Jane Garb

Enhanced angiogenesis and growth of collaterals by in vivo administration of recombinant basic fibroblast growth factor in a rabbit model of acute lower limb ischemia dose-response effect of basic fibroblast growth factor

The purpose of this study was to evaluate the effects of exogenous recombinant basic fibroblast growth factor (bFGF) on angiogenesis in severely ischemic tissue beds. We used a two-stage procedure to produce severe ischemia of the hindlimb of 34 New Zealand rabbits. The ischemic hindlimb received intramuscular injection of saline (group A), 1 microgram bFGF (group B), or 3 micrograms bFGF (group C), daily for 2 weeks. Tissue perfusion, skeletal muscle infarction, angiogenesis, and collateral growth were assessed by angiography, transcutaneous oximetry (TcPO2), quantitative spectrophotometric assay of triphenyltetrazolium chloride reduction in muscle, capillary density (capillaries per square millimeter), and capillary per muscle fiber ratio. There were no significant differences in baseline TcPO2 among the three groups for both thigh and calf measurements. Angiography revealed extensive perfusion of the left hindlimb in all the assessed bFGF treated animals. Both thigh and calf TcPO2 values showed a significant increase in all groups over the 14 days ischemia was induced (p less than 0.0001), but the two treatment groups exhibited a much more rapid rise in TcPO2 than the control group (p less than 0.0001). The capillaries per square millimeter and capillaries per muscle fiber ratios were significantly increased in all posttreatment measurements for all animals that received bFGF. The treatment groups with bFGF had a significant (p = 0.025) increase in thigh muscle viability compared with controls based on triphenyltetrazolium chloride reduction. Whereas there was evidence of muscle infarction in both the thighs of groups A and B, there was none in group C.(ABSTRACT TRUNCATED AT 250 WORDS)

Donepezil in the Prevention and Treatment of Post-Surgical Delirium

OBJECTIVE Delirium is a frequent complication of major surgery in older persons. The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery. METHODS A sample of 80 patients participated in this randomized, double-blind, placebo-controlled trial of donepezil. Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward. Postoperative delirium was assessed with the Delirium Symptom Interview, Confusion Assessment Method, daily medical record, nurse-observation reviews, and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also assessed for each participant. RESULTS Delirium, diagnosed by DSM-IV criteria, was found on at least 1 postoperative day in 18.8% of subjects, but there were no significant differences between the donepezil and placebo groups. When delirium was present, it lasted only 1 day, and there was no difference between the groups. Subsyndromal delirium was found on at least 1 postoperative day for 68.8% of subjects, and, when this occurred, lasted 2 days or less, on average. There was no difference between the groups in the occurrence or duration of subsyndromal delirium. There was no difference between the groups in disposition to home or to another facility. CONCLUSIONS This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery. Furthermore, postoperative delirium was not a major problem in this population.

Long-term functional status and mortality of elderly patients with severe closed head injuries.

OBJECTIVE To evaluate long-term clinical outcome of elderly patients with severe closed head injuries. DESIGN Retrospective study. PATIENTS AND METHODS All patients older than 65 years of age admitted to a regional trauma center with a diagnosis of closed head injury and an admission Glasgow Coma Scale (GCS) score of 8 or less. Using chi 2 analysis, Students t test, and multiple logistic regression, we correlated age, sex, mechanism of injury, pupillary reactivity, alcohol and drug use, admission GCS score, Injury Severity Score, Revised Trauma Score, heart rate, and blood pressure to the main outcome measures, i.e. long-term functional outcome and mortality. RESULTS Among 40 elderly patients who met the criteria, 27% were still alive at the end of 38 +/- 3 month follow-up. Eighty-five percent of patients who were discharged from the hospital were still alive long-term, but did not show significant neurologic improvement. In a univariate analysis, GCS and pupillary reactivity were predictive for long-term functional outcome and mortality. In a multivariate analysis, GCS and heart rate were predictive. All patients with an admission GCS score of 3 died in-hospital. All patients with an admission GCS score of 3 to 7 were either deceased or lived in persistent vegetative or dependent functional states. CONCLUSIONS Elderly patients with severe closed head injuries have high in-hospital mortality. Those who survived the hospital stay had high long-term survival, but did not show significant functional improvement. Prediction of long-term functional status is vital to the trauma care of elderly patients with severe closed head injuries.

Risk of dysphagia after transesophageal echocardiography during cardiac operations.

BACKGROUND Dysphagia can be a significant complication following cardiac operations. This study evaluates its incidence and relationship to intraoperative transesophageal echocardiography (TEE) for specific indications versus known factors such as stroke or prolonged intubation. METHODS Records of 838 consecutive cardiac surgical patients were reviewed, and categorized into those who received TEE for specific indications versus those who did not (nonTEE). Dysphagia was recorded when symptoms were confirmed by barium cineradiography. Multiple logistic regression identified significant factors causing dysphagia. RESULTS TEE was significantly related to the development of postoperative dysphagia by multiple logistic regression (p < 0.001). After controlling for other significant factors (stroke, left ventricular ejection fraction, intubation time, duration of operation), the odds of dysphagia for TEE patients was 7.8 times greater than for nonTEE patients. CONCLUSIONS TEE may be an independent risk factor for dysphagia following cardiac operations.

