Anestesiologia

#Tracheotomy in #poststroke dysphagia: pharyngeal electrical stimulation promotes earlier decannulation

Postado em

  • The Lancet Neurology

Background

Dysphagia after stroke is common, especially in severely affected patients who have had a tracheotomy. In a pilot trial, pharyngeal electrical stimulation (PES) improved swallowing function in this group of patients. We aimed to replicate and extend this single-centre experience.

Methods

We did a prospective, single-blind, randomised controlled trial across nine sites (seven acute care hospitals, two rehabilitation facilities) in Germany, Austria, and Italy. Patients with recent stroke who required tracheotomy were randomly assigned to receive 3 days of either PES or sham treatment (1:1). All patients had the stimulation catheter inserted; sham treatment was applied by connecting the PES base station to a simulator box instead of the catheter. Randomisation was done via a computerised interactive system (stratified by site) in blocks of four patients per site. Patients and investigators applying PES were not masked. The primary endpoint was assessed by a separate investigator at each site who was masked to treatment assignment. The primary outcome was readiness for decannulation 24–72 h after treatment, assessed using fibreoptic endoscopic evaluation of swallowing and based on a standardised protocol, including absence of massive pooling of saliva, presence of one or more spontaneous swallows, and presence of at least minimum laryngeal sensation. We planned a sequential statistical analysis of superiority for the primary endpoint. Interim analyses were to be done after primary outcome data were available for 50 patients (futility), 70 patients, and every additional ten patients thereafter, up to 140 patients. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN18137204.

Findings

From May 29, 2015, to July 5, 2017, of 81 patients assessed, 69 patients from nine sites were randomly assigned to receive PES (n=35) or sham (n=34) treatment. Median onset to randomisation time was 28 days (IQR 19–41; PES 28 [20–49]; sham 28 [18–40]). The Independent Data and Safety Monitoring Board recommended that the trial was stopped early for efficacy after 70 patients had been recruited and primary endpoint data for 69 patients were available. This decision was approved by the steering committee. More patients were ready for decannulation in the PES group (17 [49%] of 35 patients) than in the sham group (three [9%] of 34 patients; odds ratio [OR] 7.00 [95% CI 2.41–19.88]; p=0.0008). Adverse events were reported in 24 (69%) patients in the PES group and 24 (71%) patients in the sham group. The number of patients with at least one serious adverse event did not differ between the groups (ten [29%] patients in the PES group vs eight [23%] patients in the sham group; OR 1.30 [0.44–3.83]; p=0.7851). Seven (20%) patients in the PES group and three (9%) patients in the sham group died during the study period (OR 2.58 [0.61–10.97]; p=0.3059). None of the deaths or serious adverse events were judged to be related to PES.

Interpretation

In patients with stroke and subsequent tracheotomy, PES increased the proportion of patients who were ready for decannulation in this study population, many of whom received PES within a month of their stroke. Future trials should confirm whether PES is beneficial in tracheotomised patients who receive stimulation similarly early after stroke and explore its effects in other cohorts.

Funding

Phagenesis Ltd.

Anúncios

Francês é operado ao #coração sob #hipnose e sem anestesia

Postado em Atualizado em

Hipnose foi a opção para não dar a Gérard Courtois medicamentos e químicos que pudessem ser prejudiciais à saúde

Gérard Courtois, um homem de 88 anos, foi sujeito a uma cirurgia cardiovascular sem anestesia. No Hospital Universitário de Lille, em França, a solução utilizada para que Gérard se abstraísse da operação foi a hipnose, ao invés da morfina, dos ansiolíticos e de outros medicamentos que poderiam pôr em risco a sobrevivência do doente.

Explica a France Bleu que, esta segunda-feira, 48 horas após a intervenção, Gérard está a recuperar sem problemas da substituição da válvula aórtica. A intervenção costuma ser realizada com anestesia local ou geral, mas tal representa um perigo para pessoas de idade avançada.

“Por vezes, pacientes mais velhos são mais sensíveis aos efeitos secundários dos medicamentos injetáveis e estes produtos podem causar problemas neurológicos. Com a hipnose, o paciente recupera imediatamente. Há um benefício real”, explicou Arnaud Sudre. chefe de cirurgia na unidade hospitalar.

