUBJECTS AND METHODS: One hundred six MR-guided procedures were performed in 86 patients (ranging in age from 5 months to 88 years) using a clinical C-arm imaging system supplemented with an in-room RF-shielded liquid crystal display monitor, a frameless stereotaxy system, rapid gradient-echo sequences for needle guidance, and MR-compatible monitoring and surgical lighting equipment. We performed 50 biopsies and aspirations of the head and neck in 37 patients, 23 biopsies of musculoskeletal lesions in 22 patients, 16 biopsies of abdominal sites in 10 patients, six biopsies of the thoracolumbar spine or sacrum in six patients, and 11 shoulder joint injections for MR arthrography in 11 patients, in addition to 38 MR arthrographic injections on the same imaging system described in a previous report. Tissue sampling included fine-needle aspiration (n = 90) and cutting needle core biopsy (n = 41). Thirty-five patients underwent both procedures. Procedures were evaluated for success of needle placement, procedure time, and complications. RESULTS: Needle placement was successful in all cases, and no complications occurred. Tissue was sufficient for pathologic diagnosis for all but eight patients. Passes per patient averaged 2.1. For fine-needle aspiration, instrument time averaged 7 min 42 sec per pass, cutting needle core biopsy averaged 6 min 24 sec, and shoulder injection averaged 8 min. CONCLUSION: MR imaging guidance for needle procedures on a clinical 0.2-T C-arm system with supplemental interventional accessories is feasible, with relatively rapid needle placement.     

The role of the primary care physician in maximizing cognitive and behavioral recovery from moderate to severe pediatric traumatic brain injury

A study was conducted to determine whether cryotherapy of bone exposed during the surgical removal of wisdom teeth is able to reduce the intensity of pain and general discomfort. Study design. A prospective investigation of 107 patients who required extraction of two wisdom teeth, one on the left and one on the right side of the lower jaw. Cryotherapy was carried out on one side only. Employing a visual analogue scale, the intensity of pain and general discomfort (swelling, inflammation, insomnia etc.) was recorded. Other parameters such as swelling, patient preference, and duration of the operation were also recorded. The chi-squared test was employed to compare the results between the treated and non-treated sides. There was significantly less pain, swelling and discomfort following the use of cryotherapy. Patient preference was also for cryotherapy. Operation time and the occurrence of inflammation were similar in both groups. In conclusion, cryotherapy is an effective procedure for reducing pain, swelling and general discomfort following extraction of a wisdom tooth in the lower jaw without creating irreversible sequelae.     

The use of patient-controlled transcutaneous electronic nerve stimulation (TENS) to decrease the discomfort of regional anaesthesia in dentistry: a randomised controlled clinical trial

OBJECTIVE: To compare the use of topical anaesthesia and transcutaneous electronic nerve stimulation (TENS) as means of reducing the discomfort of inferior dental block injections. METHODS: One hundred adult dental patients received 2% lignocaine with 1:80,000 adrenaline for long buccal and inferior dental block anaesthesia. The long buccal injections were given first with no prior mucosal preparation. Patients received inferior dental blocks after one of the following mucosal preparations: (1) no pretreatment; (2) a 2 min application of 20% benzocaine topical anaesthetic; (3) application of patient-controlled TENS at the injection site. Patients scored injection discomfort after each administration on a 100 mm visual analogue scale. RESULTS: The discomfort of the long buccal injection did not differ between the three groups of patients (F2,97 = 1.0). There were significant differences in the pain scores for the inferior dental block injections (F2,97 = 5.3; p < 0.01). Injection discomfort following TENS was less than that following no pretreatment (p < 0.01) and after topical anaesthetic application (p < 0.05). The use of topical anaesthesia did not produce a significant change in injection discomfort compared with no pretreatment. CONCLUSION: The use of TENS reduces injection discomfort during inferior dental block anaesthesia.     

Survival characteristics of periodontally-involved teeth: a 40-year study

Four hundred and fifty-five teeth that were judged clinically to have a questionable prognosis were observed over a 40-year span in 166 patients in a private practice. Therapy initially was debridement with oral hygiene instruction, followed by flap curettage procedures and preventive maintenance recall therapy. An assessment of compliance based on oral hygiene and recall attendance was also performed. A total of 55 (12%) teeth were lost with an average survival rate of 8.8 years prior to extraction. No teeth were lost during the first 2 years of observation. The majority of extracted teeth were maxillary second molars (38.2%), followed by maxillary first molars (25.5%), and mandibular second molars (16.4%). Tooth loss patterns appeared to be bilaterally symmetrical, with 51% of teeth lost in the right quadrants and 49% lost in the left quadrants. Indications for extraction were primarily periodontal abscesses. Teeth that were considered to have a very questionable prognosis have been retained for many years after therapy, supportive treatment, and patient compliance with recall attendance.     

