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PubMed1997

Suspended rocking cradles, positional asphyxia, and sudden infant death.

OBJECTIVE: To describe the risk of unexpected death in infants who are placed in suspended rocking cardles. MAIN OUTCOME MEASURES: Ten cases of sudden infant death and 5 cases of infant asphyxia with successful resuscitation reported to the Consumer Product Safety Commission were analyzed. The death scene investigation reports and autopsy material were made available for evaluation. All 15 cases implicated a suspended head-to-toe rocking cradle. RESULTS: Infants were aged 3 months or younger and were found in the facedown prone position when discovered. The cradle was tilted at greater than 5 degrees, and the head was wedged at one end of the cradle. A locking pin was not used in 14 cases. Ten of the 15 infants died. The autopsy reports listed sudden infant death syndrome as the cause of death. CONCLUSIONS: Suspended rocking cradles represent a potentially lethal sleeping environment and should not be used without a locking pin in place. Infants should be placed in the supine position for sleep.

Asphyxia↗
PubMed2003

Ventilator-induced lung injury.

Ventilator-induced lung injury has been established as a significant risk to patients receiving PPV. Animal studies have provided definitive experimental data that support the existence of VILI. Clinical studies have implied the role of VILI in ARDS and ALI patients. In patients who have ARDS or ALI, however, VILI cannot be distinguished from exacerbation of the primary condition. Animal and clinical studies that clearly show elevated levels of cytokines when PPV is applied beyond certain limits support the concept that an inflammatory process is activated by PPV. Whether the induction of inflammatory mediators contributes to the mortality or morbidity of the ventilated patient has not been established. A potential role for anti-inflammatory therapeutic agents is promising. Therefore, the following considerations can guide the clinical care of ventilator patients: Alveolar pressure exposure (plateau pressure) should be limited to less than 32 cm H2O. Positive end-expiratory pressure should be applied to avoid end-expiratory collapse and reopening. Tidal volume should be set at approximately 6 mL/kg or further guided by plateau pressure limitation. Although studies suggest that reducing Ti, flow, and f may be important in avoiding VILI, there are no current guidelines. The results of preliminary studies investigating the preventative potential of respiratory acidosis, prone positioning, or careful vascular pressure management seem promising. Inflammatory response in VILI has been established, but a role for intervention, such as general or specific suppression of the response, has not been established.

Animals↗
PubMed2004

Excitability changes in resting forearm muscles during voluntary foot movements depend on hand position: a neural substrate for hand-foot isodirectional coupling.

When associating hand and foot voluntary oscillations, isodirectional coupling is preferred irrespective of hand position (prone or supine). To investigate the neural correlates of this coupling modality, excitability of the motor projections innervating the resting forearm was tested during cyclic voluntary flexion-extensions of the ipsilateral foot. H-reflexes, in some experiments facilitated by subliminal Transcranial Magnetic Stimulation (TMS), and Compound Muscle Action Potentials (CMAPs), evoked by supraliminal TMS, were elicited in Flexor Carpi Radialis (FCR) and Extensor Carpi Radialis (ECR) muscles at five intervals during the foot movement cycle. With the hand prone, a sinusoidal excitability modulation was observed in wrist flexors and extensors, but reversed in phase: in FCR, excitability increased during plantar-flexion and decreased during dorsiflexion, while in ECR the opposite occurred. This reciprocal organisation was confirmed by the excitability modulation of CMAPs evoked simultaneously in the two antagonists. When the hand was supinated, the H-reflex modulation reversed in phase, i.e., FCR excitability increased during foot dorsiflexion and decreased during plantar-flexion. In both muscles and hand positions tested, when the muscle-to-movement phase-lag was increased by inertial loading of the foot, H-reflex excitability modulations remained phase linked to muscular contractions, not to movement. Together, these results suggest that the subliminal excitability modulation of hand movers has a common central origin with the parallel overt activation of foot movers, is reciprocally organised, and is direction- not muscle-dependent. It may therefore represent the neural substrate for isodirectional coupling of hand (prone or supine) with the foot.

