Identification of the New Isotope

In an experiment performed at Lawrence Berkeley National Laboratory's 88-inch cyclotron, the isotope ^{244}Md was produced in the ^{209}Bi(^{40}Ar,5n) reaction. Decay properties of ^{244}Md were measured at the focal plane of the Berkeley Gas-filled Separator, and the mass number assignment of A=244 was confirmed with the apparatus for the identification of nuclide A. The isotope ^{244}Md is reported to have one, possibly two, α-decaying states with α energies of 8.66(2) and 8.31(2) MeV and half-lives of 0.4_{-0.1}^{+0.4} and ∼6 s, respectively. Additionally, first evidence of the α decay of ^{236}Bk was observed and is reported.

Restless legs syndrome in sensory axonal neuropathy: A case-control study.

INTRODUCTION: The relation between neuropathy and restless legs syndrome (RLS) remains uncertain. Previous studies have analyzed heterogeneous neuropathic populations and findings have been to date inconsistent. MATERIALS AND METHODS: We studied a neuropathic population consisting of 59 patients with acquired, mixed, small and large fiber sensory axonal neuropathy. We compared our findings to those of 59 neurological controls with a similar age/gender distribution. International RLS Study Group criteria were used and severity assessed by International Restless Legs Syndrome Severity Scores (IRLSSS), by a single blinded telephone interviewer. Mimics were excluded as well as cases with infrequent (<5 days/month) symptoms. RESULTS: RLS was significantly more frequent in patients with neuropathy than in controls (28.8% versus 8.5%; P=0.008). Patients with neuropathy and RLS were significantly older (P=0.001), had later onset RLS (P=0.001), had more frequent RLS symptoms (P=0.009) and greater IRLSSS (P=0.019), than controls with RLS. There was no relation between presence of RLS in patients with sensory neuropathy and lower limb sensory electrophysiological findings. CONCLUSIONS: Our results suggest that acquired sensory axonal neuropathy may be associated with RLS. Further larger studies of homogeneous neuropathic populations are required in view of the potential therapeutic benefit specifically for RLS symptoms in patients with neuropathy.

Regulation of neuronal plasticity and fear by a dynamic change in PAR1-G protein coupling in the amygdala.

Fear memories are acquired through neuronal plasticity, an orchestrated sequence of events regulated at circuit and cellular levels. The conventional model of fear acquisition assumes unimodal (for example, excitatory or inhibitory) roles of modulatory receptors in controlling neuronal activity and learning. Contrary to this view, we show that protease-activated receptor-1 (PAR1) promotes contrasting neuronal responses depending on the emotional status of an animal by a dynamic shift between distinct G protein-coupling partners. In the basolateral amygdala of fear-naive mice PAR1 couples to Gαq/11 and Gαo proteins, while after fear conditioning coupling to Gαo increases. Concurrently, stimulation of PAR1 before conditioning enhanced, but afterwards it inhibited firing of basal amygdala neurons. An initial impairment of the long-term potentiation (LTP) in PAR1-deficient mice was transformed into an increase in LTP and enhancement of fear after conditioning. These effects correlated with more frequent 2-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl)propanoic acid (AMPA) receptor-mediated miniature post synaptic events and increased neuronal excitability. Our findings point to experience-specific shifts in PAR1-G protein coupling in the amygdala as a novel mechanism regulating neuronal excitability and fear.

Comparison of ketamine, fentanyl and clonidine as an adjuvant during bupivacaine caudal anaesthesia in paediatric patients.