No dia antes da operação, Hélène Sergent, a enfermeira encarregue de administrar a “anestesia” a Gérard Courtois, passou algum tempo com ele para lhe explicar o procedimento e também para saber mais sobre as viagens do doente com a mulher “à Tailândia, Egito, Tunísia, Turquia e a paixão pela jardinagem”. Foram estes os temas que usou para hipnotizar Courtouis e colocar num estado de abstração que permitiu ao idoso chegar a adormecer durante a cirurgia.”Ao falar de tanta coisa, esquecemos o que está a acontecer e somos transferidos para outro lado”, explicou a enfermeira.

Sergent foi a primeira enfermeira do departamento de cardiologia a ser treinada para aplicar hipnose. Quatro profissionais de enfermagem serão formadas em breve, já que estima-se que 80% dos pacientes estarão abertos à hipnose em substituição da anestesia, informa o hospital universitário de Lille. Uma nova cirurgia com o doente sob hipnose está marcada para a próxima semana.

 

DN

#Patient consciousness during #CPR – a rare and distressing case

Postado em

  • Noticias Médicas Univadis

Among the presentations at the 2018 Euroanaesthesia congress in Denmark last week, was a case report of a patient who remained conscious and aware during resuscitation following a cardiac arrest.

Presenter, Dr Rune Lundsgaard from the Department of Anaestesiology at Herlev Hospital in Copenhagen and Nykøbing Falster Hospital, Denmark, said the scenario raises ethical questions about proper sedation during resuscitation, which is not currently part of guidelines.

The 69-year old male patient was admitted to the hospital after three days of dyspeptic symptoms. During admission a short period of tachycardia was followed by asystolic cardiac arrest. CPR was immediately initiated.

Throughout the arrest, the patient retained a high level of awareness, with open eyes and movement of the head and limbs. After three minutes of asystole, epinephrine was administered in 1mg boluses every 3-5 minutes. By the third hands-off for rhythm evaluation, the patient was orally intubated but there was still a high level of awareness. Despite 90 minutes of CPR, the patient did not survive. Autopsy later reported a complete aortic dissection.

Dr Lundsgaard said that even though the prognosis was poor, the termination of CPR raised ethical questions for the team as the patient was still conscious at the time.

#Analgesia de parto: estado de arte ou medicina baseada em evidências?

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analsegia de parto

Analgesia de parto: estado de arte ou medicina baseada em evidências?

Todo ano, centenas de novos anestesiologistas, formados em um dos 84 centros de ensino e treinamento espalhados pelo país, entram no mercado de trabalho para atender a uma grande variedade de clínicas. Muitas vezes, afortunadamente, eles seguirão uma linha de cuidado semelhante à que viveram durante os três anos de especialização. Muitas vezes, não, e o melhor caminho para desenvolver a melhor assistência é adquirir boas referências, através de busca ativa por uma bibliografia adequada ou através da opinião de colegas mais experientes.

Em um contexto no qual a anestesia obstétrica é uma rotina, quando não exclusiva, ao menos semanal, de grande parte dos colegas, é fundamental a (no mínimo) familiaridade com alguma técnica de analgesia de parto. O parto vaginal, ao contrário de sua via cirúrgica, não depende de um profissional anestesiologista para ocorrer, o que leva a um baixo índice de solicitações deste profissional, mesmo quando existe a disponibilidade, e, consequentemente, as oportunidades de se aumentar conforto e segurança para as gestantes são reduzidas. Um período de aprendizado rico em cesarianas, mas pobre em analgesia de parto torna o anestesiologista experiente em obstetrícia, mas pode trazer resultados ruins quando ele, por inexperiência, interrompe o trabalho de parto ou aumenta o grau de sofrimento das pacientes, através de procedimentos dolorosos ou eventos adversos relacionados a drogas administradas no processo.

Tendo em vista as melhores práticas anestésicas, diferentes escolas sumarizam basicamente quatro vias não exclusivas de analgesia de parto: espinhal, epidural, venosa e inalatória.