Action Potentials↗
PubMed2001

Maternal awareness of sudden infant death syndrome in North Queensland, Australia: an analysis of infant care practices.

OBJECTIVES: To assess awareness of sudden infant death syndrome (SIDS) and risk reducing recommendations in a sample of mothers in North Queensland, Australia, and to examine their infant care practices. METHOD: Interviews conducted with 195 women using a standardized questionnaire between October 1997 and January 1998. RESULTS: 191 questionnaires analyzed; 134 (70.2%) Caucasian and 57 (29.8%) indigenous women. Four women with previous SIDS experience were excluded from the analysis. Eight (4.2%) had never heard of SIDS. Twenty-nine (15.2%) had heard of SIDS and 154 (80.6%) had heard of SIDS and could list risk recommendations to reduce its incidence. Multivariate analysis identified ethnicity as the only significant predictor of maternal knowledge. Indigenous mothers knew less about SIDS: adjusted odds ratio (OR) = 5.4; 95% confidence interval (CI) = [2.1-14.0]. Avoidance of prone sleeping was the most frequently identified recommendation (n = 132), with no smoking in pregnancy (n = 48) and breastfeeding (n = 40) identified least frequently. There were 80.2% of mothers who put their infant in non-prone positions to sleep. Only 48 (25%) women identified smoking in pregnancy, and 93 (48.6%) smoking in the infant's environment as risk factors. Indigenous women were more likely to smoke in their pregnancy (P = 0.004), bed share with their infant (P = 0.0001), and have smokers in the home. CONCLUSION: There is a high level of awareness of SIDS and the main associated risk factor of infant prone sleeping, but the link between SIDS and smoking requires further emphasis. Future campaigns should ensure the SIDS message is delivered more effectively to the indigenous communities.

Adult↗
PubMed1983

Prevention of air embolism with positive end expiratory pressure.

Pulmonary air embolism is recognized as a possible complication of neurosurgical procedures performed with the patient in the sitting position. A variety of preventive and therapeutic modalities have been proposed in the literature. We have used a consistent regimen consisting of precordial Doppler monitoring, measurement of end expiratory CO2, the semireclining position, and positive end expiratory pressure (PEEP). A right atrial catheter was not used. This approach has given good results in 81 patients; there was significant air embolism in only 1 case (1.2%). We believe that PEEP is as important in the prevention as it is in the treatment of pulmonary air embolism. By flexibly adjusting the level of PEEP, one may recreate the hemodynamic equivalent of the prone position, thereby eliminating the risk of venous air embolism and simultaneously the need for right heart catheterization.

Adolescent↗
PubMed1990

Ventilatory strategies in the management of the adult respiratory distress syndrome.

This article review available strategies for mechanically ventilating patients with the adult respiratory distress syndrome. The authors first present the conventional strategies of mechanical ventilation: volume-limited mechanical ventilation with positive end-expiratory pressure (PEEP) at normal inspiratory-expiratory ratios, the approach that has been the mainstay of ventilatory support since the initial description of PEEP. This discussion attempts to summarize the rationale and goals of treatment in a practical, clinically useful manner. The second section of the article reviews less conventional ventilatory approaches, including inverse ratio ventilation, extracorporeal techniques, high-frequency ventilation, prone position, and fluctuating PEEP, and attempts to review critically the available literature regarding their application.

Extracorporeal Membrane Oxygenation↗
PubMedDate not supplied

Lower limb manual muscle testing in the early stages of Charcot-Marie-Tooth disease type 1A.

