Heat stroke : a review of cooling methods.

The prognosis of heat stroke in patients is directly related to the degree of hyperthermia and its duration. Therefore, the most important feature in the treatment of heat stroke is rapid cooling. Several cooling methods have been presented in the literature including immersion in water at different temperatures, evaporative cooling, ice pack application, pharmacological treatment and invasive techniques. This article describes the various cooling techniques in terms of efficacy, availability, adverse effects and mortality rate. Data suggest that cooling should be initiated immediately at time of collapse and should be based on feasible field measures including ice or tepid water (1-16 degrees C), which are readily available. In the emergency department, management should be matched to the patient's age and medical background and include immersion in ice water (1-5 degrees C) or evaporative cooling.

Neurosurgical management of abnormal muscle tone in childhood.

No longer are only a limited number of treatments available to help children and their families deal with childhood hypertonia. It is now possible to provide a child with a treatment specific to his or her muscle tone problems and consequently meet the family's functional goals. The prospects can only improve over the next few years, given the level of interest exhibited by pediatric neuro- and orthopedic surgeons supported by pediatricians, pediatric physical and occupational therapists, pediatric neurologists, and pediatric physiatrists.

Anesthesia for cesarean section in a patient with spinal muscular atrophy.

We describe the anesthetic management for cesarean section and tubal ligation of a 23-year-old primipara with type II spinal muscular atrophy (benign Werdnig Hoffmann). She was wheelchair-bound, had severe restrictive lung disease, and severe kyphoscoliosis, with Harrington rods extending from the thoracic to the sacral spines. A general anesthetic was given. We used propofol and alfentanil for rapid-sequence induction of anesthesia. We did not use any muscle relaxants / relaxant intraoperatively. Postoperative care was provided in the intensive care unit. The patient made a good recovery.

National trends in nonoperative care for nonspecific back pain.

BACKGROUND CONTEXT: Few empirical data are available that document changes in population-based rates for the evaluation and treatment of nonspecific back pain. PURPOSE: To determine the extent of change in the pattern of outpatient evaluation and treatment of nonspecific low back pain in the United States between 1987 and 1997. STUDY DESIGN AND SETTING: The 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey, two nationally representative surveys with similar sampling methods and questions, were used. PATIENT SAMPLE: Noninstitutionalized adults in the United States. OUTCOME MEASURES: Changes in rates of any health service for nonspecific back pain and occurrence of provider-specific care and types of services provided. Changes in the prescription of specific medication classes (ie, nonsteroidal anti-inflammatory drugs [NSAIDs], muscle relaxants, nonnarcotic and narcotic analgesics) were also investigated. RESULTS:Overall rate for outpatient treatment for nonspecific back pain in the US population was relatively stable over the decade (4.48% in 1987, 4.53% in 1997, p=.85). Among those receiving care, the proportion receiving physician care increased from 64% in 1987 to 74% in 1997 (p<.001), whereas those obtaining care from physical therapists increased from 5% to 9% during the same time period (p<.01). The proportion of respondents receiving NSAIDs, muscle relaxants, nonnarcotic analgesics and narcotic analgesics remained stable. However, the mean number of patient visits in which these medications were prescribed increased from 2.0 to 3.9 over the decade (p<.001). The proportion of individuals receiving chiropractic care (p<.01) and X- rays (p<.001) were lower in 1997 than 1987. CONCLUSIONS:The national pattern of health care for nonspecific low back pain observed in the present study serves as a basis for future investigations into the management of this major public health problem. Findings suggest that perhaps a duplication of care is partly responsible for the high degree of health care utilization in this population.

Effect of oral administration of dantrolene sodium on serum creatine kinase activity after exercise in horses with recurrent exertional rhabdomyolysis.

