[Central venous cannulation - always with ultrasound support?]. / Zentralvenöse Punktion - nur noch mit Ultraschall?

Central Venous Cannulation - Always with Ultrasound Support?.Ultrasound guided puncture (UGP) improves success and complication rates of central venous cannulation. By some authors UGP with imaging devices are strongly recommended for all cannulations of subclavian or internal jugular veins. In order to review the current literature a computer based abstract search in Medline was performed for the period from January 1972 to May 2000 limited by the key words "catheterization, central venous catheter, internal jugular vein, subclavian vein, axillary vein, femoral vein, ultrasound, ultrasonography, Site-Rite und Smart Needle". UGP of the internal jugular vein was recommended in 29 prospective randomized studies, 21 prospective and three retrospective studies as well as in several clinical reports. UGP of the subclavian vein was supported by only 4 studies, whereas two studies did not show any improvement of puncture results with UGP. Due to the visualisation of the vessel and the cannula imaging techniques represent the "gold standard". However, with conventional Doppler devices nearly the same success rates can be obtained. It does not seem to be justified to perform every central venous cannulation with Doppler or ultrasound support. Each anaesthetist and intensive care physician should be able to perform central venous cannulation without a Doppler or ultrasound device. However, in cases of abnormal anatomy UGP can be helpful to prevent complications. Especially children, patients with coagulation disorders and physicians with limited experience in central venous cannulation can benefit from UGP.

Health care utilization and cost among health maintenance organization members with temporomandibular disorders.

AIMS: Little has been reported on the use of health care services and consequent costs among persons with temporomandibular disorders (TMD). This project compared the use and cost of medical and dental care services for TMD patients and matched comparison subjects. METHODS: Patients were continuously enrolled members of Kaiser Permanente Northwest Division who had at least 1 TMD Clinic visit or TMD-related procedure between January 1990 and December 1995 (n = 8,801). An equal number of comparison subjects were identified electronically and matched on 14 variables, including age and gender. Utilization and cost estimates were determined and compared for selected medical and dental services. RESULTS: For both groups, the mean age was about 40.5 years, and approximately 80% were female. The TMD subjects used significantly more services than did comparison subjects and had mean costs that were 1.6 times higher for all services. Outpatient visits accounted for about 40% of the difference in mean costs. About 10% of TMD subjects and comparison subjects accounted for about 40% and 47% of the costs in each group, respectively. Female TMD subjects and comparison subjects had higher costs than their male counterparts, and male TMD subjects had higher costs than female comparison subjects. CONCLUSION: Patients with TMD used more of all types of services and had higher costs. A small proportion of the subjects accounted for a large proportion of the costs. Gender was an important factor in utilization and cost. Utilization and cost differences were consistent over a wide range of service categories and could not be explained by TMD alone.

[Horner's syndrome following lumbar epidural anaesthesia--subdural block?]. / Horner-Syndrom bei lumbaler Epiduralanästhesie--Subduraler Block?

A 28 year old primipara (37th gestational week) was scheduled to undergo delivery by caesarean section under epidural anaesthesia. An epidural catheter was easily inserted in the L3/L4 interspace. After a negative aspiration test 5 ml of bupivacaine 0.25% plus adrenaline 1:200,000 were injected and five minutes later 2 x 5 ml of bupivacaine 0.5% plus fentanyl 0.005 mg/ml were given. Ten minutes after the test dose the patient reported warmth and paraesthesia in the right leg and pelvis and numbness in the right periorbital region. The catheter was drawn back 1.5 centimeters and the operation could be performed under regional anaesthesia with supplemental doses of bupivacaine. Sensory level at the end of the operation was Th 4 which decreased continuously in the following two hours. Ocular symptoms (miosis, ptosis, right-sided numbness) as well as numbness in the right hand and leg persisted four hours longer. The most probable explanation for this peripheral Horner's syndrome is a subdural blockade caused by the first bupivacaine doses. The only known prophylaxis is a fractioned epidural injection of local anaesthetics.

[Prevention of intraoperative hypothermia in children]. / Prävention intraoperativer Hypothermie bei Kindern.

UNLABELLED: Children are very sensible to the occurrence of intraoperative hypothermia (HT) (core temperature < or = 36.0 degrees C) during general anaesthesia because their regulation capacity is less effective than in adults and due to a large skin-surface area compared with their body mass. We compared the efficacy of different heating devices to prevent HT in children during surgery. METHODS: With approval of the local ethics committee 50 children between one and seven years, scheduled for peripheral surgery lasting at least 2 hours were included in this study. Anaesthesia was standardized in all patients. Patients were randomly divided into 5 groups. In group 1, in addition to the usual cotton blankets, room temperature was elevated to 27-28 degrees C. In group 2, room temperature was maintained at 27-28 degrees C, and the patients were additionally wrapped into an aluminum blanket. In group 3, elevated room temperature was combined with a convective heating blanket. Patients in group 4 were warmed with an aluminum blanket, while the room temperature was maintained at 22 degrees C. In group 5, room temperature was maintained at 22 degrees C and patients were warmed with a convective heating device (Tab. 1). Room and core body temperature (tympanon membrane) were continuously measured. ANOVA and Fisher's exact Test (significance level: p < 0.05) were performed for the statistical analysis of the results. RESULTS: The demographic data of all 5 groups, the infused fluid volume and the anaesthetic technique were similar. There were no significant differences concerning age, height and weight of the pediatric patients (Tab. 2). The core temperature decreased by -1.7 degrees C in group 1. In group 4 core temperature decreased by -1.6 degrees C. Using a convective warming system in normal ambient temperature (group 5) core temperature increased by 0.2 degree C and was as effective in the prevention of HT as group 2. A significant increase in core temperature occurred in group 3 +0.7 degree C (Tab. 3 and Fig. 1). DISCUSSION: OR temperature seems to be a critical factor influencing heat loss. Increasing OR temperature and covering with cotton sheets was not effective in preventing the heat loss. Increasing room temperature in combination with aluminum sheets is one alternative to prevent HT. Our study shows that the use of a convective warming device prevents HT during a 2-hour surgery in young children even at a OR temperature of about 22 degrees C. In conclusion, in pediatric patients the use of a convective heating system proved to be an effective alternative to room heating.