Charcot-Marie-Tooth disease (CMT) is a genetically and clinically heterogeneous disorder that affects approximately one in 2,500 individuals. CMT 1A, which is due to a duplication in the area containing the PMP-22 gene on chromosome 17, is the most frequent CMT subtype. To date, there is no consensus among authors about which muscles are weakened in the early stages of CMT, even though this knowledge would be crucial for deciding the most appropriate interventions to restore balance between muscles and prevent the development of deformities. The aim of this study was to evaluate the strength of several lower limb muscles in the early stages of CMT 1A. In a series of 45 patients (age 10-72 years; 21 males, 24 females) affected by CMT 1A, we evaluated 83 non-operated lower limbs that corresponded to the two milder stages of a five-level functional classification. The strength of two foot muscles, seven leg muscles, two thigh muscles, and three pelvic girdle muscles was graded using the manual muscle testing techniques of Daniels and Worthingham; the power of the triceps surae was graded, in the prone position, using a 4-level scale of ability to raise the heel from the floor. Muscle strength was determined on the basis of interobserver agreement estimated by kappa statistics between two observers. The flexor hallucis brevis and lumbricals were very weak in all the limbs; the leg muscles were strong in more than 90% of limbs, except the peronei (strong in 83.13%); all the triceps surae were strong in the prone test, but 16.87% were weak in the standing test; all the proximal muscles were strong. In the large majority of patients in the early stages of CMT 1A, the intrinsic foot muscles are very weak and the leg and proximal muscles are strong.

Adolescent↗
PubMed1995

[Radiological and anatomical investigation of calcific tendinitis of the gluteus maximus tendon].

The radiological findings in four cases of gluteus maximus tendinitis were retrospectively analyzed. All the patients underwent radiographic, CT and MRI examinations. Amorphous or round calcifications were detected on lateral radiographs in three cases, and on CT in all cases. A small cortical erosion was observed in three cases on both radiographs and CT. MRI showed a thickened gluteus maximus tendon, but no other specific features. In the supine position, which is common in routine CT and MRI studies, the calcific deposits appeared to be distributed along the vastus lateralis muscle tendon. To correlate these radiographic observations with the topographic anatomy of the tendon's insertion, we investigated 14 thighs of seven cadavers, and clarified that the tendon's insertion was the main component of the lateral femoral intermuscular septum. Consequently we performed MRI on a volunteer in a prone position who was asked to maintain contraction of the gluteus maximus and quadratus femoris muscles. The images obtained showed clearly that the gluteus maximus tendon was directed dorsally. In conclusion, radiography and CT are the modalities of choice for diagnosis of this entity. Additionally, radiologists should be aware that the gluteus maximus tendons are directed laterally as a main part of the lateral femoral intermuscular septum on routine CT and MRI.

Buttocks↗
PubMed2001

A comparison between dynamic pelvic magnetic resonance imaging and videoproctography in patients with constipation.

PURPOSE: This study attempts to compare the diagnostic efficacy of dynamic pelvic magnetic resonance imaging with that of videoproctography for the presence of rectocele, sigmoidocele, and intussusception as well as the measurement of anorectal angle and perineal descent in constipated patients. METHODS: Patients volunteering for the study and fulfilling the criteria for videoproctography to evaluate constipation were also scheduled for dynamic pelvic magnetic resonance imaging. Patients undergoing videoproctography were placed in the left lateral decubitus position, after which 50 ml of liquid barium paste was introduced into the rectum. After this, approximately 100 ml of thick barium paste similar to stool in consistency was injected into the rectum, and the patient was instructed to defecate while video images were taken. For dynamic pelvic magnetic resonance imaging, air, to be used as contrast, was allowed to accumulate in the rectum via examination with the patient in the prone position. A capsule was taped to the perineal skin immediately posterior to the anal orifice for marking. Sagittal and axial T1 images were obtained through the pelvis at 8-mm intervals with dynamic breathhold sagittal images of the anorectal region obtained at rest and during strain and squeeze maneuvers. Total acquisition time per maneuver was approximately 19 seconds. The tests were performed by different examiners blinded to the result of the other evaluation. The investigations were independently interpreted, findings compared, and patients questioned regarding their impression of dynamic pelvic magnetic resonance imaging and videoproctography. RESULTS: From June 1996 to April 1997, 22 patients (15 females) with a mean age of 68 (range, 21-85) years underwent both videoproctography and dynamic pelvic magnetic resonance imaging. Dynamic pelvic magnetic resonance imaging was only able to detect 1 of 12 (8.3 percent) anterior rectoceles and one of two (50 percent) posterior rectoceles identified by videoproctography. It failed to recognize any of the rectoanal intussusception (zero of four) but did show 9 of 12 (75 percent) sigmoidoceles. Significant discrepancy of measurement of the anorectal angle and perineal descent exists between the two studies, and dynamic pelvic magnetic resonance imaging was not able to detect any (0 of 11) of the patients with increased fixed perineal descent and only half (one of two) of the patients with increased dynamic perineal descent noted on videoproctography. All 22 patients preferred dynamic pelvic magnetic resonance imaging over videoproctography because of greater comfort. CONCLUSION: Occasionally, the increased cost of new technology can be justified by the enhanced diagnostic yield. The ability to avoid unnecessary surgery or, conversely, to continue to search for otherwise occult pathology that can be surgically corrected justifies routine application of these new tools. However, this study has shown that, despite a cost of approximately ten times more for dynamic pelvic magnetic resonance imaging than for videoproctography, no clinical changes were made. Thus, on the basis of this study, we cannot endorse the routine application of dynamic pelvic magnetic resonance imaging for the evaluation of constipated patients. In certain selected individuals, it may play a role, but further study is necessary to clarify its exact role.

