[Clinical experience in interscalene brachial plexus block combined with Ho's method of C3-4 block for shoulder and proximal upper extremity surgeries].

BACKGROUND: Brachial plexus block, first performed in 1889 by Halsted, has been widely used for surgery of shoulder and upper third of upper extremity. But the level of block is inadequate for surgery of the deeper tissue. If high volume of local anesthetic (40 ml) is used to block C3-4, complications like Horner's syndrome and phenic nerve palsy would be frequent. The landmark of C-3 and C-4 nerve root is difficult to identify. The purpose of this study was to design a new method to block easily the C-3 and C-4 nerve roots for surgery of shoulder deep tissue. METHODS: Sixty-five patients with ASA physical status I-III and age from 15 to 65 yr were studied. They included 42 male and 23 female patients who received interscalene brachial plexus block together with Ho's method of C-3, C-4 block in the space of 10 mon since 1985. The Ho's point which circumscribes the landmark for C3-4 block is a point at which the outer margin of the external jugular vein intersects the sternocleidomastoid muscle. In this technique we punctured the skin with a needle vertically at the chosen point until it touched the anterolateral side of the C-4 transverse process, normally, not deeper than 1.25 cm. This block was usually done for surgery of the shoulder and upper third of upper extremity. We used 0.5% bupivacaine 10 ml combined with 2% lidocaine 10 ml for interscalene brachial plexus block and 2% lidocaine 10 ml only for C3-4 block. RESULTS: Only 3 out of total 65 blocks failed. For these 3 cases we shifted the regimen from nerve block to general anesthesia. The successful rate was 95.4%. One case was initially planned for general anesthesia. However, difficult intubation was encountered due to masseter muscle spasm/rigidity during anesthetic induction. Three days later, this case was successfully anesthetized with this block. BP, EKG, and SaO2 did not differ preoperatively and intraoperatively. If the operation time is limited to 3 h, the result has always been satisfactory. CONCLUSIONS: Interscalene brachial plexus block combined with Ho's method of C3-4 block is technically safe and economical for patients receiving shoulder and proximal third of upper extremity surgery. We must make selection of patients carefully and exclude those whose anatomical landmarks are difficulty identified. As such, good result is expected.

Effect of circadian variation in energy expenditure, within-subject variation and weight reduction on thermic effect of food.

Thermic effect of food (TEF) studies give conflicting answers to research questions and in many cases data from one laboratory to another is not comparable because of the utilization of different experimental methods. Likewise, how weight reduction affects measurement of TEF is controversial. Two studies were conducted on how TEF affects energy expenditure. The first study examined how resting energy expenditure (REE) measurements can affect TEF studies and how much within-subject variation is found in TEF studies. The TEF of a standard meal was measured in six subjects for 6.5 h on three different occasions by indirect calorimetry. REE was measured on each subject for 1 h before the meal was given on each measurement occasion. On a separate day, the energy expenditure was measured on each subject during the same time period as the TEF measurement, but without any food given to determine if a circadian increase in REE over the time period of the measurement was observed. We found no circadian increase in energy expenditure during the 6.5 h of the REE study. While the within-subject variation in REE (four measurements) had an average coefficient of variation of 5.2% (range 2.4-8.5%), the coefficient of variation of the TEF measured (three measurements) was 26.4% (range 13.6-50.9). In the second study, REF and the TEF were measured before and after weight reduction in moderately overweight adult women. Nine women weighing between 62.1 and 84.7 kg lost an average of 7.3 kg while on a reduced calorie, low fat diet for between 12 and 14 weeks. After weight reduction, the average REE of these subjects decreased by 8.8% or 515 kJ (123 kcal)/24 h. The TEF of these nine women was measured for 6.5 h before and after weight reduction using 16 oz of Sustacal, 2008 kJ (480 kcal). Before weight reduction the thermic effect of Sustacal was 264 kJ (63 kcal) or 13% of calories consumed, and after weight reduction it was 251 kJ (60 kcal) or 12.5% of calories consumed. We did not find the TEF to be lower than expected in these subjects before weight reduction, since TEF is often reported to be around 10% of energy consumed, and it was not changed after weight reduction.