BACKGROUND: Caudal epidural analgesia with bupivacaine is very popular in paediatric anaesthesia for providing intra- and postoperative analgesia. Several adjuvants have been used to prolong the action of bupivacaine. OBJECTIVES: To compare the efficacy of ketamine, fentanyl and clonidine in terms of quality and duration of analgesia they produce when added with caudal bupivacaine by single shot technique in children. METHODS: Eighty children, age one to ten years, undergoing sub-umbilical surgery, were prospectively randomized to one of four groups: caudal analgesia with 0.75 ml/ kg of 0.25% bupivacaine in normal saline (Group B) or caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine with 1 µg/kg of clonidine in normal saline (Group BC) or caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine with ketamine 0.5mg/kg (Group BK) or caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine with fentanyl 1 mcg/kg (Group BF). Post-operative pain was assessed for 24 hours using the FLACC scale. RESULTS: The mean duration of analgesia was significantly longer in Group BC (629.06 ± 286.32 min) than other three groups P < 0.05. The pain score assessed using FLACC scale was compared between the four groups, and children in Group BC had lower pain scores, which was statistically significant. The requirement of rescue medicine was lesser in Group BC. Clonidine in a dose of 1 µg/kg added to 0.25% bupivacaine for caudal analgesia, during sub-umbilical surgeries, prolongs the duration of analgesia of bupivacaine, without any side effects in compare to fentanyl or ketamine. CONCLUSION: We conclude that clonidine in a dose of 1 µg/kg, added to 0.25% bupivacaine for caudal analgesia and administered as a 0.75 ml/kg mixture in children, for subumbilical surgery, significantly prolongs the duration of post-operative analgesia when compared to 0.75 ml/kg of 0.25% bupivacaine in normal saline than 0.75 ml/kg of 0.25% bupivacaine with ketamine 0.5 mg/kg or 0.75 ml/kg of 0.25% bupivacaine with fentanyl 1 mcg/kg or 0.75 ml/kg of 0.25% bupivacaine alone, without any side effects.

Preemptive use of small dose fentanyl suppresses fentanyl induced cough.

BACKGROUND: Fentanyl, a synthetic opioid, is a popular choice amongst anaesthesiologists in the operating room. Pre induction intravenous fentanyl bolus is associated with coughing in 28-65% of patients. Fentanyl induced cough is not always benign and can be remarkably troublesome at the most critical moment of anaesthesia when airway reflex is lost. OBJECTIVES: To study the effect of pre emptive use of minimal dose fentanyl through the peripheral venous cannulae on the incidence of cough by a larger bolus of intravenous fentanyl. METHODS: One hundred and fifty patients aged 18-75 years undergoing elective surgical procedures were randomized into three groups of 50 each. The first group received 0.5 ml saline 0.9% intravenously one minute prior to the administration of fentanyl 150 µg (3 ml); the second group received pre emptive fentanyl 25 µg (0.5 ml) prior to the administration of fentanyl 125 µg (2.5 ml); and the third group received preemptive fentanyl 25 µg (0.5 ml), followed by the administration of fentanyl 150 µg (3 ml). Based on the number of coughs observed, cough severity was graded as mild (1-2), moderate (3-5), or severe (>5). RESULTS: The incidence of fentanyl induced cough was significantly lower in both pre emptive group 4 (8%) for 125 µg fentanyl and 7 (14%) for 150 µg than in the saline group 15 (30%). CONCLUSION: Pre-emptive use of minimal dose fentanyl 25 µg administered one minute before a larger bolus dose of fentanyl (125 or 150 µg) can effectively suppress cough.

Retained portion of the appendix following laparosocpic appendicectomy causing peritonitis and ileus.

We describe a patient who developed peritonitis and paralytic ileus due to a retained portion of the inflammed appendix following laparoscopic appendicectomy (LA). The details of the presentation and management are discussed along with a brief review of the unusual complications LA.

Hormonal profiles and biochemical indices of bone turnover in Indian women.

UNLABELLED: The study establishes Indian referent database for bone turnover markers. The levels of markers decreased across the four quartiles of BMD showing a negative correlation with BMD. The study depicts that levels of hormones and bone turnover makers can aid in identifying women at risk for osteoporosis. INTRODUCTION: Biochemical markers of bone turnover reflect changes in bone metabolism earlier and aid in the management of osteoporosis. Since a referent database for Indian women is lacking, the study was initiated to establish the same and suggest that hormonal profiles and markers of bone turnover can aid in identifying women at risk for osteoporosis. METHODS: Osteocalcin (OC), bone specific alkaline phosphatase ((BSAP), C-terminal crosslinking telopeptide of type-I collagen (CTX-I), deoxypyridinoline (DPD), follicle-stimulating hormone (FSH) and estrone glucuronide (E(1)G) were measured in 365 Indian women (20-70 years) and correlated with BMD measurements by dual energy absorptiometry (DXA) using one way analysis of variance (ANOVA). RESULTS: The mean levels of bone resorption markers; CTX-I and DPD increased significantly across the age showing a negative correlation with BMD. The increase in levels of CTX-I and DPD was significantly higher (p < 0.0001) as compared to the femoral and spinal BMD, which dropped only 30-36%. The levels of bone turnover markers and FSH decreased across the four quartiles of spinal and femoral BMD showing a negative correlation whereas E(1)G levels increased across the four quartiles. CONCLUSION: The bone turnover markers were comparatively low in cohort of Indian women studied.