A Sociedade Americana de Anestesiologia, através de seu próprio sítio virtual, exibe uma publicação com diretrizes para anestesia obstétrica, publicada em 2016, e pode ser uma orientação inicial para o profissional inexperiente, pois traça todas as possibilidades de atuação nos diferentes momentos do parto. Essa publicação endossa como padrão-ouro de analgesia a via epidural, seja com a presença constante do médico que aplica, seja através da administração controlada pelo paciente, especialmente, no período inicial e na fase ativa, porém, com eficácia diminuída no período expulsivo, quando pode ser indicada a via espinhal de analgesia, em decorrência da dilatação cervical que a mesma promove.

Historicamente, o neuroeixo é a via de preferência para assistência a esses procedimentos, porém, apesar da eficácia em reduzir ou abolir a dor, tanto a via espinhal quanto a epidural podem interromper a progressão do trabalho de parto, pois este depende de uma complexa interação entre liberação hormonal, musculatura lisa uterina e musculatura esquelética, especialmente de membros inferiores. Ao produzir diminuição de força ou bloqueio motor nessas fibras, essa interação pode ser prejudicada tão intensamente a ponto de causar parada de progressão do feto e comprometer a atuação da futura mãe no processo, o que, consequentemente, leva à alteração da via vaginal pela cirúrgica. Tendo em vista este potencial, além dos riscos subjacentes aos bloqueios, alguns autores estudaram as seguintes vias alternativas de analgesia: inalatória e venosa.

A via inalatória com Óxido Nitroso foi estudada com sucesso, principalmente na fase ativa do trabalho de parto, com resultados de eficácia inferiores à epidural contínua, e maior incidência de náuseas e vômitos, porém com menor taxa de conversão para cesariana, sendo pouco indicada no período expulsivo, apesar de ser superior ao placebo nesse contexto. Essa técnica é realizada através da inalação de mistura não hipóxica (concentração de oxigênio mínima de 25%) de óxido nitroso e oxigênio, de maneira contínua ou de válvulas de auto-demanda pela paciente e pode ocorrer tanto no ambiente de centro cirúrgico ou na acomodação de internação, sendo que o uso de dispositivos que liberam uma concentração fixa não hipóxica foram avaliados quanto à sua segurança e foram aprovados para uso sem a necessidade de monitorização hemodinâmica contínua.

A via venosa de administração é frequentemente utilizada pelos próprios obstetras, para veicular medicações como escopolamina e dipirona, que podem atenuar as dores do processo, e são úteis no contexto em que o profissional responsável pela analgesia não está disponível, mas pode ser utilizada para administração de opioides, que são especialmente mais eficazes em produzir analgesia. Poucos estudos consideraram fentanil e sufentanil venosos com esta finalidade, mas o remifentanil, pelo seu perfil farmacológico, tornou-se uma opção francamente viável e foi estudado isoladamente ou em comparação com a via epidural de administração. Foi avaliado no contexto de analgesia controlada pela paciente e também o uso anestésico, isoladamente ou em comparação com diferentes vias e drogas e concluiu-se que ele pode apresentar eficácia similar à epidural, na fase inicial, na fase ativa e no período expulsivo, com um perfil baixo de eventos adversos, menor taxa de conversão para cesarianas, mas a taxa de satisfação das gestantes em comparação com epidural foi conflitante, melhor em alguns estudos e pior em outros. Estudos maiores explorando segurança e eficácia ainda são extremamente necessários para a inclusão desta via como consagrada ao lado da tradicional.

Quando o jovem profissional se depara com o desafio de precisar realizar analgesia de parto e inevitavelmente apresentar pouca ou nenhuma experiência, o natural é ser orientado por colegas mais antigos ou mesmo pelo próprio obstetra que indicou o procedimento, e, invariavelmente, concluir que é mais prático realizar o bloqueio espinhal com baixo volume e concentração de anestésico local, associado ou não a fentanil no período próximo ao período expulsivo e torcer para que o bloqueio motor seja pequeno e não comprometa essa fase. Porém, o arsenal disponível para a ocasião pode ser bastante amplo, e decidir a via mais adequada demanda o conhecimento dos limites da instituição, da equipe, da paciente, além de estudo aprofundado sobre o tema e, logicamente, experiência com esse cuidado.

