Scheduled acetaminophen with as-needed opioids compared to as-needed acetaminophen plus opioids for post-cesarean pain management.

BACKGROUND: Combination opioid-acetaminophen drugs are commonly used for pain management after cesarean delivery. The aim of this study was to determine if scheduled acetaminophen decreases opioid use compared to as-needed combination acetaminophen-opioid administration. METHODS: We performed a retrospective chart review of women who underwent cesarean delivery before and after a clinical practice change. All patients received spinal anesthesia containing intrathecal morphine 200µg and scheduled non-steroidal anti-inflammatory drugs for 48h postoperatively. The first group (As-Needed Group, n=120) received combination oral opioid-acetaminophen analgesics as needed for breakthrough pain. The second group (Scheduled Group, n=120) received oral acetaminophen 650mg every 6h for 48h postoperatively with oral oxycodone administered as needed for breakthrough pain. The primary outcome was opioid use, measured in intravenous morphine mg equivalents, in the first 48h postoperatively. RESULTS: The Scheduled Group used 9.1±2.1mg (95% CI 5.0-13.2) fewer intravenous morphine equivalents than the As-Needed Group (P <0.0001) over the study period. Fewer patients in the Scheduled Group exceeded acetaminophen 3g daily compared to the As-Needed Group (P=0.008). Pain scores were similar between study groups. CONCLUSIONS: After cesarean delivery, scheduled acetaminophen results in decreased opioid use and more consistent acetaminophen intake compared to acetaminophen administered as needed via combination acetaminophen-opioid analgesics, without compromising analgesia.

Increased vegetable and fruit consumption during weight loss effort correlates with increased weight and fat loss.

BACKGROUND: Individuals who focused on calorie counting lost more weight than those who focused on increasing vegetable and fruit (V&F) intake in a weight loss program. We now present serum carotenoid data (biomarkers of V&F intake) from both groups and test whether these biomarkers correlate with changes in weight and body fat. DESIGN: Sixty obese volunteers were randomized to one of the following weight loss programs: 500 kcal per day reduction (Reduction) or a focus on consuming eight vegetables per day and 2-3 fruits per day (HiVeg). Volunteers in the Reduction group were 36.8±10.3 years with a body mass index of 33.5; 83% were white, 17% chose not to report race; 70% were not Hispanic or Latino, 13% were Hispanic or Latino and 17% chose not to report ethnicity. Volunteers in the HiVeg group were 30.4±6.6 years with a body mass index of 33.2: 74% white, 11% Asian, 5% black or African American, 5% multiracial and 5% chose not to report race; 89% were not Hispanic or Latino, 5% were Hispanic or Latino and 5% chose not to report ethnicity. Subjects were taught basic nutrition principles, received breakfast and lunch 5 days per week for 3 months, meals 2 days per week during month 4, then regular phone calls to month 12. RESULTS: Total serum carotenoid concentrations increased from baseline to 3 months and remained elevated at 12 months, but there was no difference between groups. Changes in weight, fat and % fat correlated negatively with serum carotenoid concentrations. CONCLUSION: Increased serum carotenoids (a biomarker for V&F intake) correlated with improved weight and fat loss indicating that increased V&F consumption is an appropriate strategy for weight loss. However, in light of the fact that the Reduction group lost more weight, the consumption of increased V&F for the purpose of weight loss should happen within the context of reducing total caloric intake.

Salivary cortisol increases after bariatric surgery in women.

Cortisol increases have been associated with psychological and physiological stress; however, cortisol dynamics after weight loss (bariatric) surgery have not been defined. Obese participants not using exogenous glucocorticoids were eligible to participate. Female participants (n=24) provided salivary cortisol samples at bedtime, upon awakening the following morning, and 30 min after awakening before, and at 6 or 12 months after bariatric surgery. The Medical Outcomes Study Short Form-12 version 2 questionnaire regarding health-related quality of life was also completed. Preoperatively, mean body mass index was 45.1±8.1 kg/m2. Mean late night (1.8±1.1 nmol/l), awakening (10.7±7.4 nmol/l), and after-awakening (11.5±7.9 nmol/l) salivary cortisol values were within normal ranges. The cortisol awakening response (mean 21.1±79.7%, median 13.7%) was at the low end of normal. Preoperatively, participants had lower mental and physical health-related quality of life scores than US adult norms (p<0.001). Salivary cortisol was not correlated with measures of health-related quality of life. Mean BMI decreased over time (p<0.001) and participants experienced improved physical and mental health-related quality of life (p≤0.011). Postoperative late night salivary cortisol was not different from preoperative values. Awakening and after-awakening cortisol levels were higher than preoperative values (15.3±7.7 nmol/l, p=0.013; 17.5±10.2 nmol/l, p=0.005; respectively), but the cortisol awakening response was not changed (mean 26.7±66.2%; median 7.8%). Morning salivary cortisol increased at long-term follow-up after bariatric surgery. Although self-evaluated mental and physical health improved after surgery, the cortisol awakening response is at the low end of normal, which may indicate continued physiological stress.

