Volume 106, Issue 12

Context: Epidural anesthesia for labor pain is frequently complicated by maternal hypotension. Objective: To test whether continuous epidural infusion (CEI) of local anesthetic, without bolus administration, lowers the incidence of hypotension in parturient patients. Methods: In a single-blind clinical study, subjects were randomly assigned to CEI-only (10 mL/h of 0.2% ropivacaine hydrochloride without bolus) or control (10 mL of 0.2% ropivacaine hydrochloride per hour with 10-mL bolus) epidural dosing groups. The incidence of hypotension (20% decrease in systolic blood pressure or mean arterial pressure (MAP), systolic blood pressure lower than 100 mm Hg, or MAP lower than 65 mm Hg) was recorded for 2 hours after dosing. Statistical analysis included a 2×2 χ 2 analysis, the Fisher exact test, and paired two-tailed t tests. Results: Fifty subjects were studied, with 25 randomly assigned to each study group (CEI-only vs control). Baseline blood pressure was not different between groups (CEI-only, 127 [11]/77 [8.7] mm Hg; control, 131 [14]/78 [2]). The incidence of hypotension was lower in the CEI-only group than in the control group (5 [20%] vs 15 [60%]; P =.009), with intervention required in 1 (20%) of 5 CEI-only subjects and 7 (47%) of 15 control subjects. Sensory block reached the T10 dermatome in 54.4 (18) minutes in the CEI-only group and 38 (24) minutes in the control group ( P =.04). Pain scores and maternal and fetal pulse rates were not different between groups. Analgesic supplementation (250 μg of epidural fentanyl) was used more frequently in the CEI-only group (72% vs 32%; P =.01), without adverse effects. Conclusions: Continuous epidural infusion of 0.2% ropivacaine hydrochloride without bolus administration reduces the incidence of hypotension by 67% and is safer than traditional bolus dosing for routine labor. This method requires further study in high-risk patients, including those with preeclampsia and cardiovascular disease.

Diffuse malignant mesothelioma is the most common primary tumor involving the pleura. Unfortunately, it also poses the most difficulty for physicians to diagnose and treat. Latency from the time of initial asbestos exposure, clinical features of chest pain and dyspnea, and radiographic findings of pleural effusion or pleural thickening are the characteristic features. Pathologic verification remains challenging. The primary distinctions to be made are between reactive and neoplastic mesothelial processes and between malignant mesothelioma and metastatic adenocarcinoma. Adequate tissue sampling is important to help diagnose malignant mesothelioma. This article describes a rare subtype of mesothelioma and illustrates the difficulty in establishing the diagnosis. Also included is a discussion of the clinical features, diagnostic dilemmas, and unsatisfactory outcome associated with this disease.

Recent advances in molecular biology have provided physicians with genetic testing strategies that can be used to predict adverse drug reactions (ADRs). Many ADRs can be linked to single-nucleotide polymorphisms in genes that control aspects of drug disposition. We report a case in which a standard dose of methotrexate resulted in life-threatening mucositis, neutropenia, and thrombocytopenia in a 61-year-old woman. The patient was found to have a genetic anomaly in an enzyme that plays a key role in folate metabolism. Methotrexate is known to deplete folate levels. As data accumulate and genetic testing strategies improve, it should be possible to predict ADRs in individual patients, thereby resulting in better patient care and a reduction in medical expenditures.

Context: The policy of the American Osteopathic Association (AOA) on the approval of allopathic residency training has evolved since the mid-1980s, when such a policy became necessary because of the low number of osteopathic medical residency positions compared with the number of students graduating from colleges of osteopathic medicine. Resolution 42 (A/2000), the Approval of ACGME (Accreditation Council on Graduate Medical Education) Training as an AOA-Approved Internship, requires that trainees justify a special circumstance requiring them to seek ACGME-accredited training, and complete all rotational requirements of an AOA-approved osteopathic internship. Objective: To examine the evolution of AOA approval of allopathic residency training and to present the available data on Resolution 42 as it points to the future of osteopathic graduate medical education (OGME). Methods: An electronic review of the literature was conducted using Medline, the search engine on the JAOA 's Web site, and Google. Bibliographies from relevant articles were used to find related citations, and further searches were done using the names of authors of major articles on OGME. Finally, the AOA's database of Resolution 42 petitions was cross-referenced with the AOA's membership database. Results: Nine hundred thirty-seven trainees had applied for Resolution 42. Almost two thirds of the applicants were in family medicine and internal medicine residency programs, and most (55%) programs were in six states: New York, Illinois, Ohio, California, Pennsylvania, and Texas. The special circumstance most documented was location preference. Conclusion: The sustained advancement of the osteopathic medical profession is dependent on OGME and accreditation policy. By regularly assessing the achievements of policies and programs, educators can better shape the future of osteopathic medicine.