Desarrollo de un modelo experimental para el estudio de la toxicidad cardiaca inducida por bupivacaína, implicaciones para la anestesia en Cirugía Ambulatoria / Development of an experimental model for the study of bupivacaine induced cardiotoxicity, implications for anesthesia in Ambulatory Surger

Objetivo: Recientemente existe un renovado interés por las técnicas locorregionales, asistiendo a una gran demanda tanto por los pacientes como por los equipos quirúrgicos, especialmente en la cirugía ambulatoria. La descripción de casos clínicos graves asociados a intoxicación por bupivacaína es un evento infrecuente, sin embargo, para mejorar nuestro conocimiento y prevenir la toxicidad de los anestésicos locales es necesario el desarrollo de modelos animales. Los efectos adversos cursan con alteraciones electrocardiográficas relacionadas especialmente con la conducción ventricular y con prolongación del intervalo QRS. Poder detectar una intoxicación grave por anestésicos locales antes de que ocurra un colapso cardiovascular tendría importantes consideraciones clínicas. Nuestro objetivo fue desarrollar un modelo no letal de intoxicación aguda por bupivacaína y correlacionar los niveles del fármaco con el complejo QRS como marcador instantáneo de una intoxicación grave por anestésicos locales. Material y métodos: Se estudiaron 8 cerdos large-White premedicados con ketamina, 20 mg/kg, y anestesiados con tiopental sódico (19 ± 8 mg/kg-1) como inductor y sevoflurano 1 CAM (2,6 %) para el mantenimiento anestésico. Se canalizaron la arteria y vena femoral para la monitorización invasiva, determinaciones analíticas y de niveles de bupivacaína. Al finalizar la instrumentalización, se administró bupivacaína en dosis de 4 mg/kg-1. Se realizaron determinaciones analíticas antes y al 1, 5, 10 y 30 minutos de administración del fármaco. Se evaluó la correlación entre los niveles de bupivacaína en sangre y el intervalo QRS. Se consideró significativo una p < 0,05. Análisis estadístico: Test de correlación de Spearman. Resultados: Ningún animal falleció como resultado de la experiencia. El porcentaje medio de aumento del QRS fue de 185 ± 60 ms. Hubo una correlación estadísticamente significativa entre la duración del intervalo QRS y los niveles plasmáticos de bupivacaína, coeficiente de correlación de Spearman: 0,80; p < 0,0001. Conclusión: Nuestro modelo ha permitido el estudio de uno de los aspectos más relevantes de toxicidad de la bupivacaína. El ensanchamiento del intervalo QRS se ha relacionado positivamente con los niveles de bupivacaína. La modificación instantánea de este parámetro puede ser un marcador clínico instantáneo de gran utilidad en la práctica clínica diaria

Objective: Recently there has been an extraordinary advance in the techniques of regional anaesthesia, assisting to a great demand from the patients and the surgical team especially in day surgery. Reports of serious cardiac bupivacaine intoxication are fortunately unusual, however in order to improve our knowledge and prevention of local anaesthetic toxicity the development of animal models is needed. The adverse event comes along with important electrocardiographic alterations, especially those related to ventricular conduction such as the QRS interval widening. Detecting a severe intoxication with local anaesthetic before a cardiovascular collapse takes place involves important clinical considerations. We aimed to develop a non-lethal steady model of bupivacaine intoxication and correlate bupivacaine plasma levels with the QRS complex duration as an instantaneous marker of severe local anaesthetic intoxication. Material and methods: Eight mini-pigs were premedicated with ketamine and anesthetized with intravenous sodium thiopental 5 mg/kg. The anesthetic maintenance was performed with sevoflurane 1 CAM (2.6 %). Femoral artery and vein were canalized for invasive monitoring, analytical blood gas samples and bupivacaine levels determinations. After instrumentation and motorization, a bupivacaine bolus of 4 mg/kg-1 was administered. Electrocardiographic parameters were recorded and blood samples were taken before and 1, 5, 10 and 30 min after the drug administration. We correlated venous plasma concentration with the QRS widening observed. Statistical: Spearman rank correlation coefficient. A P-value < 0.05 was considered statistically significant. Results: No animal died as a result of the experience and hemodynamic data and blood gas analysis were maintained at physiological range. The mean maximal percent increase in QRS interval was 185 ± 60 ms. There was a statistically significant positive correlation between the QRS interval and bupivacaine plasmatic levels. (Correlation coefficient of r = 0,80 (p < 0,0001). Conclusions: This porcine model of bupivacaine intoxication has been steady, obtaining important electrocardiographic modifications and keeping alive all animals. The relevant QRS interval widening was positively correlated with bupivacaine plasmatic levels. The instantaneous modification of this electrocardiographic parameter could be a useful clinical marker of serious bupivacaine intoxication in a daily basis

Charcot-like arthropathy: A newly-recognized subset of psoriatic arthritis.

