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The insertion of an epidural catheter for labour analgesia may be challenging. This observational study compared pressures during insertion of an epidural catheter in pregnant (n = 35) and non-pregnant (n = 10) women, using an acoustic device for locating the epidural space that also records and stores pressure data during the procedure. In both groups, we compared the maximum pressure just before loss of resistance, the pressure in the epidural space and the pressure in the inserted epidural catheter. Maximum pressure just before loss of resistance in the pregnant women was significantly lower compared with the non-pregnant women. Pressures in the epidural space and with the disposable tubing connected to the inserted epidural catheter were greater in pregnant women than in non-pregnant women. The results support the hypothesis that physiological changes in the third trimester of pregnancy are the reason why epidural catheters are more difficult to insert in women in labour.

Twelve healthy cattle (weighing 188–835kg) were placed in stocks and sedated with xylazine. Caudal epidural puncture was performed using an acoustic device that indicated a decrease in resistance with a change in pitch. Lidocaine was injected to verify correct needle placement by assessing needle prick stimuli applied on the left and right side of the tail root and the perineal region, and the loss of tail and anal sphincter tone. Pressure measurements were recorded during penetration of the different tissue layers and in the epidural space. A clear and sudden decrease in the pitch of the acoustic signal was audible in all 12 cattle. All cows showed clinical effects indicating successful epidural anaesthesia. The pressure in the epidural space after puncture was −19±10mmHg. The device may be of assistance in identifying the epidural space in cattle.

A crucial step in performing successful percutaneous dilatational tracheostomy is the correct introduction of the needle and guide wire into the trachea. We describe an alternative technique, in which an acoustic signal is used as guidance to confirm correct tracheal needle placement.

A recent prospective study performed in three mid-size psychiatric departments in Germany (Mueller et al. 2003, Pharmacopsychiatry 36: 98–104) has shown that TDM of antidepressants when used under routine clinical conditions improves the mental health of the patient and reduces the occurrence of adverse drug effects – but only if the psychiatrists ordering TDM does react appropriately to the reports from the TDM laboratory (Vuille et al. 1991, Pharmacopsychiatry 24: 190–195; Hiemke et al. 2003, Psychopharmakotherapie 10: 11–14). We compared these findings to our university hospital setting, analysing the 262 orders for a plasma level determination that our staff psychiatrists had issued in the year 2001. The total turnover for that year was 3,531 inpatients and 11,524 outpatients. Thus, our staff psychiatrists deemed it necessary to perform TDM in only 2% of the patients entrusted to them, suggesting that our clinicians greatly believe in their patients' compliance and pharmacokinetic conformity. For 227 of these 262 patients, a plasma level analysis was ordered only once, with 84% of these plasma levels being in the recommended range. In contrast, plasma levels for the remaining 35 patients, for whom more than one TDM during the course of treatment was judged necessary by our clinicians, only 46% of these 35 patients had plasma levels in the recommended range upon their first TDM (p=0.0002, Fisher's exact test, two-sided). Of the 27 inpatients of the 35 patients for whom TDM was ordered a second time, the median waiting time was 3 days. Actually, in as much as 38% of the cases TDM was ordered on same day the dose was changed by the clinician. In the 8 patients of the outpatient clinic for whom TDM was ordered more than once, TDM was never ordered 0–3 days after changing the dose, in 25% TDM was ordered 4–7 days after the dosing change, and in 75% it was ordered 8+ days after (p<0.0001 with respect to inpatient setting, chi square test). In 7 of the 35 patients who presented with plasma levels above the recommended range at the first TDM, the dose was not changed in 4 patients or even increased in 2 patients. Thus, with respect to the whole patient sample of 35, the proportion of such inappropriate dose adjustment to TDM was 17% (i.e., 6 of 35 adjustments), comparable to the German and the Swiss hospital staff psychiatrist sample.

Beneficial effects of TDM require an adequate use of the procedure. This study analysed retrospectively the use of TDM in 35 of 262 patients for whom TDM was requested a second time. When looking at the 35 patients the median waiting time was only 3 days which was too early, i.e. before reaching steady state. Moreover, many dose changes were inconsistent with reported drug concentrations in blood. These results indicate that the application of TDM in clinical routine needs to be improved.