Laparoscopic biopsy in patients with abdominal lymphadenopathy.

BACKGROUND: Abdominal lymphadenopathy (AL) - a common clinical scenario faced by clinicians - often poses a diagnostic challenge. In the absence of palpable peripheral nodes, tissue has to be obtained from the abdominal nodes by image-guided biopsy or surgery. In this context a laparoscopic biopsy avoids the morbidity of a laparotomy. AIM: This retrospective analysis of prospectively collected data represents our experience with laparoscopic biopsy of abdominal lymph nodes. MATERIALS AND METHODS: Between October 2000 and November 2005, 28 patients with AL underwent laparoscopic biopsy. Pre-operative radiological imaging studies had identified a nodal mass in 20, a solitary node in 1, a cold abscess in 1 and a mesenteric cystic lesion in 1 patient. In five patients with chronic right lower abdominal pain and normal ultra-sonographic findings mesenteric nodes were identified and biopsied during diagnostic laparoscopy. RESULTS: The sites of biopsied lymph nodes included para-aortic (10), mesenteric (8), external iliac (3), left gastric (2), obturator (1), aorto-caval (1) and porta hepatis (1). One patient with enlarged peripancreatic nodes mass and another with a mesenteric cystic mass had cold abscesses drained in addition to biopsy. There were no perioperative complications and the median postoperative stay was 2 days (range 1-4 days). Histopathology revealed tuberculosis in 23 patients, reactive adenitis in 2, lymphoma in 1 metastatic carcinoma in 1, and a retroperitoneal sarcoma in 1. CONCLUSIONS: In patients with AL, laparoscopy provides a safe and effective means of obtaining biopsy. It is of particular value in patients in whom (a) the nodes are small or present in locations unsuitable for image-guided biopsy, (b) adequate tissue cannot be obtained by image-guided biopsy or (c) previously undiagnosed lymphadenopathy is encountered during diagnostic laparoscopy.

Breakage of fascial closure device during laparoscopic surgery.

Breakage of instruments during laparoscopic surgery is rare. However, when it does occur, locating and retrieving the broken part of the instrument can be cumbersome. Moreover, inability to do so may carry serious medicolegal implications. We report a patient in whom the tip of a fascial closure device broke during laparoscopic surgery. This was located by intraoperative fluoroscopy and retrieved from the extraperitoneal plane via a small incision. The paper discusses the probable factors responsible for breakage of the fascial closure device in our patient and reviews the previously reported cases of the rare complication of breakage of instruments during laparoscopic surgery.

Laparoscopically guided transperitoneal percutaneous nephrolithotomy for calculi in pelvic ectopic kidneys.

Although percutaneous nephrolithotomy is a well-established endourological modality for the management of calculi in the normally placed kidney, it is not easy to apply in the management of calculi in pelvic ectopic kidneys. We report the cases of three patients who were found to have large calculi in pelvic ectopic kidneys and subsequently underwent laparoscopically guided transperitoneal percutaneous nephrolithotomy, all with successful outcome. In all patients, complete stone clearance was achieved in a single operation with no intraoperative or postoperative morbidity. They remain asymptomatic and recurrence-free at a follow-up ranging from 2 to 38 months. Laparoscopic guidance allows the transperitoneal route to be used safely for percutaneous nephrolithotomy in patients with calculi in pelvic ectopic kidneys. We believe it to be a feasible, safe, and valid minimally invasive management option for this uncommon but challenging urological condition.

Intrahepatic subcapsular hematoma complicating laparoscopic cholecystectomy.