OBJECTIVE: To determine the effect of oral administration of dantrolene sodium on serum creatine kinase (CK) activity after exercise in horses with recurrent exertional rhabdomyolysis (RER). ANIMALS: 2 healthy horses and 5 Thoroughbreds with RER. PROCEDURE: 3 horses received 2 doses of dantrolene (4, 6, or 8 mg/kg, p.o., with and without withdrawal of food) 2 days apart; 90 minutes after dosing, plasma dantrolene concentration was measured spectrofluorometrically. On the basis of these results, 5 Thoroughbreds with RER from which food was withheld received dantrolene (4 mg/kg) or an inert treatment (water [20 mL]) orally 90 minutes before treadmill exercise (30 minutes, 5 d/wk) during two 3-week periods. Serum CK activity was determined 4 hours after exercise. Plasma dantrolene concentration was measured before and 90 minutes after dosing on the first and last days of dantrolene treatment and before dosing on the first day of the inert treatment period, RESULTS: 90 minutes after dosing, mean +/- SEM plasma dantrolene concentration was 0.62 +/- 0.13 and 0 microg/mL in the dantrolene and inert treatment groups, respectively. Serum CK activity was lower in dantrolene-treated horses (264 +/- 13 U/L), compared with activity in water-treated horses (1,088 +/- 264 U/L). Two horses displayed marked muscle stiffness on the inert treatment. CONCLUSIONS AND CLINICAL RELEVANCE: In 5 horses with RER from which food had been withheld, 4 mg of dantrolene/kg administered orally provided measurable, though variable, plasma concentrations and significantly decreased serum CK activity after exercise in 4 of those horses.

GHB-C rats: the control line of GHB-sensitive (GHB-S) and GHB-resistant (GHB-R) rats.
Lobina C, Colombo G, Orru A, Maccioni P, Gessa GL, Carai MA.
Brodie Department of Neuroscience, University of Cagliari, Viale Diaz 182, I-09126 Cagliari, Italy.
Gamma-hydroxybutyric acid (GHB)-sensitive (GHB-S) and GHB-resistant (GHB-R) rats have been selectively bred for their opposite sensitivity to the sedative/hypnotic effect of GHB. This opposite sensitivity has been found to generalize to the GABA(B) receptor agonist, baclofen. A control line [named GHB-control (GHB-C)] has been derived from the foundation stock of GHB-S and GHB-R rats. GHB-C rats have been bred without any evaluation of their sensitivity to GHB. The experiments described here were designed to evaluate the sensitivity of GHB-C rats, from the 13th generation, to the sedative/hypnotic effect of GHB (1 g/kg, i.p.) and baclofen (20 mg/kg, i.p.). All measures (onset, sleep time and r = sleep time/onset) of sensitivity to GHB- and baclofen-induced sedation/hypnosis in GHB-C rats were significantly different from and intermediate to those recorded in GHB-S and GHB-R rats. Furthermore, these values were similar to those recorded in the foundation stock. These results suggest that GHB-C rats may constitute a valid control line for GHB-S and GHB-R rats, representing the "general population" from which GHB-S and GHB-R rats were derived. Furthermore, the relative equidistance of sensitivity to GHB- and baclofen-induced sedation/hypnosis of GHB-C rats from those of GHB-S and GHB-R rats suggests that genetic factors contributes to the development of both sensitivity in GHB-S rats and resistance in GHB-R rats.

Five ways to prevent nighttime leg cramps. Leg cramps can ruin a good night's sleep, but there are ways to prevent them.
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Prescription analgesic and antidepressant utilization and cost among elderly Medicaid beneficiaries before and after nursing home admission.