Adult↗
PubMed2000

[Diagnostic evaluation of the breast using PET: optimization of data acquisition and postprocessing].

PURPOSE: Development and evaluation of an optimized protocol for PET examinations of the female breast with 2-F-18-fluoro-2-deoxyglucose (F-18-FDG). METHODS: All PET measurements were performed with a whole-body PET system (ECAT EXACT HR+). In order to examine the women with the breasts freely pendant, a special extension for the patient table made of carbon layer composite was designed. After data acquisition in the 3D modus, emission data were sorted into 2D sinograms using the Fourier rebinning algorithm and reconstructed by means of an ultra-fast iterative 2D algorithm (HOSP). The reconstructed emission scans were superimposed onto the corresponding transmission images. The protocol presented was evaluated in examinations on 6 women with breast lesions after the administration of 150-220 MBq F-18-FDG. From two adjacent bed positions, emission and transmission data were acquired over periods of 20 min and 10 min, respectively. For comparison, dynamic magnetic resonance (MR) image series were acquired with a whole-body MR system (MAGNETOM SP 4000) using a double-breast coil. RESULTS AND CONCLUSION: Using the designed extension of the patient table, it was possible to examine corpulent women despite the limited patient port of the PET system in the prone position with the breasts freely pendant. Alongside a reduction in motion artifacts, this positioning also offers the possibility of making a direct comparison between PET and MR images. Despite the fact that the amount of F-18-FDG applied to the patient was markedly reduced, the combination of 3D data acquisition and iterative image reconstruction resulted in excellent quality of the emission scans. By super-positioning of iteratively reconstructed emission and transmission scans, anatomical localization of breast lesions visualized on the emission scans could be improved. The postprocessing of the PET data described was completed in 60 min, this meaning that the presented concept can readily be employed in clinical practice.

Algorithms↗
PubMed1993

[SIDS--a retrospective study in Slovakia].

This is an analysis of 102 cases of SIDS from retrospective studies in the Zilina and Senica districts. The incidence of SIDS in the Zilina district was 2.04/1000 (period 1969-1978) and 1.04/1000 (period 1980-1984). The incidence of SIDS in the Senica district was 0.82/1000 (period 1979-1990). According to preliminary results of the epidemiological study of SIDS in Slovakia (1991) the incidence is only 0.89/1000 which amounts, however, to 23.1% of the post-neonatal mortality. In the investigation nine indicators were evaluated: age at the time of death, morbidity before death, place of death, education of mother, position of infant at time of death, birth weight succession of child in family. The assembled results were compared with data in the literature. Because of similar results it is assumed that the following risk factors participate in the incidence of SIDS: age (2-4 months), time between midnight and 6 a.m., low socio-economic status of family, lower education of mother, incidence of SIDS in the family, short interval between childbirths, prone position during sleep, succession of child in family (third or subsequent), effect of smoking. The investigation did not confirm as risk factors a lower birth weight and inadequate postnatal adaptation. In the conclusions some possible ways of prevention are outlined.