From repairing the consequences of disease to managed wellness: lessons from 20 years of managing dental care.

As the 21st century approaches, dentistry will be challenged by multiple pressures. The demographic trends of a growing population are outpacing the supply of dental manpower. Economic trends, including fewer family wage jobs, less full-time employment, and more single-parent families, create pressure on the ability to afford dental care. Competitive and reform pressures continue in the health-care field and are gaining momentum in dental care. Even without these pressures, traditional dental approaches have not been able to address the bulk of the needs of the population, as indicated by published assessments of the dental health of various segments or the overall use of dental services in the country. The challenge created by these demographic, economic, and competitive pressures on the KPDCP and the dental profession as a whole is to shift away from the individual patient, disease-model repair and improve management of dental wellness as the means of improving access to dental services for an even greater number of people. This challenge can be met by implementing the currently neglected clinical knowledge contained in our dental literature, taking action to find answers for the things we do not know, and by applying our knowledge to preventing the onset and/or progression of dental disease, decreasing unneeded and/or ineffective treatments, and avoiding premature entrance into the cycle of rerestoration.

Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office.

OBJECTIVES: Primary care medical clinics are good settings for smoking interventions. This study extends this strategy with a smokeless tobacco intervention delivered by dentists and dental hygienists in the course of routine dental care. METHODS: Male users of moist snuff and chewing tobacco (n = 518) were identified by questionnaire in clinic waiting rooms and then randomly assigned to either usual care or intervention. The intervention included a routine oral examination with special attention to the part of the mouth in which tobacco was kept and an explanation of the health risks of using smokeless tobacco. After receiving unequivocal advice to stop using tobacco, each patient viewed a 9-minute videotape, received a self-help manual, and was briefly counseled by the dental hygienist. RESULTS: Long-term success was defined as no smokeless tobacco use at both 3- and 12-month follow-ups, with those lost to follow-up counted as smokeless tobacco users. The intervention increased the proportion of patients who quit by about one half (12.5% vs 18.4%, P < .05). CONCLUSIONS: These results demonstrate the efficacy of a brief dental office intervention for the general population of smokeless tobacco users.

[The synthetic somatostatin analog octreotide: effect on interdigestive pancreas secretion and gastrointestinal motility in man]. / Synthetisches Somatostatinanalogon Octreotide: Wirkung auf interdigestive Pankreassekretion und gastrointestinale Motilität beim Menschen.

The aim of the present study was to determine the effects of a therapeutical dose of the long-acting cyclic somatostatin analogue octreotide (SMS 201-995) on cyclical interdigestive small intestinal motor function and exocrine pancreatic secretion in humans. Five fasting healthy subjects swallowed a gastroduodenal multi-lumen tube assembly and received continuous infusions of saline and octreotide (720 ng/kg/hr) for at least one interdigestive motor cycle or two hours. Upper gastrointestinal motility was recorded continuously by standard manometry. Duodenal chymotrypsin outputs were measured at 15 minutes intervals using polyethylene glycol as a dilution marker. Octreotide significantly decreased the length of the interdigestive motor cycle to one third of the control period (p < 0.01). Phase II proportion was reduced to less than 5% of the cycle length (controls: 66%; p < 0.01). The propagation velocity of octreotide-induced motor activity fronts was significantly slower compared with migrating motor complexes during the control period (controls: 6.8 +/- 0.4 cm/min, octreotide: 2.3 +/- 0.4 cm/min; p < 0.05). Overall duodenal chymotrypsin output was markedly inhibited by octreotide (5% of controls; p < 0.01). Moreover, during octreotide administration coupling between interdigestive motor activity and pancreatic exocrine enzyme secretion was disrupted. In conclusion short administration of a therapeutical dose of octreotide exerts similar effects on upper intestinal interdigestive human motor secretory parameters as naturally occurring molecular forms of somatostatin at pharmacological doses.

Smokeless tobacco habits and oral mucosal lesions in dental patients.

As part of a smokeless tobacco (ST) intervention study, we collected data on tobacco use habits and oral health for 245 male ST users aged 15 to 77. The study sample was identified during routine dental office visits and represents a relatively diverse population of patients. Oral health data collection included grading the clinical appearance of oral mucosal lesions using Greer and Poulson's classification system, as well as identifying and recording the primary anatomic location of ST placement. Results show that 78.6 percent of ST users had observable oral lesions, 23.6 percent of which were in the most clinically advanced category (degree III). Of the lesions noted, 85 percent were in the same location the patient identified as his primary area of smokeless tobacco placement. In a comparison sample of 223 non-ST-users with the same age distribution, only 6.3 percent had observable lesions. A multiple logistic regression model for ST users showed that lesion presence and severity were most significantly related to current frequency of ST use.