A retrospective study to assess the results of CT-directed peri-neural root infiltration in a cohort of 56 patients with low back pain and sciatica.

Fifty-six patients with low back pain and sciatica following radiological investigation were found to have abnormalities at multiple levels, more than one of which could be responsible for the clinical picture or at a single level, which correlated poorly with the clinical findings. Thirty-four patients had a diagnostic peri-neural root infiltration to clarify whether surgery would be appropriate. Evaluation of the technique was by reduction in analgesia. Eighteen patients have had surgery, 14 with a successful, two a moderate and two a poor outcome. Four patients have been denied and two are awaiting an operation. Ten patients referred for a diagnostic procedure deferred surgery in favour of a therapeutic course. Of 22 patients referred directly for a therapeutic course, 15 had a successful, three a moderate and four a poor result. CT-directed peri-radicular root infiltration is a useful adjunct in the management of low back pain and sciatica.

Spontaneous bilateral carotid and vertebral artery dissection presenting as a Collet-Sicard syndrome.

Spontaneous dissection of the internal carotid arteries usually presents with unilateral headache, neck pain, focal ipsilateral cerebral ischaemic symptoms and a Horner's syndrome. Lower cranial nerve palsies are only rarely observed. We report a case of carotid and vertebral dissections presenting as a unilateral palsy of the ninth to twelfth cranial nerves (Collet-Sicard syndrome).

Corticosteroids and the prevention of adverse reactions to myelography.

Side-effects of iohexol myelography were compared after pre-treatment with oral dexamethasone (n = 42) or placebo (n = 44) in a prospective, randomized, double blind, controlled clinical trial. Although myelogram side-effects were commoner in the placebo group, the differences generally did not reach statistical significance. The routine prophylactic use of oral corticosteroids for myelogram side-effects therefore cannot be recommended and our results may cast doubt on their use in the treatment of these symptoms once they have developed. These findings also suggest that inflammatory processes (allergic or chemical irritant), relating to the contrast agent itself, against which corticosteroids might have been expected to act, have at most a minor pathogenetic role in postmyelogram symptomatology.

CT-directed perineural infiltration in the localization of radicular pain in a patient with neurofibromatosis.

Computed tomography-guided infiltration of lumbar or sacral nerve roots with local anaesthetic can be a valuable aid in localizing the spinal level from which radicular pain originates especially when multiple abnormalities are present. This is illustrated by the case of a young woman with neurofibromatosis complaining of sciatica.

Serial MRI of the brain in asymptomatic patients infected with HIV: results from the UCMSM/Medical Research Council neurology cohort.

Seventy-six homosexual or bisexual men underwent two cranial MRI studies at a mean interval of 13 months; 23 were HIV seronegative, 41 seropositive but asymptomatic (Center for Disease Control (CDC) groups II/III), and 12 had AIDS related complex (ARC)/AIDS (CDC group IV). Agreement between two neuroradiologists was rated as very good for assessment of enlargement of ventricles and good for widening of cerebral sulci and the presence of focal lesions. For assessment of serial studies, the agreement was moderate. The prevalence of cerebral atrophy and focal white matter lesions was no higher in the asymptomatic patients (CDC group II/III) than in appropriate seronegative controls. Some patients with ARC/AIDS showed evidence of developing cerebral atrophy during the study period when serial scans were compared. The imaging evidence supports the other data obtained from this cohort, which suggest that no significant CNS involvement occurs in HIV infection before the development of ARC/AIDS.

Chiari malformation in adults: relation of morphological aspects to clinical features and operative outcome.