Epidemiologic Factors↗
PubMed2004

Optical coherence tomography under general anesthesia in a child with nystagmus.

PURPOSE: To describe a method that permits optical coherence tomography scanning to be performed under general anesthesia. DESIGN: Observational case report. METHODS: A 7-year-old child underwent optical coherence tomography scanning under general anesthesia. He was positioned prone, with the neck extended to enable vertical facial alignment on the scanner. An anti-Trendelenburg trend on the operating table minimized the degree of neck extension required. Intravenous fluids, modest ventilator airway pressures, and compression stockings were used to minimize perioperative hemodynamic disturbance and the potential for orthostatic hypotension associated with the anti-Trendelenburg trend. RESULTS: High-quality, diagnostically important optical coherence tomography scans were obtained. CONCLUSION: With appropriate patient positioning and anesthetic management, optical coherence tomography scanning can be performed on uncooperative adults and children under general anesthesia.

Anesthesia, General↗
PubMed1991

[The seated position in patent foramen ovale?].

Anesthetic management of patients presenting for posterior cranial fossa surgery in the seated position includes detection and treatment of venous air embolism. Atrial positioning of a central venous (cv) line may be verified by either X-ray or an atrial ECG tracing. We report a case where a chest X-ray film proved superior. A 26-year-old white female was scheduled for posterior cranial fossa exploration. A cv line was inserted via the left antecubital vein; the chest X-ray film documented correct positioning of the catheter tip within the atrium but an aberrant course of the superior vena cava. Echocardiography was performed in the induction room and indicated a patent foramen ovale. In view of the risk of paradoxical air embolism, surgery was postponed. Subsequent cardiologic and radiologic examinations revealed a patent foramen ovale and a persisting left superior vena cava draining into a dilated coronary sinus. Surgery was rescheduled and carried out uneventfully in the prone position. This case demonstrates: 1) an advantage of a thoracic-X-ray film compared to atrial ECG tracing as not only the catheter tip position, but also the course of the catheter can be identified; and 2) the usefulness of preoperative screening for a patent foramen ovale in patients scheduled for surgery in the seated position.

Adult↗
PubMed1980

Surface pressure distribution of the human body in the recumbent position.

Surface pressure measurements of human body weight as distributed on 4 different commercial beds were examined. Sixty-five water-filled bladders connected to pressure transducers were employed to measure the pressure distribution patterns of the human body. These pressure measuring bladders were distributed on a sheet shaped to conform to the human figure and then placed on 5 different surfaces, including an orthopedic 720 coil mattress and box spring, a standard 500 coil bed, a standard 10-inch deep waterbed, a hybrid bed composed of a central water core surrounded by polyurethane, and the floor. Subjects were tested in both a supine and prone position on the various surfaces after the pressure measuring sheet was interposed. The results demonstrated a more uniform pressure distribution over the entire body on both the waterbed and the orthopedic bed than on any of the other surfaces. The softer (500 coil) bed, the hybrid bed, and the floor supported the body essentially on only 5 points (occiput, shoulders, buttocks, calves and heels) in the supine position. The water and orthopedic beds differed markedly, having more uniform and equally distributed surface pressures. The skin pressures measured over the bony prominences were significantly greater than the critical value for ischemia (30mmHg), thereby enhancing the development of decubiti--particularly in the beds which poorly distribute body weight.

Beds↗
PubMed2001

[Relevance of nerve blocks in treating and diagnosing low back pain--is the quality decisive?].