Detection of intravascular injection of regional anaesthetics in children

PURPOSE: Detection of intravascular injection of local anaesthetic during placement of regional blocks in children by using epinephrine-induced tachycardia or hypertension may produce false positive and false negative findings. This study evaluates ECG changes as markers of intravascular injection of local anaesthetics with epinephrine, during placement of epidural blocks in children. METHODS: Observational study in a teaching hospital of all epidural anaesthetics administered to paediatric patients during one year. General anaesthesia, where used, was not controlled. An ECG rhythm strip was recorded during test dose injection and analyzed for changes in rate, rhythm, and T-wave configuration. RESULTS: During the study period, 742 paediatric epidural blocks were administered. There were 644 caudal (284 without catheters), 97 lumbar, and one thoracic epidural anaesthetics. Satisfactory placement was achieved in 97.7% of patients. Intravascular injection was detected in 42 (5.6%) of epidural anaesthetics (3.8% and 6.7% of straight needle and catheter injections, respectively). Detection was by immediate aspiration of blood in six patients, and by heart rate increases > 10 bpm in 30. Five had heart rate decreases suggesting a baroreceptor response. Five had heart rate increases < 10 bpm that were possible responses to noxious stimuli. Of 30 patients with known intravascular injection and for whom ECG strips were available, 25 (83%) had T-wave amplitude increases > 25%, and 29 (97%) had ECG changes in T-wave or rhythm in response to the epinephrine injection. There were no false positives. CONCLUSION: In order to reduce risks associated with epidural anaesthesia in children, epinephrine should be added to the local anaesthetic test dose, the ECG should be monitored continuously for changes in heart rate, rhythm, and T-wave amplitude. Epidural injections should be given in small increments.     

Intradermal anaesthesia: comparison of several compounds

OBJECTIVE: To compare the efficacy of different local anaesthetics to produce intradermal anaesthesia for venous cannulation and the discomfort associated with skin infiltration. DESIGN: Randomized, double blind study. SETTING: Induction room of a university hospital. PATIENTS: Convenience sample of 600 patients (18-65 years; ASA I-II) scheduled for elective surgery. INTERVENTIONS: Patients received one of six preparations: 0.9% saline, 1% prilocaine (Xylonest), 1% lidocaine (Xylocain), 1% mepivacaine-1 (Meaverin), 1% mepivacaine-2 (Scandicain), 1% procaine (Novocain). A skin wheal was raised on the dorsum of the hand by injecting 0.1 ml intradermally and 0.1 ml subcutaneously via a 27-g hypodermic needle. 60 seconds later an 18-g intravenous cannula was passed through that skin wheal into a vein. MEASUREMENTS: A visual analog scale (VAS) for pain (0 = no pain/10 = most pain imaginable) was used to assess pain elicited by raising the skin wheal and inserting the cannula. MAIN RESULTS: With regard to analgesic potency all five local anaesthetics were comparable (mean VAS-score 1.7-2.09) and effective when compared to 0.9% saline (mean VAS-score 4.2; P < 0.001). Infiltration pain was least with mepivacaine-1 (mean VAS-score 1.0; P < 0.001) and highest with procaine (mean VAS score 2.7; P < 0.001). CONCLUSIONS: Of the local anaesthetics tested, Mepivacaine-1 is the drug of choice for skin infiltration as its injection elicits least discomfort.     

Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Mayo Perioperative Outcomes Group