As informações que geram evidências em medicina devem ser interpretadas com cuidado antes de serem adaptadas à prática diária, e a pouca valorização delas em prol da experiência pessoal pode tornar qualquer debate técnico em um “como eu faço”, que, se por um lado, pode perder em validade científica, é rico em detalhes que só o estado de arte pode promover. Por esta razão que o bom anestesiologista deve sempre se preocupar em avaliar a qualidade do serviço que ele oferece, seja por refino bibliográfico ou próprio.

Autor:

Referências:

  • Sociedade Americana de Anestesiologia (www.asahq.or), em Practice Guidelines for Obstetric Anesthesia
  • Sociedade Brasileira de Anestesiologia (www.sbahq.org)
  • Acta Anesthesiol Scand. 2005 Aug; 49 (7): 1023-9
  • Anaesthesia. 2017 Sep; 72 (9): 1155-1156
  • Electron Physician. 2017 Dec 25; 9 (12): 6002-6009
  • Clinical Medicine Insights (Efficacy and Safety of Remifentanil as an Alternative Labor Analgesic).
  • Rev Bras Anestesiol 2010; 60: 3: 334-346
  • Korean J Anesthesiol 2017 August 70(4): 412-419

#Droperidol tops #midazolam for #acute behavioural disturbance

Postado em

  • Noticias Médicas Univadis

New research suggests droperidol is superior to midazolam for the prehospital management of acute behavioural disturbance.

With backing from the Emergency Medicine Foundation (EMF) Australasia, the Queensland Ambulance Service (QAS) in Australia has conducted the world’s first comparison of midazolam with droperidol in a prehospital setting. The study revealed that droperidol was associated with fewer adverse events, a shorter time to sedation, and fewer requirements for additional sedation.

In 2016, the QAS introduced droperidol as one of several initiatives to reduce escalating violence against paramedics. This new prospective study compared patient outcomes before and after the introduction of droperidol.

The data showed fewer adverse events with droperidol compared to midazolam (7% vs. 23%; absolute difference 16%; 95% CI 8-24%; P=.0001). Median time to sedation was 22 minutes with droperidol versus 30 minutes with midazolam. Additional prehospital sedation was required in 4 per cent of droperidol patients and 14 per cent of midazolam patients. Approximately 7 per cent of droperidol and 42 per cent of midazolam patients required further sedation in the emergency department. However, there were no differences in patient or staff injuries.

The authors predict that droperidol will now become extensively embedded in ambulance services around the world.

#Lumbar puncture needle type alters risk of complications

Postado em

While atraumatic needles have been proposed to lower complication rates following lumbar puncture, several surveys show that clinical adoption of these needles remains limited. Findings from a new study however suggest using atraumatic needles rather than conventional traumatic needles for lumbar punctures is not only as effective, but results in a significant decrease in complications. 

As part of a new study, published in The Lancet , researchers undertook a systematic review and meta-analysis of randomised controlled trials with more than 30,000 participants in 28 countries, comparing atraumatic and conventional needles. 

They found the incidence of post-dural puncture headache was significantly reduced from 11 per cent in the conventional needle group to 4.2 per cent in the atraumatic group. The need for intravenous fluid or controlled analgesia was lower with atraumatic needles (2.2 per cent vs 4.5 per cent) as was the requirement for epidural blood patch (1.1 per cent vs 3.0 per cent). Rates of failure and success on first attempt were similar for both needle types.

Writing in a linked commentary, Diederik van de Beek and Matthijs Brouwer, of the University of Amsterdam recommend clinicians “change practice” and begin using atraumatic needles for lumbar punctures. 

Nath S, Koziarz A, Badhiwala J et al. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta- analysis of randomised controlled trials. The Lancet. Published online 06 December 2017. DOI: 10.1016/S0140-6736(17)32451-0

Van de Beek D & Brouwer MC. Atraumatic lumbar puncture needles: practice needs to change. The Lancet. Published online 06 December 2017 DOI:10.1016/ S0140-6736(17)32480-7

#How to Diagnose Aortic Dissection Without Breaking the Bank

Postado em

By Anton Helman | on November 13, 2017

Living Art Enterprises / Science Source

Living Art Enterprises / Science Source
It used to be said that missing the clinical diagnosis of aortic dissection was “the standard” as it is rare and often presents atypically. The diagnosis rate of aortic dissection changed with the landmark International Registry of Acute Aortic Dissection (IRAD) study in 2000, which deepened our understanding of the presentation.1 Nonetheless, aortic dissection remains difficult to diagnose, with one in six missed at the initial ED visit.