Diagnostic nerve blocks: The popularity of neural blockade as a diagnostic tool in painful conditions, especially in the spine, is due to features like the unspecific character of spinal pain, the irrelevance of radiological findings and the purely subjective character of pain. It is said that apart from specific causes of pain and clear radicular involvement with obvious neurological deficits and corresponding findings of a prolapsed disc in MRI or CT pictures, a diagnosis of the anatomical cause of the pain can only be established if invasive tests are used [5]. These include zygapophyseal joint blocks, sacroiliacal joint blocks, disc stimulation and nerve root blocks. Under controlled conditions, it has been shown that among patients with chronic nonradicular low back pain, some 10-15% have zygapophyseal joint pain [58], some 15-20% have sacroiliacal joint pain [36, 59] and 40% have pain from internal disc disruption [60]. The diagnostic use of neural blockade rests on three premises. First, pathology causing pain is located in an exact peripheral location, and impulses from this site travel via a unique and consistent neural root. Second, injection of local aneasthetic totally abolishes sensory function of intended nerves and does not affect other nerves. Third, relief of pain after local anaesthetic block is attributable solely to block of the target afferent neural pathway. The validity of these assumptions is limited by complexities of anatomy, physiology, and psychology of pain perception and the effect of local anaesthetics on impulse conduction [28]. Facet joints: The prevalence of zygapophyseal joint pain among patients with low back pain seems to be between 15% and 40% [62], but apparently only 7% of patients have pure facet pain [8, 29]. Facet blockade is achieved either by injection of local anaesthetic into the joint space or around the medial branches of the posterior medial rami of the spinal nerves that innervate the joint. There are several problems with intraarticular facet injections, mainly failure to enter the joint capsule and rupture of the capsule during the injection [11]. There is no physiological means to test the adaequacy of medial nerve block, because the lower branches have no cutaneous innervation. Medial ramus blocks (for one joint two nerves have to be infiltrated) are as effective as intraarticular joint blocks [37]. Reproducibility of the test is not high, the specifity is only 65% [61]. For diagnosis of facet pain fluoroscopic control is always necessary as in the other diagnostic blocks. Sacroiliacal joint: Definitely the sacroiliacal joint can be the source of low back pain. Stimulation of the joint by injection in subjects without pain produces pain in the buttock, in the posterior thigh and the knee. There are many clinical tests which confirm the diagnosis, but the interrater reliability is moderate [53]. Intraarticular injection can be achieved in the lower part of the joint with fluoroscopic guidance only, but an accurate intraarticular injection, which is confirmed by contrast medium, even at this place is often difficult. It is not clear whether intraarticular spread is necessary to achieve efficacy. Discography: Two primary syndromes concerning the ventral compartment have been described: anular fissures of the disc and instability of the motion segment. In the syndrome of anular tear, leakage of nucleus pulposus material into the anulus fibrosus is considered to be the source of pain. The studies of Vaharanta [71] and Moneta [41] show a clear and significant correlation between disc pain and grade 3 fissures of the anulus fibrosus. intervertebral discs are difficult to anaesthetize. Intradiskal injections of local anaesthetics may succeed in relieving the patient's pain, but such injections are liable to yield false negative results if the injected agent fails to adequately infiltrate the nerve endings in the outer anulus fibrosus that mediate the patient's pain. In the majority of cases MRI provide adaequate information, but discography may be superior in early stages of anular tear and in clarifying the relation between imaging data and pain [71]. Selective spinal nerve injection: In patients with complicated radiculopathy, the contribution of root inflammation to pain may not be certain, or the level of pathology may be unclear. Diagnostic root blocks are indicated in the following situations: atypical topography of radicular pain, disc prolapses or central spinal stenosis at more than one level and monoradicular pain, lateral spinal stenosis, postnucleotomysyndrome. Injection of individual spinal nerves by paravertebral approach has to be used to elucidate the mechanism and source of pain in this unclear situations. The premise is that needle contact will identify the nerve that produces the patient's characteristic pain and that local anaesthetic delivered to the pathogenic nerve will be uniquely analgesic. Often, this method is used for surgical planning, such as determining the site of foraminotomy. All diagnostic nerve root blocks have to be done under fluoroscopic guidance. Pain relief with blockade of a spinal nerve cannot distinguish between pathology of the proximal nerve in the intervertebral foramen or pain transmitted from distal sites by that nerve. Besides, the tissue injury in the nerve's distribution and neuropathic pain (for instance as a result of root injury) likewise would be relieved by a proximal block of the nerve. Satisfactory needle placement could not be achieved in 10% of patient's at L4, 15% at L5 and 30% at S1 [28]. The positive predictive value of indicated radiculopathy confirmed by surgery ranged between 87-100% [14, 22]. The negative predictive value is poorly studied, because few patients in the negative test group had surgery. Negative predictive values were 27% and 38% of the small number of patients operated on despite a negative test. Only one prospective study was published, which showed a positive predictive value of 95% and an untested negative predictive value [66]. Some studies repeatedly demonstrated that pain relief by nerve root block does not predict success by neuroablative procedures, neither by dorsal rhyzotomy nor by dorsal gangliectomy [46]. Therapeutic nerve blocks - facet joints: Intraarticular injection of steroids offer no greater benefit than injections of normal saline [8, 15] and long lasting success is lacking. In this case, a denervation of the medial branches can be considered. To date three randomized controlled studies of radiofrequency facet denervation have been published. One study [20] reported only modest outcomes and its results remained inconclusive, another study [72] with a double blind controlled design showed some effects in a small selected group of patients (adjusted odds ratio 4.8) 3, 6 and 12 months after treatment, concerning not only reduction of pain but alleviating functional disability also. The third study (34a) showed no effect 3 months after treatment. Discogenic pain: Intradiscal radiofrequency lesions, intradiscal injections of steroids and phenol have been advocated, but there are no well controlled studies. Just recently, intradiscal lesion and denervation of the anulus has been described with promising results, but a randomized controlled study is lacking up to now [31, 55]. Epidural Steroids: Steroids relieve pain by reducing inflammation and by blocking transmission of nociceptive C-fiber input. Koes et al. [33] reviewed the randomized trials of epidural steroids: To date, 15 trials have been performed to evaluate the efficacy, 11 of which showed method scores of 50 points (from 100) ore more. The trials showed inconsistent results of epidural injections. Of the 15 trials, 8 reported positive results and 7 others reported negative results. Consequently the efficacy of epidural steroid injections has not yet been established. The benefits of epidural steroid injections seem to be of short duration only. Future efficacy studies, which are clearly needed, should take into account the apparent methological shortcomings. Furthermore, it is unclear which patients benefit from these injections. In our hands the injection technique can be much improved by fluoroscopic guidance of the needle, with a prone position of the patient, and lateral injection at the relevant level and with a small volume (1-2 ml) and low dose of corticosteroid (20 mg triamcinolone in the case of a monoradicular pain, for example). In the case of epidural adhesions in postoperative radicular pain [50], the study of Heafner showed that the additional effect of hyaloronidase and hypertonic saline to steroids was minimal. In our hands there was no effect in chronic radicular pain 3 months after the injection.