A 64-year-old woman underwent endoscopic retrograde cholangiopancreatography for bile duct stones, followed 2 days later by an uneventful laparoscopic cholecystectomy. She presented after 10 days with upper abdominal discomfort, nausea, and pyrexia. Investigations revealed a decrease in hemoglobin, and computed tomography identified a large intrahepatic subcapsular hematoma in segments V and VI. There was no intraabdominal collection and the rest of the viscera were normal. The collection was drained percutaneously under ultrasound guidance and a wide-bore catheter placed. She was treated with intravenous antibiotics and the catheter was removed 14 days later upon cessation of drainage. Serial ultrasonographic examinations showed a reduction in the size of the hematoma and complete resolution at 4 months. She remained well and asymptomatic at follow-up 16 months later. We report this case due to its rarity and review the previously documented cases of this complication.

Oculocutaneous albinism.

Oculocutaneous albinism represents a group of inherited skin disorders characterized by a generalized reduction of cutaneous, ocular and pilar pigmentation from the time of birth. Oculocutaneous albinism types 1 and 2 are the most common, but several other types have been described. A defect in the melanin synthesis pathway, resulting in reduced formation of melanin, is responsible for oculocutaneous albinism. Aetiology, clinical manifestations, diagnosis and management are discussed.

The role of laparoscopy in the management of common bile duct obstruction in children.

BACKGROUND: Laparoscopic common bile duct exploration is commonplace in adults; however, this procedure is not often performed in children. The goal of this study was to evaluate the results of laparoscopic common bile duct exploration in children. METHODS: Of 50 patients undergoing laparoscopic cholecystectomy, six patients (12%) had obstructing lesions of the common bile duct (CBD). Five children underwent laparoscopic common bile duct exploration, and one child had a preoperative endoscopic sphincterotomy and stone removal. RESULTS: The mean age at laparoscopic CBD exploration was 11.6 years (range, 5-16). The obstructing lesion was visualized by intraoperative cholangiography in all five patients. The mean operative time for laparoscopic cholecystectomy along with CBD exploration was 215 min (range, 160-282). The transcystic laparoscopic CBD exploration was performed using a 7-Fr, multichannel rigid, or 10-Fr flexible fiberoptic cystoscope. The stones were either pushed into the duodenum with the scope or extracted through the cystic duct using a 3-Fr Segura basket. In one patient, a candidial ball disintegrated during an attempt to remove it with the basket. A repeat cholangiogram at the end of each procedure showed an anatomically normal CBD with free flow of contrast into the duodenum. All patients enjoyed a quick recovery. They were started on a regular diet on the same day of surgery and discharged on the 1st or 2nd postoperative day. One patient with sickle cell disease developed a pulmonary infarction and required 5 additional days of hospitalization. One patient developed recurrent choledocholithiasis 6 months after laparoscopic exploration and was treated successfully with endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic CBD exploration can be performed safely at the time of the cholecystectomy in children. Endoscopic sphincterotomy before cholecystectomy is not necessary. We recommend laparoscopic CBD exploration for obstructing lesions of the CBD. Endoscopic sphincterotomy should be reserved for recurrent lesions of the CBD after laparoscopic cholecystectomy.

Comparison of four nonculture diagnostic tests for Chlamydia trachomatis infection.

OBJECTIVE: Chlamydia trachomatis (CT) is one of the commonest sexually transmitted diseases leading to urethritis, epididymitis, prostatitis in men and urethritis, cervicitis, endometritis and pelvic inflammatory disease, sometimes complicated by infertility and ectopic gestation in women. Since culture of fastidious bacteria in a monocellular medium is not available in most laboratories we compared direct immunofluorescence antigen detecting test (DFA) with three other nonculture tests-antigen detecting enzyme immunoassay (EIA), Papanicolaou staining (Pap) and Geimsa stain for endocervical swabs from women in reproductive age group. METHODS: Three hundred and fifty seven women between 16 and 41 years of age and attending family welfare clinics of IRR were evaluated for the presence pap smears. In 100 cases DFA staining was compared with Geimsa staining. RESULTS: DFA test was positive in 60/357 (16.8%), EIA in 29 (8.1%) of cases and Pap smear in 37 (10%) cases. In the second group DFA was positive in 17 (17%) and Geimsa in 10 (10%) cases. CONCLUSION: Amongst the four tests DFA showed maximum sensitivity. ELISA is less expensive but has lower sensitivity. Pap stain also has less sensitivity and good specificity, the quality of smear is likely to affect the diagnosis. Though Geimsa stain is cheapest, for chlamydial cervicitis in our experience it was not as sensitive as DFA. Thus each laboratory must decide the method depending on its resources.