Repetitive transcranial magnetic stimulation (rTMS) has been reported to demonstrate slight effects in the treatment of depression. Hence, a novel bilateral versus unilateral and sham stimulation design was applied to further assess rTMS' antidepressant effects. Forty one medication free patients with major depression, admitted to a psychiatric unit specialising in affective disorders, were consecutively randomised into 3 groups. Group A1 (n = 12) received unilateral active stimulation consisting of high frequency (hf) rTMS over the left dorsolateral prefrontal cortex (LDLPC) and subsequent sham low frequency (lf) rTMS over the right dorsolateral prefrontal cortex (RDLPC). Group A2 (n = 13) received simultaneous bilateral active stimulation consisting of hf-rTMS over the LDLPC and lf-rTMS over the RDLPC. Group C (n = 13) received bilateral sham stimulation. Stimulation was performed on 10 consecutive workdays. All patients received antidepressant medication on the first day of stimulation, which was continued during and after the stimulation period. As no significant difference in antidepressant outcome between group A1 and A2 was found, the two groups were pooled. The time course of the outcome variables Hamilton depression rating scale (HDRS(21)) and Beck depression inventory (days 0, 7, 14, 28) by repeated measures analysis of variance revealed no significant group differences (in terms of a group by time interaction), whereas there was a significant effect of time on all three outcome variables in all groups. The results suggest that rTMS as an "add on" strategy, applied in a unilateral and a bilateral stimulation paradigm, does not exert an additional antidepressant effect.

BACKGROUND AND OBJECTIVE:In previous studies we have demonstrated that it is possible and safe to identify the lumbar epidural space by an acoustic and visible signal. The use of an experimental set-up constructed for this purpose, the acoustic puncture assist device, the lumbar epidural puncture procedure became both audible and visible. In the present study we have extended the use of the device to localize the thoracic epidural space. We have also evaluated whether the device can be used as a practical tool to confirm correct catheter placement. METHODS:In 100 consecutive patients a prototype of the acoustic puncture assist device was connected to the epidural needle in order to localize the epidural space. The device translates the pressure encountered by the needle tip into a corresponding acoustic and visible signal and enables the anaesthesiologist to detect the epidural space by means of the acoustic signal. After catheter insertion, local anaesthetic was administered. Subsequently the epidural block was tested. In 10 patients the device was also connected to the epidural catheter after its insertion into the epidural space. RESULTS:In all 100 patients included in the study the epidural space was successfully located by means of the acoustic signal. The only recorded complication was intravascular catheter placement in two patients. CONCLUSIONS:It is possible to localize the thoracic epidural space guided by an acoustic signal. The method was shown to be safe, reliable and simple. Potential implications of this technique include better needle control, improved monitoring for training purposes and for clinical documentation of the thoracic epidural puncture as well as identifying correct catheter placement.

Zernig, Gerald MD*; Lechner, Theresa MD*; Kramer-Reinstadler, Karin MD*; Hinterhuber, Hartmann MD*; Hiemke, Christoph PhD†; Saria, Alois PhD* Author Information

Standardized assessment of a family's characteristics (conflict management, cohesion, etc.) is not used routinely, although these variables may play an important role in the course of psychological disorders in children. The present study investigated differences within the features of families of children with hyperkinetic and emotional disorders. Families of 20 boys diagnosed with Attention Deficit Hyperkinetic Disorder and 20 boys with Emotional Disorder (ages 6-12 years) by giving the Mannheim Parents Interview and the teacher's form of the Conners scale were included for evaluation and compared with a matched, healthy control group of 20 boys. Parents were asked to complete a form assessing the family's characteristics ("Familienklima-Testsystem"), including Cohesion, Expressiveness, Conflict Tendency, Individual Independence, Achievement Orientation, Intellectual-Cultural Orientation, Active-Recreational Orientation, Moral-Religious Emphasis, and Organization. Comparison of groups was made by the Kruskal-Wallis test and Mann-Whitney U test. There are significantly more conflicts in families whose children belong to the two disorder groups. Compared with a matched healthy control group, there is low Expressiveness, Independence, and Cultural and Active-Recreational Orientation in the Emotional Disorder group and a significant lack of Organization and Cohesion in the Attention Deficit Hyperkinetic Disorder group. Altogether there seems to be a significant association of Attention Deficit Hyperkinetic Disorder symptoms with the family's Cohesion and Organization. One implication is that therapists focus their efforts not only on the children with disorders but also on their families.

Sixty patients scheduled for lumbar epidural anesthesia were included in a study in which we evaluated the efficacy of localizing the epidural space by means of an acoustic signal. A prototype of an acoustic Puncture assist device, connected to the epidural needle by an extension tube, generated the pressure needed to perform the epidural puncture and translated this pressure into corresponding acoustic and visible signals. The device frees the anesthesiologist to handle the epidural needle with both hands and to detect the epidural space by means of these signals. In all 60 patients (100%), the epidural space was successfully located by using the acoustic signal. In all cases this was confirmed by the pressure measurement, which proved to be a reliable indicator for correct identification of the epidural space. We conclude that it is possible to locate the epidural space by means of the acoustic puncture assist device. The method proved to be reliable, safe, and simple in this study. The benefits of this new epidural puncture technique include better needle control, teaching, control of correct catheter placement, and documentation. The last can be an important adjunct to anesthesia practice.