Higher need for removal of osteosynthesis material after multi-piece versus one-piece Le Fort I osteotomy: A retrospective study of 339 patients.

The aim of the present study was to identify the risk factors for removal of osteosynthesis material after multi-piece Le Fort I osteotomy compared to standard one-piece Le Fort I osteotomy (LF1). Medical files of patients treated with multi-piece or one-piece LF1 were retrospectively reviewed, including the indication for removal and time between insertion and removal. A total of 339 patients were included: 290 patients with LF1 and 49 patients with multi-piece LF1. Patients undergoing multi-piece LF1 had 2.7-times significantly higher (p < 0.001) relative risk of osteosynthesis removal in the upper jaw (42.9%) than patients undergoing LF1 (15.9%). Significant independent predictors of removal of osteosynthesis material after multi-piece LF1 were older age (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.0-1.2; p = 0.028), simultaneous bilateral sagittal split osteotomy (OR 7.8, 95% CI 1.2-50.3; p = 0.031), and no previous surgically assisted rapid palatal expansion (OR 0.14, 95% CI 0.03-0.69; p = 0.15). Significantly higher removal rates of osteosynthesis material were found after multi-piece LF1. Therefore, all patients must be informed of the higher risk for removal of osteosynthesis material when undergoing a multi-piece LF1.

Interactions of warfarin with garlic, ginger, ginkgo, or ginseng: nature of the evidence.

OBJECTIVE: To review and characterize the evidence describing potential interactions between warfarin and garlic, ginger, ginkgo, or ginseng. DATA SOURCES: Searches of MEDLINE (1966-1999), other bibliographic databases, several abstracting services, and tertiary references were conducted. STUDY SELECTION AND DATA EXTRACTION: Articles were examined by each author, and additional citations were obtained from the references of these articles. Preference was given to Englishlanguage articles of human studies. DATA SYNTHESIS: Evidence is lacking for an interaction of warfarin wth galic or ginger. One case report associates ginseng use with decreased warfarin-maintained anticoagulation effect. Another case report links concomitant use of ginkgo and warfarin with the development of intracerebral hemorrhage. Hemorrhage and tendencies were noted in four cases with ginkgo use and in three cases with garlic; in none of these cases were patients receiving warfarin. CONCLUSIONS: The true risks of these interactions and effects are difficult to characterize due to the limited number and nature of existing reports.

Ten ml bupivacaine 0.125% with 12.5 micrograms epinephrine is a reliable epidural test dose to detect inadvertent intravascular injection in obstetric patients. A double-blind study.

A double-blind study was designed in order to determine the specificity and sensitivity of an epidural test dose to detect inadvertent intravenous injection in obstetric patients undergoing epidural analgesia. Forty unselected obstetric patients were given an intravenous injection of 10 ml bupivacaine 0.125% with 12.5 micrograms epinephrine (test dose) or 10 ml normal physiologic saline. The maternal heart rate was monitored by the direct ECG mode of a fetal monitor and registered simultaneously with the tocogram. The primary investigator was blinded to the solution he injected into an antecubital vein. After the injection was given, he recorded his judgment of which solution he had administered. Eight other anesthesiologists made similar judgments on the basis of the recordings plus various levels of additional information (presence or absence of epidural analgesia, time of injection, subjective signs and symptoms). In contrast to the primary investigator, the blood pressure values were not given to them. For the primary investigator, the specificity of the test dose was 100% and the sensitivity 97.5%. The judgments of the 8 other anesthesiologists resulted in an excellent specificity (99.1%) and a good sensitivity (91.9% with information on time of injection and subjective signs and symptoms). The better performance of the primary investigator is probably due to the availability of blood pressure data.

Anesthesia in repeat mediastinoscopy: a retrospective study of 101 patients.

In most medical textbooks, a mediastinoscopy is considered an absolute contraindication for a repeat mediastinoscopy. Retrospectively, perioperative data from 101 patients were evaluated in whom repeat mediastinoscopy was performed. The complication rate was 23% in 18 patients; 10% of these were directly related to the surgery. The surgical complications observed were hemorrhage, biopsy of the esophagus, paresis of a recurrent laryngeal nerve, and pneumothorax, which were all treated successfully. The patients receiving a nondepolarizing relaxant had fewer complications than patients given only a single dose of succinylcholine. In this patient population, the mortality rate was zero. This review concludes that an earlier mediastinoscopy is not necessarily an absolute contraindication for repeat mediastinoscopy.

The effects of the addition of sufentanil to 0.125% bupivacaine on the quality of analgesia during labor and on the incidence of instrumental deliveries.