OBJECTIVE: The aim of the study is to describe a group of patients with a highly destructive and asymptomatic form of psoriatic arthritis, mimicking a Charcot-like joint disease. METHODS: We studied 180 patients with psoriatic arthritis and identified 4 patients with arthritis mutilans mimicking a Charcot-like joint disease. Clinical history, physical exam, and immunological testing were performed as well as X-ray of affected joints. Synovial membrane and sural nerve biopsies were performed and diagnosis of psoriasis was confirmed by skin biopsy. RESULTS: Four patients with psoriatic arthritis mutilans according to Moll and Wright classification criteria (1) and Charcot-like joint disease were identified and evaluated. There were 2 males and 2 females, all Caucasians. The mean age +/- SD was 57.8 +/- 14.2 years. Mean arthritis duration +/- SD was 6 +/- 4.6 years and mean cutaneous duration +/- SD was 13 +/- 10.4 years. All patients had polyarthritis and a sudden onset of bilateral, painless, and highly destructive arthropathy involving large, non-weight bearing (elbows) and weight bearing (knees), and also small joint of hands and feet. Synovial membrane biopsy showed findings similar to those found in Charcot joint disease, including ischemic neuropathy. CONCLUSION: A newly-recognized subset of patients with psoriatic arthritis and Charcot-like joint disease according to clinical, radiographic and histological features is described. The proposed neurovascular theory may explain the pathogenesis of this presentation.

Clinical correlations of small bowel CT and contrast radiology findings in Crohn's disease.

BACKGROUNDS AND OBJECTIVE: Aim of the present study was to evaluate the clinical correlates of small bowel CT patterns in patients with Crohn's disease (CD), as compared to barium studies and endoscopic findings, as far as parameters of disease activity are concerned. MATERIAL AND METHODS: Thirty five patients with pathologically proven CD were studied by means of helical single detector CT (13) or multidetector CT (22), after administration of low density contrast by mouth (13) or by nasojeunal tube (22). Eight hours later, all patients were studied with barium administered by mouth (13) or with barium and methilcellulose administered by nasojeunal tube (22). Clinical activity was assessed by CDAI score, ESR, CRP, alpha1 glycoprotein and fibrinogen levels. In twenty one patients, colonoscopy was also performed. RESULTS: Sensitivity of small bowel CT versus endoscopy was of 88% while sensitivity of barium studies was of 77% versus endoscopic findings, and it reached 100% for the combination of both exams. We found positive correlations between the detection at CT of "target sign" and a CDAI score > 150 or abnormal values of CRP, ESR, alpha1 glycoprotein. Abnormal ESR or fibrinogen levels were correlated with the detection of fistulas at CT scans. The diameter of enlarged mesenteric lymph nodes was correlated with alpha1 glycoprotein values. No similar correlations were detected for contrast radiology findings. DISCUSSION: This study underscores the clinical usefulness of performing small bowel CT in adjunct to conventional diagnostic studies in Crohn's disease patients. CT findings (either by oral route or nasojeunal tube) correlate with parameters of disease activity.

Characterization of the expression of the alternative splicing of the ED-A, ED-B and V regions of fibronectin mRNA in bovine ovarian follicles and corpora lutea.

Fibronectin is an extracellular matrix glycoprotein. Alternative splicing of fibronectin mRNA within three specific regions, the extra domains (ED) A and B and the variable (V) or IIICS region, result in the production of different isoforms of fibronectin. These isoforms differentially regulate tissue developmental processes, such as those occurring during follicular and luteal development. The specific isoforms of fibronectin present in follicles and corpora lutea have not been identified. To identify these, primers for reverse transcription polymerase chain reaction (RT-PCR) were designed to the known bovine amino acid sequence of exons flanking the ED-A, ED-B and V regions. PCR products from bovine fetal liver cDNA were determined to be bovine fibronectin by the correct product size and DNA sequence homology to other species, and to the known bovine amino acid sequence. Bovine ovarian follicles (0.5-9 mm diameter) and corpora lutea (cyclic, early to late mid-luteal phase) were shown to express ED-A+, ED-A-, ED-B+, ED-B-, V+ and V fibronectin isoforms, similar to the liver, lung and kidney of fetuses, but generally not of adult animals. Thus follicles and corpora lutea express isoforms of fibronectin usually expressed in developing tissues.

Cutaneous presentation of acute myeloid leukemia in a "classical" Kaposi's sarcoma patient.

