Lidocaine pretreatment with tourniquet versus lidocaine-propofol admixture for attenuating propofol injection pain: a randomized controlled trial.

OBJECTIVE: Findings from studies investigating optimal techniques for attenuating propofol-related injection pain are inconsistent. In previous studies, lidocaine pretreatment using a tourniquet has been reported to be superior, inferior, or equivalent to a lidocaine-propofol admixture for reducing pain. This discordance could represent either no meaningful difference in the treatments or underlying methodological differences in the previous studies. We hypothesized that tourniquet-controlled pretreatment with lidocaine would be superior to lidocaine-propofol admixture for reducing propofol injection pain. METHODS: This randomized controlled trial compared 3 groups-a control group (saline pretreatment/saline admixture; n = 50), a pretreatment group (lidocaine pretreatment/saline admixture; n = 51), and an admixture group (saline pretreatment/lidocaine admixture; n = 50). The primary outcome was verbal pain score after injection. The incidence of pain on injection was explored as a secondary outcome. RESULTS: The median (interquartile range) verbal pain score after study solution injection were as follows-control group: 3 (0-6), pretreatment group: 0 (0-0), and admixture group: 0 (0-2). The pretreatment group had significantly lower pain scores when compared with the admixture group (P = 0.016), and both groups were superior to the control group. The pretreatment group had fewer subjects experiencing any injection pain than did the admixture group (20% vs. 44%, respectively; P = 0.024). CONCLUSIONS: Tourniquet-controlled pretreatment with lidocaine is statistically superior to admixing lidocaine with propofol for reducing propofol injection pain intensity, but the clinical importance of this small effect is questionable. However, pretreatment more effectively eliminates injection pain.

The lateral capitellohumeral angle in normal children: mean, variation, and reliability in comparison to Baumann's angle.

BACKGROUND: Angular deformity is the most common complication of supracondylar humerus fracture. Baumann's angle (BA) is an established radiographic measure of coronal plane deformity after this injury. Numerous radiographic methods have been used to assess sagittal plane deformity, however, the mean, variability, and reliability of these measures has not been established. The purpose of this study was to determine the mean, SD, and intraobserver/interobserver reliability of the lateral capitellohumeral angle (LCHA) in children without evidence of fracture and compare them with those of BA. METHODS: Seventy-one sets of anteroposterior and lateral elbow radiographs were selected and stratified into 6-year age categories with equal number of males and females in each category. Five physicians performed 3 separate measurements of LCHA and BA on each film set. Statistical calculations were performed to determine mean, SD, measurement reliability, and differences between patients groups. RESULTS: The mean LCHA ±1 SD and BA ± 1 SD measurements were 50.8 ± 6 degrees and 71.5 ± 6.2 degrees, respectively, and did not vary significantly by age, side, or sex (P>0.05). The LCHA showed good intraobserver (correlation coefficient 0.67) and fair interobserver (0.37) reliability, whereas BA showed excellent intraobserver (0.86) and interobserver (0.80) reliability. The expected SD for repeated measurement of a radiograph by a single observer was 2.6 degrees for BA and 5.2 degrees for LCHA. CONCLUSIONS: The LCHA is a simple measurement to perform using digital tools. In normal elbows, the mean angle is 51 ± 6 degrees and does not vary by age, side, or sex. LCHA variability in normal elbow radiographs is similar to BA. Its reliability is inferior to BA, but improves with age. Sagittal angulation abnormality of at least 12 degrees (<39 or >63 degrees) is necessary to be confident that the change is not because of measurement error alone. Further research is needed to better define the relationship of sagittal plane angular deformity to clinical outcome. LEVEL OF EVIDENCE: Diagnostic study with poor reference standard, Level IV.

Pulmonary exacerbations are associated with subsequent FEV1 decline in both adults and children with cystic fibrosis.