Demographic characteristics in adult paternity for first births to adolescents under 15 years of age.

PURPOSE: To examine parental demographic characteristics by adult (> or = 20 years at baby's conception) and teenage (< 20 years at baby's conception) paternity in births to very young adolescents (< 15 years at baby's conception). METHODS: This was a population-based, retrospective cohort analysis of all 12,317 very young adolescent mothers residing in California with a first singleton live birth during 1993-1995. Risks for adult, compared to teenage, paternity were evaluated using multivariate logistic regression. RESULTS: Adult fathers, responsible for 26.7% of births to very young adolescents, were a mean of 8.8 years older than the mother. The risk factors for adult compared to adolescent paternity were as follows: father's educational attainment of at least 3 years below that considered adequate for his age [adjusted odds ratio (AOR) = 8.34], father's (AOR = 2.46) or mother's (AOR = 1.36) educational attainment 1-2 years below that considered adequate for their age, mother's birthplace outside the United States (AOR = 3.12), and father's Hispanic ethnicity (AOR = 1.60) or African-American race (AOR = 1.50). CONCLUSIONS: Adult fathers were responsible for over one quarter of the births in our study. Adolescent pregnancy prevention focusing on younger adolescents must programmatically address adult paternity. Variations in adult paternity patterns across cultural groups suggest that we need further study of the role that cultural beliefs and practices play in very young adolescent pregnancy.

PIP: This study examined parental demographic characteristics among persons aged over 20 years, under 20 years, and under 15 years at conception of the first birth in California. Data were obtained from California birth certificates in 1993, 1994, and 1995 and from the 1990 Census. The sample included 12,317 very young mothers of a total of 657,122 single first live births to California residents. The mean age of very young mothers was 13.7 years. Very young mothers tended to be in high school, Hispanic, and born in the US. The birth rate for mothers aged 10-14 years was 1.4/1000; 2.6/1000 for Hispanics, 3.0/1000 for African-Americans, and 0.3/1000 for Whites. Adult males were fathers of 24.3% of babies born to mothers aged 11-12 years. The mean age of fathers was 22.7 years. Adult males were fathers of 26.8% of babies born to mothers aged 13-14 years. Final multivariate models reveal that inadequate educational attainment was a risk factor for adult paternity in births to very young mothers. The risk for adult paternity increased as the father's education adequacy decreased. Race or ethnicity were lower risk factors than father's educational attainment. Very young adolescent mothers who were foreign born were very likely to be involved with an adult male. Adult fathers were an average of 8.8 years older than very young mothers. Adolescent pregnancy prevention programs need to target adult men.

Early definitive intervention by thoracoscopy in pediatric empyema.

PURPOSE: Nineteen children had early thoracoscopic intervention for empyema between 1992 and 1997 at the LeBonheur Children's Medical Center. The authors have evaluated the results of this treatment. METHODS: Thoracoscopic intervention was performed at the fibrinopurulent state of empyema. An irrigating laparoendoscope was inserted, loculi were disrupted, debris was evacuated, and a chest tube was passed through the port site. RESULTS: The patients were aged between 11 months and 16 years (mean, 6.5 years). The etiology of the empyema was parapneumonic in 17, and there was one case each of perforated appendicitis and mediastinal histoplasmosis. They underwent thoracoscopy at a mean of 4.6 days after hospital admission (range, 1 to 12 days). Chest tubes were removed at 1 to 5 days (mean, 2.9 days) after operation, and resolution of fever occurred at 1 to 9 days (mean, 3.8 days) postoperatively. Patients were discharged home between 4 and 10 days (mean, 6.1 days) postoperatively, and the mean hospital stay was 10.3 days (range, 5 to 21). There were no complications. The surgical technique was simple and well tolerated, requiring few disposable items, and the mean operating time was 77 minutes. CONCLUSIONS: Thoracoscopy eliminated the morbidity of thoracotomy and the discomfort and expense of prolonged chest tube drainage. Thoracoscopy may be used as early first-line therapy in a majority of pediatric patients with fibrinopurulent empyema.