A case of early cutaneous involvement by an acute myeloid leukemia in a Caucasian man, previously affected by a "classical" Kaposi's sarcoma is reported. The diagnoses were based upon histologic examinations and appropriate hematologic investigations. After reviewing extensively the literature about the association of lymphoreticular system malignancies and Kaposi's sarcoma, possible implications and hypothetical etiopathogenetic mechanisms are discussed.

[Hospitals and immigration: analysis of a case series]. / L'ospedale di fronte all'immigrazione: analisi di una casistica.

The "immigrants problem", with the inevitable social aspects which this new phenomenon involves, has grown lately into a matter of primary interest to the public opinion of our country. The hospital too, in its capacity as leader among the sociosanitary institutions, has witnessed a change to some extent of the demand for services resulting from this reality. The Authors intend therefore to re-define here the whole body of a large metropolitan hospital patients, referring to an extensive statistical information and analyzing with special attention the statistics about foreign citizens. To this purpose they have considered all the cases of hospitalization occurred during a five-year period, from 1985 to 1989. The gathered data have been elaborated and analyzed from a more strictly demographic standpoint and (in particular) from the epidemiological point of view, comparing the data resulting among the immigrants with those regarding the whole body of hospitalized people during the same period. The data so obtained show, in spite of some significant differences due almost certainly to social differences, a superimposition on the italian reality, reproducing on a smaller scale its distinctive features. Even if this research is restricted to a specific situation, the results obtained can be considered a basis to make further similar studies within other hospital structures, in order to point out the different and variable demands for hospital services originating from this new social reality.

Changing perspectives on health care development in Grenada

In this article the writer outlines and describes the programme of health care implemented by the People's Revolutionary Government (PRG), states that the emphasis on health care is now preventative rather than curative and that health care is perceived as a total community effort rather than a package of pre-determined services delivered to a community. (AU)

A comparison of the nutritional value of two weaning foods

The nutritional values of a traditional banana porridge and a new commercially produced porridge, Cerex, were compared in a feeding trial. The banana porridge contained banana flour, wheat flour, condensed milk and water. Cerex porridge was made from cerex (corn, rice, soya and fortified skimmed milk powders) made isocaloric to the banana porridge (100 Kcal/100g) with the addition of oil, sugar and water. The porridges were fed at libitum as the only source of nutrients to 8 children recovering from malnutrition for 10 days on each porridge in a cross over design. There were 5 girls and 3 boys, aged 6-16 months, all of whom were about 80 percent weight for height at the start of the study. Anthropometric measurements and the intakes of porridges were recorded. The protein and energy content of the porridges as fed were measured. The children gained weight at the same rate on both porridges: a rate comparable to that achieved on "high calorie milk" used as a routine for treating malnutrition in TMRU. The mean rate of weight gained on cerex porridge was 13.1 ñ 6.3 (SD) g/kg/d, for banana porridge 12.5 ñ 5.2 (SD) g/kg/d. This is 3 times as fast as a normal child of the same average weight and 13 times as fast as a normal child of the same average age. The mean food intakes of cerex (147 ñ 19 (SD) g/kg/d) and banana (156 ñ 16 (SD) g/kg/d) porridges were not significantly different nor was there a statistical difference in the mean energy intakes between cerex (159 Kcal/kg/d) and banana (161 Kcal/kg/d) porridges. Although cerex porridge provided more protein (5.39 > 3.73g/kg/d.p < 0.05), the protein in green banana porridge was more efficiently utilized for balanced weight gain as the energy cost of weight gain was the same on both porridges. At the projected retail price for cerex, that porridge provides more energy/dollar than green banana flour porridge based on the actual retail price of banana flour. However, the difference is outweighed by the advantage of utilizing a locally produced food, if the total cost from production at the farm, through cost to national budget, to cost to consumer is considered. The advantage of being able to grow the food in a backyard or small farm is considered for the rural population. We conclude that the traditional banana porridge should be acceptable and economically the use of indigenous foodstuff is desirable (Summary)

Knowledge and use of birth control in Barbados

Based on material collected in Barbados in 1964, this paper examines knowledge and use of birth control in terms of 3 types of family union - married, common law, and visiting. Analysis of knowledge of birth control is dealt with for the sample at large, for educational attainment, and for the average number of methods known by each woman. The relative importance of the different methods known is also treated by family type and education. The extent to which women in the sample make use of birth control is discussed from 4 aspects. First, the growing use of the different methods among younger-age cohorts is made evident from tabulations of methods-last used. Second, information on the agencies and individuals recommending the use of different contraceptives emphasizes the degree to which the partner's influence is responsible for resort to birth control. Third, the proportions of users in religious groups show that religion is not a barrier to the use of any method. Fourth, the material is treated from the standpoint of age cohorts, since there is, in many cases, a vagueness as to the age at which use began, although women are able to identify the inter-pregnancy period when use began