BACKGROUND: Patients with cystic fibrosis (CF) frequently experience pulmonary exacerbations that may lead to a faster subsequent decline in pulmonary function; however, this relationship has not been clearly established. The purpose of this study was to determine the association between the frequency of pulmonary exacerbations and subsequent forced expiratory volume in 1 sec (FEV(1) ) decline in adults and children with CF. METHODS: Cohort study of subjects followed in the Cystic Fibrosis Foundation Patient Registry from 2003 through 2006. Mixed effects modeling was used to estimate differences in rates of decline in FEV(1) in 2004-2006 for patients with 0, 1, 2, or 3+ pulmonary exacerbation(s) in 2003. RESULTS: Of 8,490 subjects who met inclusion criteria, 60% had 0 exacerbations, 23% had 1, 10% had 2, and 7% had 3+ exacerbations in 2003. Compared to children with no pulmonary exacerbations in 2003, children with one or more exacerbations experienced a significantly (P < 0.001) greater rate of FEV(1) decline in 2004-2006. In contrast, among adults, only those with 3+ exacerbations in 2003 had a significantly (P = 0.01) greater rate of FEV(1) decline in 2004-2006 than those with no exacerbations in 2003. CONCLUSIONS: There is a strong association between the frequency of pulmonary exacerbations and subsequent decline in pulmonary function. In adults, having 3+ exacerbations, and among children, having any exacerbations is associated with a greater rate of decline in the ensuing 3 years. Improved prevention, identification, and treatment of pulmonary exacerbations are likely to have long-term benefits for patients with CF, especially children.

Failure to recover to baseline pulmonary function after cystic fibrosis pulmonary exacerbation.

RATIONALE: Patients with cystic fibrosis periodically experience pulmonary exacerbations. Previous studies have noted that some patients' lung function (FEV(1)) does not improve with treatment. OBJECTIVES: To determine the proportion of patients treated for a pulmonary exacerbation that does not recover to spirometric baseline, and to identify factors associated with the failure to recover to spirometric baseline. METHODS: Cohort study using the Cystic Fibrosis Foundation Patient Registry from 2003-2006. We randomly selected one pulmonary exacerbation treated with intravenous antibiotics per patient and compared the best FEV(1) in the 3 months after treatment with the best FEV(1) in the 6 months before treatment. Recovery to baseline was defined as any FEV(1) in the 3 months after treatment that was greater than or equal to 90% of the baseline FEV(1). Multivariable logistic regression was used to estimate associations with the failure to recover to baseline FEV(1). MEASUREMENTS AND MAIN RESULTS: Of 8,479 pulmonary exacerbations, 25% failed to recover to baseline FEV(1). A higher risk of failing to recover to baseline was associated with female sex; pancreatic insufficiency; being undernourished; Medicaid insurance; persistent infection with Pseudomonas aeruginosa, Burkholderia cepacia complex, or methicillin-resistant Staphylococcus aureus; allergic bronchopulmonary aspergillosis; a longer time since baseline spirometric assessment; and a larger drop in FEV(1) from baseline to treatment initiation. CONCLUSIONS: For a randomly selected pulmonary exacerbation, 25% of patients' pulmonary function did not recover to baseline after treatment with intravenous antibiotics. We identified factors associated with the failure to recover to baseline, allowing clinicians to identify patients who may benefit from closer monitoring and more aggressive treatment.

Compliance with multiple-dose vaccine schedules among older children, adolescents, and adults: results from a vaccine safety datalink study.

OBJECTIVES: We studied compliance with multiple-dose vaccine schedules, assessed factors associated with noncompliance, and examined timeliness of series completion among older children, adolescents, and adults. METHODS: We conducted a large, multisite, retrospective cohort study of older children, adolescents, and adults in the Vaccine Safety Datalink population from 1996 through 2004. We quantified the rates of completion of all required doses for varicella, hepatitis A, and hepatitis B vaccines according to their recommended schedules. RESULTS: Among those who received a first dose of varicella (n = 16 075), hepatitis A (n = 594 917), and hepatitis B (n = 590 445) vaccine, relatively few completed the series (55%-65% for hepatitis B vaccine and 40%-50% for hepatitis A and varicella vaccines in most age groups). Compliance was lowest among adolescents (35.9%) and Medicaid recipients (29.7%) who received varicella vaccine and among younger adult age groups who received hepatitis A vaccine (25%-35% across those age groups). Even among series completers, there was a relatively long interval of undervaccination between the first and last doses. CONCLUSIONS: Compliance with multiple-dose vaccine series among older children, adolescents, and adults is suboptimal. Further evaluations of strategies to improve compliance in these populations are needed.