Subarachnoid or epidural needle placement in an anesthetized patient is controversial because general anesthesia and muscle relaxation may mask neural trauma. However, placement of a needle or catheter in the subarachnoid space for the purpose of cerebral spinal fluid (CSF) drainage is frequently performed in anesthetized patients undergoing neurosurgery. The records from 530 consecutive transsphenoidal surgeries performed with lumbar CSF drainage were reviewed to determine the types of neurologic complications attributable to spinal drainage and their rates of occurrence. All patients were anesthetized during CSF drain placement. A 19-gauge malleable needle was placed in 473 (89%) patients. Subarachnoid catheters (20- or 16-gauge catheters placed via 18- or 14-gauge epidural needles, respectively) were placed in 17 (3%) patients. In 40 (8%) patients, the type of drain was unspecified. No new neurologic deficits attributable to spinal drain insertion were detected in the immediate postoperative period or within 1 yr of surgery. Thirteen patients developed postdural puncture headache (2.5%, exact 95% confidence interval 1.3%-4.2%); seven required epidural blood patch (1.3%, 0.5%-2.7%). The low incidence (0%, 0.0%-0.7%) of neurologic injury from spinal drain insertion in anesthetized patients from this study is similar to the incidence of neurologic complications historically reported for both CSF drain insertion and spinal anesthesia. Implications: The performance of regional anesthesia in an anesthetized patient is controversial due to the possibility of unrecognized nerve injury. We report no cases of nerve injury caused by the placement of cerebrospinal fluid drainage needles and catheters in 530 anesthetized patients undergoing neurosurgery.     

Defective expression of early activation genes in cartilage-hair hypoplasia (CHH) with severe combined immunodeficiency (SCID)

PURPOSE OF STUDY: To examine factors which may predispose to tooth fracture, and to assess the compressive strengths of foods and sweets which are associated with tooth fracture in vivo. POPULATION STUDIED: Consecutive dental patients presenting with one or more fractured posterior teeth at the surgeries of three general dental practitioners, over a four-month period. METHOD: A pro forma was designed to elicit information on the factors associated with tooth fracture and the nature and extent of such fractures. Three general dental practitioners were requested to complete a pro forma for each patient presenting with a fractured posterior tooth over a four-month period. Foods and sweets considered to be associated with tooth fracture were identified and their compressive strengths tested. FINDINGS: A total of 129 cases of fractured posterior teeth were recorded, of which 48% occurred in the mandibular arch and 52% in the maxillary arch. In the mandible, 75% of tooth fractures occurred in molars while in the maxillary arch 50% occurred in molars. In 57% of cases assessed, no identifiable causative item was noted. Forty-five per cent of fractures were in teeth which had been restored on three or more surfaces. Compressive forces of 0.16KN to 2.2KN were obtained for food items implicated in tooth fractures. CONCLUSION: As mesio-occlusodistal restorations were identified as a major predisposing factor to tooth fracture in this study, with mandibular first molar teeth particularly affected, placement of cuspal coverage restorations may be considered to be a justifiable preventative measure in teeth identified as being at risk.     

The effect of ultrasonics on sealer distribution and sealing of root canals

The purpose of this study was to compare the ultrasonic and hand methods of sealer placement using three types of sealers: Sultan "Grossman's formula," AH-26, and CRCS. The effect of these methods on radiographic density, sealer distribution, and on the apical seal of the different sealers was evaluated. The in vitro experiment was carried out using human extracted mandibular incisors and mesio-buccal roots of maxillary first and second molars. Following standardized canal instrumentation, 120 single canal mandibular incisors were randomly assigned to six groups, depending on the type of sealer and method of sealer placement (hand versus ultrasonic). An additional ten teeth were used as controls. In the molar groups 40 canals were randomly assigned to two groups, with the method of sealer placement as the variable. Eight canals were used as controls. Postsealer analyses using radiographic density scores transformed to mm of sealer indicated that ultrasonics was superior to manual placement only for CRCS. Taken together, our investigation suggests that ultrasonics may enhance the placement of some sealers (i.e. CRCS) but not of others (i.e. AH-26 or Sultan). Method of sealer placement had no effect on apical leakage and therefore apparently on apical seal.     

A case with sarcomatoid hepatocellular carcinoma

BACKGROUND AND OBJECTIVES: The goal of the present investigation was to compare the double-segment and the needle-through-needle techniques for combined spinal and epidural anesthesia (CSE) in a prospective, randomized, blinded study. METHODS: With Ethical Committee approval and patient's consent, 120 patients were randomized to receive CSE by the needle-through-needle (SST; n=60) or the double-segment technique (DST; n=60). A blind observer measured the time required from skin disinfection to readiness for surgery (loss of pinprick sensation up to T10), failure of dural puncture, need for epidural top-up before surgery, patient acceptance, and occurrence of complications. RESULTS: No neurologic complications were observed in either group. Time to readiness for surgery was 22.7+/-8.2 minutes in the SST group and 29.8+/-8.31 minutes in the DST one (P < .001). Dural puncture was unsuccessful in three patients in the SST group (5%) and in one patient in the DST group (1.6%) (ns); inadequate spread of spinal anesthesia was observed in five patients in the SST group (8.3%) and in eight patients in the DST group (13.3%) (ns). No difference in the incidence of hypotension, postdural puncture headache, and back pain was observed between the two groups. Acceptance of anesthetic procedure was better in the SST (85%) than in the DST group (66.6%) (P < .05). CONCLUSIONS: The needle-through-needle technique for CSE requires less time, has no greater failure rate, and results in greater patient satisfaction than the double-segment technique. The use of a spinal needle with an adjustable locking mechanism and protruding up to 15 mm beyond the Tuohy needle improved successful spinal block in the needle-through-needle technique compared with previous reports.     