Effect of dietary fiber on the metabolizable energy of human diets.

Two diets consisting of natural foods that differed in fiber content were fed to 12 men for 6 wk each in a crossover design. Diet 1 contained 37 g total dietary fiber (TDF) from fruits and vegetables and diet 2 contained 16 g TDF from fruit and vegetable juices in a 2800-kcal menu. Seven-day food, urine and fecal composites were made and analyzed for their gross energy, fat, protein and carbohydrate content during the fourth and fifth weeks of each dietary consumption period. The metabolizable energy (ME) of these diets was determined (gross energy of the diet - gross energy of urine and feces) and calculated by Atwater's general energy conversion factors (4, 9, 4), by specific energy conversion factors used in a U.S. food table and by formulas derived by various researchers. The coefficients of availability of energy and the energy-containing nutrients, fat, protein and carbohydrate, were lower while subjects were consuming the higher fiber diet. The specific energy conversion factors of the U.S. food table gave better estimates of the true ME of the lower fiber diet than the higher fiber diet, overestimating the ME of these diets by only 6% (diet 1) and 4.6% (diet 2).

Modification of sweet acidophilus milk to improve utilization by lactose-intolerant persons.

Enhanced digestion of yogurt by lactose-intolerant individuals is believed to be due to inherent beta-galactosidase (lactase) in the culture organisms that aids in the hydrolysis of ingested lactose. However, sweet acidophilus milk, which contains lactase-rich organisms, does not enhance lactose digestion. Using breath-hydrogen measurements to indicate malabsorption in 14 human subjects, we compared utilization of: milk, yogurt, heated yogurt, yogurt plus lactose, heated yogurt plus lactase, sweet acidophilus milk (SAM), and SAM made with sonicated cells. Results indicate that both the reduction of lactose during fermentation and the presence of indigenous bacterial lactase are responsible for the increased ability to tolerate lactose in yogurt. Improved utilization of SAM by sonication suggests that intracellular lactase is not available during digestion and that sonication releases the lactase activity from the cells.

Amelioration of the adverse effect of a gastrointestinal challenge with Salmonella enteritidis on weanling rats by a yogurt diet.

The response of yogurt-fed rats and the corresponding unfermented milk-fed rats to an infectious gastrointestinal challenge has been compared. After 1 (2 trials), 7 (4 trials), 14 and 21 (1 trial each) days on freeze-dried milk or yogurt diets, the rats were inoculated intra-gastrically by intubation per os with 4.5 X 10(10) +/- 0.7 colony forming units (mean +/- SEM) of Salmonella enteritidis. Challenged and control rats were monitored during the 3 weeks post-inoculation for viability, weight gain, feed consumption, and feed efficiency. In general, challenged yogurt-fed rats exhibited significantly superior weight gain and feed efficiency (but not feed consumption) values in week 1 post-infection, but the differences were not significant in week 2 post-infection. Sick milk- and yogurt-fed rats convalesced in week 3. Pooled mortality data indicated that yogurt-fed rats survived better than milk-fed rats. Yogurt did not prevent salmonellosis per se but significantly reduced the mortality and weight gain deceleration.

Contribution of Streptococcus thermophilus to growth-stimulating effect of yogurt on rats.

The origin of the growth-stimulating factor in yogurt was studied in rats fed liquid or freeze-dried diets of milk, yogurt, milks fermented individually by Streptococcus thermophilus and Lactobacillus bulgaricus, milks to which cells of Streptococcus thermophilus and Lactobacillus bulgaricus were added. Diets containing sonicated cells, cell supernatant, and cell fractions also were fed. Milk fermented by Streptococcus thermophilus and milk plus Streptococcus thermophilus cells stimulated growth as effectively as did yogurt. That finding and the absence of stimulation in rats fed Lactobacillus bulgaricus showed that Streptococcus thermophilus is responsible for stimulation of growth by yogurt. Growth was stimulated by an intracellular factor and not by fermentative changes in the milk.