Humans↗
PubMed1990

Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study.

OBJECTIVE: To determine the relation between sleeping position and quantity of bedding and the risk of sudden unexpected infant death. DESIGN: A study of all infants dying suddenly and unexpectedly and of two controls matched for age and date with each index case. The parents of control infants were interviewed within 72 hours of the index infant's death. Information was collected on bedding, sleeping position, heating, and recent signs of illness for index and control infants. SETTING: A defined geographical area comprising most of the county of Avon and part of Somerset. SUBJECTS: 72 Infants who had died suddenly and unexpectedly (of whom 67 had died from the sudden infant death syndrome) and 144 control infants. RESULTS: Compared with the control infants the infants who had died from the sudden infant death syndrome were more likely to have been sleeping prone (relative risk 8.8; 95% confidence interval 7.0 to 11.0; p less than 0.001), to have been more heavily wrapped (relative risk 1.14 per tog above 8 tog; 1.03 to 1.28; p less than 0.05), and to have had the heating on all night (relative risk 2.7; 1.4 to 5.2; p less than 0.01). These differences were less pronounced in the younger infants (less than 70 days) than the older ones. The risk of sudden unexpected death among infants older than 70 days, nursed prone, and with clothing and bedding of total thermal resistance greater than 10 tog was increased by factors of 15.1 (2.6 to 89.6) and 25.2 (3.7 to 169.0) respectively compared with the risk in infants of the same age nursed supine or on their side and under less than 6 tog of bedding. CONCLUSIONS: Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days. Educating parents about appropriate thermal care and sleeping position of infants may help to reduce the incidence of the sudden infant death syndrome.

Age Factors↗