Primary non-Hodgkin''s lymphoma of the larynx in an AIDS patient

BACKGROUND AND OBJECTIVES: Interscalene brachial plexus block is a useful technique to provide anesthesia and analgesia for the shoulder and proximal upper extremity. The initial needle direction at the interscalene groove has been described as being "perpendicular to the skin in every plane" (1). A cross-sectional (axial) approach may offer a more easily conceptualized directed needle placement. The purpose of this study is to define the cross-sectional anatomy and idealized needle angles important to interscalene brachial plexus block. METHODS: Following IRB approval, 50 patients were studied. Cross-sectional volume coil T1-weighted magnetic resonance images (MRI) were obtained from 50 patients undergoing cervical region imaging for other reasons. At the interscalene groove, a simulated needle path to contact the ventral rami or trunks of the brachial plexus was approximated at the level of C6 or C6-C7 interspace. The angle of this needle path intersecting the sagittal plane was recorded for each patient. RESULTS: The mean angle of the simulated needle path relative to sagittal plane was determined to be 61.1 +/- 6.1 degrees (range, 50-78 degrees). In 13 of 50 (26%) MRI scans, the cervical nerve roots were not visualized at the level of C6 and were measured at the C6-C7 level. CONCLUSIONS: These findings suggest initial needle placement at the interscalene groove should be angled less perpendicularly relative to the sagittal plane than is often observed. A cross-sectional approach enables more practical visualization of initial needle placement. A more accurate initial needle placement may minimize the number of needle passes necessary to contact the nerve roots, thereby more efficiently obtaining a successful block.     

Reasons for discontinuing intracavernous injection therapy with prostaglandin E1 (alprostadil)

OBJECTIVES: To clarify the reasons why experience with self-injection therapy for erectile dysfunction shows high dropout rates. METHODS:We studied 86 patients 36 to 76 years old who had been on home treatment for at least 3 months. Sixty-nine patients (80%) were continuing to use injections, and 17 (20%) had discontinued the treatment. Patients were evaluated by interview and clinical examination. RESULTS: Patients still in the program used one injection every 2 weeks, and those who had given up treatment had used one injection in 3 weeks (P = 0.31). They were in the program for 39+/-27 and 16+/-22 months (P = 0.002), respectively, and had used 50 (95% confidence interval [CI] 21 to 91) versus 12 (95% CI 4 to 20) injections, respectively (P<0.0001). Injections producing unsatisfactory penile rigidity, prolonged erections, hematoma at injection site, corporal fibrosis, secondary penile deviation, and mean estimated duration of a pharmacoinduced erection showed no significant differences. Patient satisfaction (P = 0.02), estimated partner satisfaction (P = 0.02), increase in self-esteem (P = 0.01), and negligible effort in performing injections (P = 0.001) all showed significantly better results for those still in the program. CONCLUSIONS: Reasons for dropout from self-injection therapy are not based on objective side effects and discomfort. Patients leaving the program are less motivated, less satisfied with the quality of pharmacoinduced sexuality, consider the effort to perform injections to be substantial, and have not achieved improved self-esteem.     