Reducing the pain of local anesthetic infiltration: Warming and buffering have a synergistic effect

STUDY OBJECTIVE To compare room-temperature unbuffered lidocaine, warm lidocaine, buffered lidocaine, and warm buffered lidocaine to determine which of the four solutions is least painful during infiltration. DESIGN Randomized, controlled, double-blinded, volunteer study. TYPE OF PARTICIPANT Thirty-two young healthy adults. MAIN RESULTS Each subject received four subcutaneous injections of 1% lidocaine: room-temperature unbuffered, warm, buffered, and warm buffered. After each injection, participants recorded their perception of pain associated with infiltration of the solution on a visual analog scale. Mean pain scores for the four solutions were determined and analyzed. The mean perceived pain score for the warm buffered solution was significantly lower than for any of the other solutions (versus warm: P = .0005; versus buffered: P = .0028; versus room temperature: P = .0001). There was no statistically significant difference between either the warm solution or buffered solution and the room-temperature unbuffered lidocaine. The difference in mean pain score for the warm buffered solution, compared with those for the warm, buffered, and room-temperature solutions, suggests that warming and buffering have a synergistic effect. CONCLUSION Skin infiltration with warm buffered lidocaine is significantly less painful than infiltration with room-temperature unbuffered lidocaine, warm lidocaine, or buffered lidocaine.

p53 tumor suppressor oncogene expression in squamous cell carcinoma of the hypopharynx

Background. Although abnormalities of the p53 tumor suppressor oncogene system are being detected in many human cancers, the frequency and prognostic significance of such events in squamous cell cancer of the head and neck remain unknown.

Multicenter review of protease inhibitors in 89 pregnancies

Context: Despite the success of highly active antiretroviral therapy, the optimal approach for preventing perinatal HIV‐1 transmission is not known. Objective: A retrospective survey was conducted at six centers in the United States and Puerto Rico from January 1997 to October 1998 to evaluate the effects of protease inhibitor use during pregnancy on maternal and infant safety, prematurity rate, and frequency of perinatal HIV‐1 transmission. Results: In the study, 91 live infants, including 3 sets of twins, and 1 neonate who died shortly after birth were born to 89 women. HIV perinatal transmission rate in this series was 0 (95% confidence interval [CI], 0%‐3%). Prematurity rate was 19.1%, comparable to rates in earlier reports of HIV‐1‐infected women. In multiple regression analysis, only cocaine use and premature rupture of membranes were associated with prematurity (p = .03 and .008, respectively). The gestational week during which the protease inhibitors were initiated was not found to be significantly associated with prematurity. Adverse maternal, obstetric, and infant events possibly related to protease inhibitors were uncommon. Conclusions: Protease inhibitors appeared generally safe in mothers and infants in this series. No perinatal HIV‐1 transmission occurred. Further prospective, controlled studies are needed to define the optimal management of HIV‐1 in pregnancy.

Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis.

We conducted a meta-analysis of studies reporting diabetes case management interventions to examine the impact of case management on blood glucose control (HbA1c). Databases used for the search included Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo. A composite estimate of effect size was calculated using a random effects model and subgroup analyses were conducted. Twenty-nine salient studies involving 9397 patients had sufficient data for analysis. Mean patient age was 63.2 years, 49% were male, and ethnicity/race was 54% White. Type 2 diabetes was the focus in 91% of studies. Results showed a large overall effect size favoring case management intervention over controls or baseline values on HbA1c (ES=0.86, 95%CI: 0.52-1.19, Z=5.0, p<0.001). This corresponds to a mean HbA1c reduction of 0.89 (95%CI: 0.63-1.15). Subgroup analyses showed clinical setting, team composition, and baseline HbA1c were important predictors of effect size, but not diabetes self-management education which was poorly described or absent in most diabetes case management interventions examined. Nurse-led case management provides an effective clinical strategy for poorly controlled diabetes based on a meta-analysis of clinical trials focusing on blood glucose control.

Motivational interviewing delivered by diabetes educators: Does it improve blood glucose control among poorly controlled type 2 diabetes patients? ☆ ☆☆

AIM To determine whether glycemic control is improved when motivational interviewing (MI), a patient-centered behavior change strategy, is used with diabetes self management education (DSME) as compared to DSME alone. METHODS poorly controlled type 2 diabetes (T2DM) patients (n=234) were randomized into 4 groups: MI+DSME or DSME alone, with or without use of a computerized summary of patient self management barriers. We compared HbA1c changes between groups at 6 months and investigated mediators of HbA1c change. RESULTS study patients attended the majority of the four intervention visits (mean 3.4), but drop-out rate was high at follow-up research visits (35%). Multiple regression showed that groups receiving MI had a mean change in HbA1c that was significantly lower (less improved) than those not receiving MI (t=2.10; p=0.037). Mediators of HbA1c change for the total group were diabetes self-care behaviors and diabetes distress; no between-group differences were found. CONCLUSIONS DSME improved blood glucose control, underlining its benefit for T2DM management. However, MI+DSME was less effective than DSME alone. Overall, weak support was found for the clinical utility of MI in the management of T2DM delivered by diabetes educators.

Survival following moderate-dose preoperative radiation therapy for carcinoma of the rectum

We performed a retrospective study of patients with carcinoma of the rectum or rectosigmoid undergoing surgical resection. Forty‐two patients received adjuvant preoperative radiation therapy (4000–4500 rad). One hundred twenty patients underwent surgical resection alone. Survival of radiation patients was significantly improved over that of Surgery Only patients, even after adjusting for nontreatment factors using Cox regression. Crude 5‐year survival was 63% for radiation patients (74% adjusted) compared to 46% for surgery‐only patients (48% adjusted) (P < 0.025). Radiation patients also had longer disease‐free survival than surgery‐only patients (P < 0.05) and fewer recurrences (14% versus 37%; P < 0.025). Fewer radiation patients had lymph nodes involved with tumor than surgery‐only patients (20% versus 35%; P = 0.07). Although 71% of radiation patients experienced radiation reactions, these were primarily mild and transitory. We believe that preoperative radiation is an effective and safe adjunct to surgery in the treatment of rectal cancer and that its use can lead to improved survival rates.