Herein lies the difficulty. Aortic dissection must be considered in all patients with chest, abdominal, or back pain; syncope; or stroke symptoms. Yet, we shouldn’t be working up every one of them, creating a resource utilization disaster. However, early, timely diagnosis is essential because each hour that passes from the onset of symptoms correlates with a 1 percent to 2 percent increase in mortality.

In this column, I’ll elucidate how to improve your diagnosis rate, without overimaging, by explaining five pain pearls, the concepts of “CP +1” and “1+ CP,” physical exam nuances, and how best to initially utilize tests.

The Five Pain Pearls of Aortic Dissection

Ask the following three things of all patients with torso pain:
What is the quality of pain? (The pain from aortic dissection is most commonly described as “sharp,” but the highest positive likelihood ratio [+LR] is for “tearing.”)
What was the pain intensity at onset? (It is abrupt in aortic dissection.)
What is the radiation of pain? (It is in the back and/or abdomen in aortic dissection.)
A 1998 study that reviewed a series of aortic dissection cases showed that for the 42 percent of physicians who asked about these three things, the diagnosis was suspected in 91 percent. When fewer than three questions were asked, dissection was suspected in only 49 percent.2

Think of aortic dissection as the subarachnoid hemorrhage of the torso. Just like a patient who presents with a new-onset, severe, abrupt headache should be suspected of having a subarachnoid hemorrhage, if a patient describes a truly abrupt onset of severe torso pain with maximal intensity at onset, think aortic dissection.
If you find yourself treating your chest pain patient with IV opioids to control severe colicky pain, think about aortic dissection.
Migrating pain has a +LR of 7.6.1 In addition to the old adage, “Pain above and below the diaphragm should heighten your suspicion for aortic dissection,” severe pain that progresses and moves in the same vector as the aorta significantly increases the likelihood of aortic dissection.
The pain can be intermittent as dissection of the aortic intima stops and starts. The combination of severe migrating and intermittent pain should raise the suspicion for aortic dissection.
Painless Aortic Dissection

While IRAD reported a painless aortic dissection rate of about 5 percent, a more recent study out of Japan reported that 17 percent of aortic dissection patients had no pain.3 These patients presented more frequently with a persistent disturbance of consciousness, syncope, or a focal neurological deficit. Cardiac tamponade was more frequent in the pain-free group as well.

The Concepts of “CP +1” and “1+ CP”

The intimal tear in the aorta can devascularize any organ from head to toe, including the brain, heart, kidneys, and spinal cord. Thus, 5 percent of dissections present as strokes, and these certainly are not the kind of stroke patients who should be receiving tPA! An objective focal neurologic deficit in the setting of acute, unexplained chest pain (CP) has +LR of 33 for aortic dissection, almost diagnostic. Some of the CP +1 phenomena to think about include torso pain, cerebrovascular accident, paralysis, hoarseness (recurrent laryngeal nerve), and limb ischemia.

These three coronal reconstructions from contrast enhanced CT angiograms of the chest show an extensive dissection of the thoracic aorta. This is a De Bakey type I or Standord A aortic dissection.

(click for larger image) These three coronal reconstructions from contrast enhanced CT angiograms of the chest show an extensive dissection of the thoracic aorta. This is a De Bakey type I or Standord A aortic dissection.
Source: Living Art Enterprises / Science Source
In addition to thinking of CP +1, it may help to think backwards in time (1+ CP) and ask patients who present with end-organ damage if they had torso pain prior to their symptoms of end organ damage. For example, ask patients who present with stroke symptoms if they had torso pain before the stroke symptoms.