Rate of neuronal fallout in a transsynaptic cerebellar model

PURPOSE: A retrospective study was undertaken of the late adverse reactions following the injection of contrast media. The purpose was to determine whether there was a difference between non-ionic monomeric (iohexol) and non-ionic dimeric (iodixanol) contrast media in the reactions produced. MATERIAL AND METHODS: A total of 3,408 patients were sent a written questionnaire in which they were asked to confirm or deny any subjective discomfort or adverse event during a period of one hour to one week after a previous radiological examination with contrast medium. Patients who had undergone angiography (i.v. or i.a. injection) and CT (i.v. injection) were included. Objective signs of an allergy-like reaction were listed and the patients were asked to subjectively quantify any consequent discomfort. RESULTS: The compliance rate was 84%. Of the 3075 injections finally included in the study, 133 (4.3%) had resulted in contrast-medium-related adverse reactions of which 72 (2.3%) were immediate and 61 (2%) were late. Iohexol induced late reactions in 14/851 (1.7%) cases, and iodixanol in 24/1218 (2.0%) cases following i.v. injection and in 23/1006 (2.3%) cases following i.a. injection. The differences were not significant. There were no differences between the two contrast media in the subjective rating of discomfort except that the patients who had received iodixanol also had the highest individual-intensity score. No patient had been hospitalized owing to an adverse reaction and all reactions had been regarded as mild or moderate. CONCLUSION: The number of late adverse reactions was low. There was no difference in the frequency of the late adverse reactions following i.v. injection between iodixanol and iohexol. There was also no difference in the reactions between the i.a. and i.v. injections of iodixanol.     

Comparative study of antifungal activity of sertaconazole, terbinafine, and bifonazole against clinical isolates of Candida spp., Cryptococcus neoformans and dermatophytes

The aim of this study was to investigate the visibility of secondary caries in the gingivobuccal and gingivolingual corners of teeth restored with amalgam restorations. Standard Class II cavities were created in 15 orthodontically extracted mandibular premolar teeth, and the teeth were randomly divided into five groups of three teeth each. In four of the groups, a 1.0- or 1.5-mm cavity was prepared in the gingivolingual or gingivobuccal corner of the restoration. No lesions were created in group 5, the control group. The teeth were restored with amalgam. The teeth were adapted in the actual tooth space of 15 volunteers with one mandibular premolar missing. Radiographs of each patient were taken with the bisecting-angle technique and the bite wing technique. The radiographs were sorted at random and given to 15 members of the professoriate who were often involved in detecting caries and to 17 members who were not normally involved in detecting caries. The bitewing technique was found to be more reliable than the bisecting-angle technique in detecting secondary caries in gingivobuccal approximal corners (P < .05). It was also found that, in group 1, the bisecting-angle technique was more reliable than the bitewing technique in detecting caries in gingivolingual corners (P < .05). No significant differences were found in the correct evaluation of radiographs between the faculty who were normally involved in the detection of caries and those who were not.     

Management of fibrosing pancreatitis in children presenting with obstructive jaundice

OBJECTIVES: Post-radical prostatectomy stress incontinence occurs in up to 20% of patients. Postprostatectomy incontinence is initially treated with undergarments, pads, or drip collectors. Patients with persistent leakage are often treated with a transurethral bulking agent (Contigen) or placement of an artificial genitourinary sphincter (AGUS). We have compared the direct costs of each treatment at our institution over 10 years. METHODS: The Mayo Clinic estimating office provided the Medicare and non-Medicare charges for patients receiving both collagen injection (outpatient) and AGUS placement (2-day hospitalization) during August 1995. The Mayo Store provided the current price of all undergarments, pads, and drip collectors carried. Two local grocery stores provided the cost of Depends undergarments. RESULTS: The following items were the least expensive carried at the Mayo Clinic Store: Entrust undergarments, Active Style pads, and Conveen drip collectors at $0.99, $0.52, $1.05 each, respectively. The average cost of Depends undergarments was $0.52 each. The cost of wearing 5 of the least expensive undergarments or pads per day for 10 years is $9497. The average estimated Medicare and non-Medicare cost for outpatient (general anesthesia) collagen injection is $4300 and $5625, respectively. The average Medicare and non-Medicare cost for AGUS placement is $15,400 and $20,300, respectively. Factoring in our current 22.4% reoperation rate, the average per patient Medicare and non-Medicare cost for AGUS placement is $18,850 and $24,847, respectively. CONCLUSIONS: The cost of the AGUS placement compares favorably with the cost of transurethral collagen injection (under general anesthesia) in patients requiring several (more than three) collagen injection treatments or requiring the continued use of undergarments after collagen injection. Whereas the cost of transurethral collagen injection, when effective, compares favorably with conservative treatment, AGUS placement is significantly more expensive than conservative management for almost all patients except the exceedingly rare patient wearing more than 9 undergarments or pads per day. When the psychosocial benefit of urinary continence is considered, however, transurethral injection of collagen or AGUS placement often becomes the preferred treatment.     