To determine whether clinical features attributed to cerebellar ectopia could be related to the severity of the malformation, and if morphological features could be related to operative outcome, a retrospective study of 141 patients with the adult Chiari malformation was carried out, 81 receiving operative treatment. Morphological parameters derived from preoperative clinical imaging were compared with presenting clinical features and postoperative outcomes. Patients with the most severe cerebellar malformation, defined as descent of the cerebellar tonsils to or below the axis, had disabling ataxia and nystagmus more frequently. Those with brainstem compression had limb weakness and muscle wasting more frequently. Operative outcome was significantly less favourable in patients with severe cerebellar ectopia (12% improved, 69% deteriorated) than in those with minor ectopia (50% improved, 17% deteriorated). Patients with a distended cervical syrinx had a more favourable outcome than those without. Morphological features help predict operative risk.

The influence of needle size on post-myelography headache: a controlled trial.

This study aimed to test the hypothesis that the use of fine rather than larger calibre needles for myelography reduces the incidence of post-procedural headache. 160 patients were randomized in a prospective controlled trial of 22 gauge versus 26 gauge needles. The incidence and overall severity of headache as measured at 1, 4 and 21 days after myelography was not significantly different in the two groups.

Solitary cerebral metastasis from a papillary carcinoma of the thyroid.

A woman aged 52 was treated with radioactive iodine for a papillary carcinoma of the thyroid. Four years later she developed signs and symptoms of an intracranial space occupying lesion. A computed tomographic scan showed a mass in the right posterior frontal region. Although she was suspected of having metastatic disease a definite diagnosis was not established until she died 6 months later when post-mortem examination confirmed that she had a cerebral metastasis from a papillary carcinoma of the thyroid. There was no evidence of metastatic disease elsewhere in the body. Cerebral metastases from papillary carcinoma of the thyroid are uncommon but may occur in patients who have metastases in bones or lungs. A search of the literature has revealed only two patients with solitary cerebral metastases.

Lumbar disc herniation causing focal expansion of the spinal canal.

A case of disc prolapse expanding the lumbar spinal canal by eroding the dorsal aspect of the body of L4 vertebra is reported. Despite no previous reports this condition is not considered to be extremely rare.

The use of intravenous digital subtraction angiography in the evaluation of neck masses.

The advent of vascular imaging techniques utilising intravenous rather than intra-arterial contrast delivery may render angiography safer and less expensive. Intravenous digital subtraction angiography is explained and its applications to the management of pulsatile neck masses illustrated.

Radionuclide imaging of the neck in rheumatoid arthritis.

Blind marking was used to assess radionuclide neck images obtained with technetium-99m methylene diphosphonate in 28 patients with rheumatoid arthritis and 12 with cervical degenerative joint disease (spondylosis). Eleven out of the 16 rheumatoid arthritis patients who had neck pain when imaged showed enhanced uptake in the region of the atlantoaxial and temporomandibular joints. In contrast, no patient with cervical spondylosis and only one rheumatoid arthritis patient without neck pain had high uptake in either joint. Changes in uptake in this region on repeat imaging correlated significantly (P less than 0.01) with changes in pain. Patients with rheumatoid arthritis, with or without neck pain, and with cervical spondylosis showed similar patterns of radiological abnormality in the cervical spine. No detailed correlation was detected between radionuclide and radiographic findings. Radionuclide abnormalities were seen in the middle and lower cervical spine in both rheumatoid arthritis and cervical spondylosis. An abnormal radionuclide image of the middle or lower neck is thus of little value except when no degenerative change is present on the radiograph. An abnormal radionuclide image of the upper neck may be a useful indication of inflammation.

Spinal arachnoid cysts: clinical and radiological correlation with prognosis.

The clinical and radiological findings in six extradural and nine intradural arachnoid cysts are discussed in relation to previous reports. Only two cysts failed to opacify during positive contrast myelography; in both cases Myodil was used and in one of them contrast medium had entered the cyst on delayed films taken at 24 h. Pain was always improved and generally cured by operation, only two patients having some residual backache. There was permanent improvement of neurological function in only eight cases. The factors associated with poor permanent recovery after surgical treatment were: 1) very marked thinning of the spinal cord by the cyst, and 2) relatively longer duration of paresis--only one case had paresis for under 2 years (mean 4.8 years) compared with only two cases for over 1 year (mean 2 years) in those with good recovery.