Anyone under the age of 40 years who presents to the emergency department with unexplained torso pain should be asked if they have Marfan syndrome. In the IRAD analysis of those under 40 years, 50 percent of the aortic dissection patients had Marfan syndrome, representing 5 percent of all dissections.1

Look. The patient doesn’t always know they have Marfan syndrome, so you need to look for arachnodactyly (elongated fingers), pectus excavatum (sternal excavation), and lanky limbs.
Listen. A new aortic regurgitation murmur has a surprisingly high +LR of 5.
Feel. Feel for a pulse deficit, which has a +LR of 2.7, much higher than that of interarm blood pressure differences.
The patient’s blood pressure needs to be interpreted with caution and insight. Do not assume that the patient with a normal or low blood pressure does not have an aortic dissection. We know from the IRAD data that only about half of patients are hypertensive at initial presentation. Patients with aortic dissections that progress into the pericardium, resulting in cardiac tamponade, are often hypotensive. Patients with dissection who have a wide pulse pressure should be considered preterminal and usually require immediate surgery.

There is a lot more to chest radiograph interpretation for suspected aortic dissection than looking for a wide mediastinum. One-third of chest radiographs in aortic dissection are normal to the untrained eye, and a common pitfall is to assume that if the chest X-ray is normal, the patient does not have an aortic dissection. There are about a dozen X-ray findings associated with dissection, but two of them are especially important: loss of the aortic knob/aortopulmonary window and the calcium sign.

Look for a white line of calcium within the aortic knob, then measure the distance from there to the outer edge of the aortic knob. A distance >0.5 cm is considered a positive calcium sign, and a distance >1.0 cm is considered highly suspicious for aortic dissection. It is always wise to compare to an old film to see if there’s been an interval change.

Eighteen percent of patients with aortic dissection will have a positive troponin test, so if you suspect the diagnosis based on other clinical findings, don’t assume isolated acute coronary syndrome when the troponin comes back positive.5 Remember that fewer than one in 100 patients with a dissection will have associated coronary ischemia in any coronary distribution (most commonly inferior).

While D-dimer seems like it might be appealing to help rule out the diagnosis in low-risk patients, for such a rare diagnosis and poor test characteristics of D-dimer for dissection, guidelines do not recommend the use of D-dimer for the workup of aortic dissection.6

Aortic dissection can be considered the retinal detachment of the torso. While the sensitivity of point-of-care ultrasound (POCUS) by emergency physicians to detect an intimal flap is only 67 percent, the specificity has been shown to be 99 percent to 100 percent.7 For patients suspected of the diagnosis, look for an intimal flap that looks similar to a retinal detachment on POCUS and look for a pericardial effusion indicative of a retrograde dissection into the pericardium.8

Take-Home Points

Remember the big pain pearls when taking a history:
Ask the three important questions.
Aortic dissection should be considered the subarachnoid hemorrhage of the torso.
Migrating pain, colicky pain, plus need for IV opioids should raise your suspicion.
Intermittent pain can still be a dissection.
Look for Marfan syndrome, listen for an aortic regurgitation murmur, and feel for a pulse deficit.
Think not only about CP +1 but also 1+ CP.
Know the radiographic findings of loss or aortic knob/aortopulmonary window and the calcium sign, and use POCUS to look for an intimal flap and pericardial effusion.
Don’t be misled by a troponin or D-dimer.
Thanks to David Carr for his expert contributions to the EM Cases podcast that inspired this article.

 

References

Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897-903.
Rosman HS, Patel S, Borzak S, et al. Quality of history taking in patients with aortic dissection. Chest. 1998;114(3):793-795.
Imamura H, Sekiguchi Y, Iwashita T, et al. Painless acute aortic dissection: diagnostic, prognostic and clinical implications. Circ J. 2011;75(1):59-66.
Singer AJ, Hollander JE. Blood pressure: assessment of interarm differences. Arch Intern Med. 1996;156(17):2005-2008.
Leitman IM, Suzuki K, Wengrofsky AJ, et al. Early recognition of acute thoracic aortic dissection and aneurysm. World J Emerg Surg. 2013;8(1):47.
Diercks DB, Promes SB, Schuur JD, et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015;65(1):32-42.
Sobczyk D, Nycz K. Feasibility and accuracy of bedside transthoracic echocardiography in diagnosis of acute proximal aortic dissection. Cardiovasc Ultrasound. 2015;13:15.
Fojtik JP, Constantino TG, Dean AJ. The diagnosis of aortic dissection by emergency medicine ultrasound. J Emerg Med. 2007;32(2):191-96.