Arterial disease and thrombosis in the antiphospholipid syndrome: a pathogenic role for endothelin 1

PURPOSE: It has been proposed that inferior vena cava filter placement should be the initial treatment of deep venous thrombosis (DVT) or pulmonary embolus (PE) in patients with coexisting malignant disease. We have chosen instead to selectively place filters only in patients with either a contraindication to anticoagulation therapy or a subsequent complication from anticoagulation therapy. The treatment efficacy and mortality rates in patients with concomitant malignant disease and venous thromboembolism using this approach was determined. METHODS: We retrospectively reviewed all patients at our institution with malignant disease in whom venous thromboembolism developed between August 1991 through August 1996 and identified 166 patients with PE (n = 8), DVT (n = 147), and DVT/PE (n = 11). Of these patients, 138 (83.1%) were initially treated with anticoagulation therapy, and 28 (16.9%) had primary filter placement because of contraindications to anticoagulation therapy (10 for intracranial tumors, 11 for recent or upcoming operations, 6 for recent hemorrhage, and 1 for a malignant bloody pericardial effusion). RESULTS: Thirty-two (23%) of the 138 patients who initially underwent anticoagulation therapy subsequently required a filter for the following reasons: bleeding (n = 15, 10.9%); recurrent thromboembolism (n = 6, 4.3%); heparin-induced thrombocytopenia (n = 1, 0.7%); and perceived high risk for bleeding with continued anticoagulation therapy (n = 11, 8%). Both bleeding and recurrent thromboembolism developed in 1 patient. Sixty patients (36%) received filters. No major technical complications occurred from filter placement. Major recurrent thromboembolic complications developed in 10 patients: DVT (n = 6, 10%), PE (n = 2, 3.3%), inferior vena cava thrombosis and phlegmasia cerulea dolens (n = 1, 1.7%), superior vena cava thrombosis (n = 1, 1.7%). Venous gangrene developed in 1 patient with DVT. The 1-year actuarial survival rates for patients treated with filter and anticoagulation therapy were 35% and 38%, respectively (P = NS). CONCLUSION: In summary, our experience suggests that 64% of patients with malignant disease and venous thromboembolism are effectively treated with anticoagulation alone; 17% require primary filter placement for standard indications, and an additional 19% require subsequent filter placement because of complications (primarily bleeding) or failure of anticoagulation therapy. Although technical complications of filter placement are low, serious life-threatening or limb-threatening thromboembolic complications developed in 17% of patients. Survival was poor in all patients, regardless of treatment. These data support a conservative approach of routine anticoagulation therapy with selective filter placement.     

Urinalysis in clinical diagnosis

STUDY OBJECTIVE: To determine if the addition of alfentanil to propofol is more effective than propofol alone to provide adequate conditions for placement of a retrobulbar block prior to cataract surgery. DESIGN: Randomized, double-blinded study. SETTING: Outpatients at a university hospital. PATIENTS: 40 adult ASA physical status I, II, and III outpatients scheduled for elective cataract surgery. INTERVENTIONS: Patients were randomly assigned to receive one of four drug combinations prior to the placement of a retrobulbar block: Group 1, propofol alone; Group 2, alfentanil 5 micrograms/kg plus propofol; Group 3, alfentanil 10 micrograms/kg plus propofol; Group 4, alfentanil 15 micrograms/kg plus propofol. All patients were preoxygenated by face mask for two minutes prior to drug administration. The quality of conditions for block placement were determined by: (1) assessing the amount of movement by the patients while the block needle was in place, (2) cooperativeness of the patients during the operation, (3) hemodynamic side effects, (4) incidence and severity of respiratory depression, (5) incidence of nausea and vomiting, (6) recall of placement of the block, and (7) time to discharge from the hospital. Measurements and Main Results: The addition of alfentanil to propofol for sedation prior to placement of the retrobulbar block resulted in a dose-dependent reduction in movement by the patients. However, the highest dose of alfentanil (15 micrograms/kg) resulted in the greatest frequency (40% of the patients in this group) of respiratory depression (SpO2 < 90%). All patients were cooperative during the operation and responsive to verbal command within 5 minutes of placement of the block. In addition, all of the patients denied being nauseated, having vomited, or recalling block placement in the recovery room or the next day. CONCLUSIONS: The combination of alfentanil and propofol may be used to sedate patients in order to limit movement and provide a cooperative, alert patient with stable hemodynamics and limited respiratory depression during placement of retrobulbar block prior to ophthalmic surgery. However, excessive dosage of these drugs may result in hazardous respiratory depression in this patient population.