Determination of Iodide in Milk Using the Iodide Specific Ion Electrode and its Application to Market Milk Samples.

The iodide specific ion electrode was used to measure the iodide content of raw and commercially processed whole and skim milks. Average iodide values for raw milk and commercially processed milks were 220 and 620 µ g/L, respectively. The specific ion electrode can also be used to measure iodide in milk contaminated with iodophor sanitizing agent since the milk converts iodophor titratable iodine to the ionic iodide. Since free sulhydryl groups are also detected by the iodide electrode, the effects of heating milk on free sulfhydryl formation and electrode activity were established. These data indicate that in conventionally pasteurized milk, sulfhydryl groups are non-reactive and are not detected by the iodide electrode. However, the increase in free sulfhydryl formation was reflected by an increase in iodide electrode activity at temperatures above those of pasteurization. Whereas the iodide specific ion electrode has been previously used successfully to measure iodide content of raw milk, this method has now been shown to be applicable to pasteurized milk if the conventional pasteurization time-temperature relationship of accepted public health standards is not exceeded.

Minerals in whey and whey fractions.

Liquid and dried acid and sweet wheys and the concentrates and permeates obtained from ultrafiltration of whey were analyzed for major and trace minerals. Calcium, magnesium, sodium, and potassium were determined by atomic absorption and phosphorus by a colorimetric method. Zinc, iron, copper, and manganese were determined by flameless atomic absorption. The composition of all wheys and their fractions differed in nutritionally important minerals. Calcium was three times as great and zinc twenty times as great in acid whey as in sweet whey.

Mineral content of dairy products. II. Cheeses.

Twenty-one kinds of commercial cheese were analyzed for fat, solids, protein, and five major and four trace minerals. Calcium, magnesium, sodium, and potassium were determined by atomic absorption; phosphorus was determined colorimetrically. Flameless atomic absorption was used to determine iron, zinc, copper, and manganese. The data agreed in general with published values, although there were instances of wide variation. The data represent a comprehensive compilation of the mineral contents of popular cheeses that should be helpful to dietitians and nutritionists.

Mineral content of dairy products. I. Milk and milk products.

Sixteen kinds of dairy products were analyzed for five major minerals and four trace minerals. Commercial samples of fluid milk, cream, concentrated milks, cultured products, butter, and frozen desserts were also analyzed for fat, solids, protein, and minerals. Calcium, magnesium, sodium, and potassium were determined by atomic absorption, and phosphorus was determined colorimetrically. Flameless atomic absorption was used to determine iron, zinc, copper, and manganese. The data generally agreed with most recently published values. However, for the trace minerals, the data differed widely in some instances. Manufacturing practices and added ingredients produced considerable variations in mineral content of market samples. These variations, however, could be limited by selection of products, so that they would not preclude the use of dairy products in diets in which mineral composition must be controlled. The coefficients of variation, which indicate the variability that can be expected for each product, generally were high for sherbet and ice milk and low for low-fat milk and skim milk.

Trace minerals in cottage cheese.

The trace minerals, iron, zinc, copper, and manganese were determined in cottage cheese curd by flameless atomic absorption. Larger curd size, added calcium chloride, and fewer washes increased the iron and zinc content in the curd.

Composition of cheddar cheese made with different milk clotting enzymes.

Six commercial milk clotting preparations from animal and fungal sources were used to make cheddar cheese. The cheeses were analyzed initially and over 6-mo ripening for proximate composition, minerals, amino acids, soluble protein, nonprotein nitrogen, free fatty acids, lactones, and flavor development. No significant differences in the composition of the cheeses could be attributed to the type of clotting enzyme. One lot of one enzyme showed increased lipolytic activity which indicated contamination and suggested that the purity of the enzyme preparation should be checked.