In a double-blinded, randomized, prospective multi-center study of 695 women, we investigated whether epidural injection of sufentanil added to 0.125% bupivacaine with epinephrine (1:800,000) reduces the total amount of local anesthetic required, resulting in less motor blockade and reduced incidence of instrumental deliveries, and improves the quality of analgesia provided by this low concentration of local anesthetic without jeopardizing the safety of the baby. In addition, other potential benefits of sufentanil (such as decrease in the incidence of shivering) and side effects were examined. It was found that adding incremental doses of 10 micrograms sufentanil up to a maximum of 30 micrograms reduced the incidence of instrumental deliveries from 36 to 24% (P less than 0.01) and significantly improved quality and duration of analgesia without depressing the neurobehavioral status of the baby. No other benefits from adding sufentanil were found. The only side effect that occurred more frequently after sufentanil was pruritus. We conclude that epidural injection of 10-30 micrograms sufentanil added to 0.125% bupivacaine with epinephrine (1:800,000) improved the quality of analgesia during labor and reduced the incidence of instrumental deliveries without jeopardizing the safety of the baby.

Plasma concentrations of epidural bupivacaine in mother and newborn: 0.125% versus 0.375%.

Central venous plasma concentrations of bupivacaine were determined in two groups of 15 parturients each who were given epidural analgesia for labor and vaginal delivery. One group received 10 ml of 0.125% bupivacaine plus epinephrine 1:800,000, the other group received 7 ml of 0.375% bupivacaine plus epinephrine 1:800,000. Plasma concentrations of bupivacaine in the umbilical venous (UV) and the umbilical arterial (UA) blood of their babies were also determined. The mean UA, UV, and maternal central venous (MV) plasma concentrations of bupivacaine differed significantly between the two groups: in patients given 0.375% bupivacaine UA values were 63% higher (P less than 0.01), UV values were 57% higher (P less than 0.01), and the MV values were 34% higher (P less than 0.05) than in patients given 0.125% bupivacaine. The measured plasma concentrations speak in favor of the less concentrated solution of bupivacaine in epidural analgesia for obstetrics. Seven milliliters of bupivacaine 0.375% is suitable for epidural analgesia in obstetrics but a low concentration-low dose technique, using 10 ml of bupivacaine 0.125% plus epinephrine 1:800,000 is safer. It provides good analgesia with minimal or no motor block and is associated with low maternal and neonatal plasma concentrations of bupivacaine, well below toxic levels and, to our knowledge, lower than in any other study.

tAnReDos--a circle application in evolution.

It is not easy to build a computerised medical record system for a microcomputer system. Several aspects of the medical environment require more than just 'off the shelf software. This paper describes some of the properties and possibilities of Circle applications. Circle software has been developed as a result of 15 years of close contacts with medical departments and is meant to be adaptable to any medical environment. Although medical applications usually are very complex, using Circle has been proven to be easy in its use. Above all, Circle applications can always be modified in such a way that they keep pace with the inherent evolution of medical applications.

Extradural analgesia and retinal haemorrhage in the newborn.

The incidence and severity of retinal haemorrhage were examined in 976 babies born by vaginal delivery. The influence of the method of analgesia, instrumental delivery and parity was studied. The mothers of 638 infants received extradural analgesia, while the other 338 received either narcotics or no analgesia. Extradural analgesia did not lead to a higher incidence of retinal haemorrhage, even though the number of vacuum extractions was doubled. With increasing parity, the total frequency and the frequency of severe retinal haemorrhage decreased (P less than 0.001). Severe retinal haemorrhage was not seen in any baby of whom the mother was para 4 or more.

Motor blockade during epidural anesthesia.

The effects of lumbar epidural anesthesia (LEA) on a previously described test of function of the rectus abdominalis muscle (the RAM-test) were compared with the effects of LEA on the Bromage test of muscle power in the hips and legs in 20 women having elective cesarean sections under LEA using 0.5% bupivacaine with epinephrine 1:200,000. The results showed no statistically significant correlation between the two tests. We conclude that zones of differential somatic motor blockade are present during LEA and that in obstetrics the RAM-test is the more appropriate test for evaluating the effects of LEA on somatic motor function. Use of the RAM-test is suggested in situations where one is interested in motor function of the abdominal wall muscles under LEA.

Long-term high frequency jet ventilation in a 3-year-old child.

Successful management of a large bronchopleural fistula in a 3-yr-old child with high frequency jet ventilation (HFJV) is described. Respiratory insufficiency in the child occurred secondary to hemophilus influenza pneumonia. After 7 days of conventional ventilatory support, a bronchopleural fistula occurred with massive lung collapse and subcutaneous and mediastinal emphysema. The child was ventilated with a high frequency jet ventilator for 37 days with resulting healing of the fistula. During ventilatory support with HFJV, no sedation or muscle relaxants were needed. Two problem areas in long-term support in children were discussed, namely, partial tube obstruction because of thick secretion and the need for proper humidification. A significant advantage of HFJV was the ability to superimpose it on spontaneous breathing with elimination of sedation or muscle relaxants.