OBJECTIVES: The objectives of this study were to describe changes in prescription analgesic and antidepressant medications and to track the costs associated with these medication changes when elderly Medicaid beneficiaries move from the community to a nursing home setting. DESIGN: Retrospective analysis of Medicaid long-term care and drugs claims data for fiscal year 2000 from three different states. SETTING: Long-term care facilities in three different states. PARTICIPANTS: We studied 1321 elderly Medicaid beneficiaries newly admitted to a nursing home during the study period. MEASUREMENTS: Pain medications were grouped into four different categories and all antidepressants were grouped into one category. For each medication category, we obtained the number of unique patients for whom it was prescribed, the number of days it was prescribed, and the amount paid by Medicaid. We then calculated the percentage of subjects prescribed and the amount paid per day for each medication class before and after nursing home admission. RESULTS: Except for skeletal muscle relaxants, 21% to 39% of beneficiaries already had claims linked to each medication class while still living in the community. After nursing home admission, the percentage of beneficiaries exposed to each medication class increased by 2% to 33%. Cost per day of therapy increased by 10% to 83%. There was significant variation among the states in utilization and cost per day of therapy. CONCLUSIONS: We draw three major conclusions: (1) community-dwelling elderly Medicaid beneficiaries in this study use more prescription analgesics and antidepressants than community-dwelling elders in prior studies; (2) there is a significant increase in medication utilization and cost on nursing home admission; and (3) significant variability in medication use and cost exists among the three states examined. Further investigation to elucidate the reasons for these differences could assist legislators in formulating sound public policy to contain Medicaid expenditures without sacrificing patient care.

muscle relaxants / relaxant in the treatment of myofascial face pain

Among the different pharmacological approaches that could be adopted in the treatment of myofascial pain of masticatory muscles, attention has to be paid to muscle relaxants / relaxant drugs, since very few studies evaluated their efficacy, despite most authors suggest their use. The present paper is a critical review of the literature on the use of the most common drugs with muscle relaxant / relaxants effects (benzodiazepines, tricyclic antidepressants) and of a muscle relaxant / relaxants drug (Tizanidine ( Zanaflex ) hydrochloride) in the treatment of such condition. From literature data it emerged that these drugs had phases of alternate enthusiasm, characterized by a not constant clinical use and a fair interest in research. Nevertheless, within all the limitations that have been discussed in this paper, the use of muscle relaxants / relaxant in patients with myofascial pain of masticatory muscles seems to be justifiable, even though further research is needed to verify their usefulness in terms of risk-benefit ratio.

Onset and duration of rocuronium-induced neuromuscular blockade in patients with Duchenne muscular dystrophy.
Wick S, Muenster T, Schmidt J, Forst J, Schmitt HJ.
Department of Anesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
BACKGROUND: In patients with Duchenne muscular dystrophy (DMD) the response to nondepolarizing muscle relaxants / relaxant is scarcely documented and conflicting. The current study was conducted to determine the time to peak effect and the time for complete spontaneous recovery after a single dose of 0.6 mg/kg of rocuronium in patients with DMD. METHODS: Twenty-four patients (12 with DMD, 12 controls, aged 10-16 yr) were studied. All patients were anesthetized with propofol and fentanyl/remifentanil. Neuromuscular transmission was monitored by acceleromyography. After induction all patients received a single dose of 0.6 mg/kg of rocuronium. The complete time course of onset and spontaneous recovery were recorded RESULTS: Significant (P < 0.01) increase in the onset times to 95% neuromuscular block was observed in DMD patients (median, 203 s; range, 90-420 s) compared with controls (median, 90 s; range, 60-195 s). The time between rocuronium administration and recovery of first twitch of the train-of-four to 90% was significantly (P < 0.01) prolonged in DMD compared with controls (median, 132 min; range, 61-209 min versus 39 min; 22-55 min). The recovery index was also significantly prolonged in the DMD group compared with controls (median, 28 min, range, 15-70 min versus 8 min; 3-14 min). CONCLUSIONS: The most striking and surprising result of this study is the delayed onset of blockade in DMD after a standard dose of rocuronium. This effect should be kept in mind in situations when a rapid airway protection is necessary in DMD patients. The documented very long recovery from rocuronium-induced block emphasizes the need for careful assessment of neuromuscular function in DMD patients.