bluuebunny/crossref_metadata_2025 huggingface dataset:
Urinary adrenomedullin levels are increased and correlated with plasma concentrations in patients with Behçet's syndrome
Authors: Evereklioglu Cem , Özbek Emin , Er Hamdi , Çekmen Mustafa , Yürekli Muhittin
Published: March 2003

Background: The objective was to measure urinary adrenomedullin (AM) levels in patients with active or inactive Behçet's syndrome and compare them to levels in healthy control subjects.

Methods: Forty‐five consecutive patients with Behçet's syndrome (20 men and 25 women with a mean age of 37.7 ± 10.8 years) and 20 age‐ and sex‐matched healthy hospital staff volunteers as control subjects (nine men and 11 women with a mean age of 36.2 ± 10.4 years) were studied. Urinary and plasma AM concentrations were measured by high‐performance liquid chromatography. We also investigated whether disease activity correlates with urinary and plasma AM levels. The Mann–Whitney U‐test was used in statistical analysis and the values were expressed as mean ± SD.

Results: Urinary excretion of AM (pmol per mg urinary creatinine) in patients with Behçet's syndrome (81.3 ± 35.1) was significantly higher (P < 0.001) than in control subjects (31.2 ± 16.1). Plasma AM levels (pmol/L) in patients with Behçet's syndrome and controls were 69.1 ± 19.2 and 20.7 ± 11.8, respectively; the difference was significant (P < 0.001). Although active Behçet's syndrome patients (n = 22) had higher urinary AM levels (92.1 ± 41.1) compared to inactive (n = 23; 70.8 ± 32.2), the difference was not significant (P > 0.05). Plasma AM levels in active Behçet's syndrome patients (77.5 ± 21.2) were also higher than in inactive (61.6 ± 17.3), but the difference was not significant (P > 0.05).

Conclusion: Urinary AM levels were higher in Behçet's patients than in control subjects. Urinary AM levels were correlated with plasma AM levels. The results suggest that the higher AM levels found in the urine may be produced by the kidney as a result of the stimulation of inflammation during the course of Behçet's syndrome, or may come from plasma, as plasma AM levels were increased. However, the exact sites of AM synthesis by the kidney (e.g. glomeruli, blood vessels and/or tubular cells) could not be determined in this study. Further studies in this respect are necessary.
Neoadjuvant androgen withdrawal prior to external radiotherapy for locally advanced adenocarcinoma of the prostate
Authors: Hara Isao , Miyake Hideaki , Yamada Yuji , Takechi Yoshizumi , Hara Shoji , Gotoh Akinobu , Fujisawa Masato , Okada Hiroshi , Arakawa Soichi , Soejima Toshinori , Sugimura Kazuro , Kamidono Sadao
Published: March 2003

Background: It is unclear whether positive interactions between radiation and androgen withdrawal for patients with locally advanced prostate cancer is synergistic or additive. The present study aimed to clarify the significance of neoadjuvant androgen ablation prior to external radiotherapy in a human prostate LNCaP tumor model and in patients with locally advanced prostate cancer.

Methods: Comparisons were made between the effect of castration prior to radiation on the growth of subcutaneous LNCaP tumors implanted into male nude mice and their serum prostate‐specific antigen (PSA) levels, and the results of castration or radiation alone. Twenty‐nine patients with histologically proven and locally advanced adenocarcinoma of the prostate were treated with luteinizing hormone‐releasing hormone analog at least 3 months before, during, and after external radiation therapy with a total dose of 70 Gy. The toxicity and response to this therapy were evaluated.

Results: Treatment combining castration and radiation resulted in synergistic inhibition of LNCaP tumor growth and a significant delay in the emergence of androgen‐independent recurrence as opposed to either treatment alone. The external radiotherapy was completed in 28 patients (96.6%), resulting in a reduction of serum PSA levels in all 28 patients to below 1.0 ng/mL. All patients were alive after a mean follow‐up period of 34 months (range 11–53) with a 3‐year PSA relapse‐free survival rate of 83.7%. Among several factors examined, only the Gleason score was significantly associated with PSA relapse‐free survival in univariate analysis, but not in multivariate analysis. Thirteen of 28 patients (46%) and 7 of 28 (25%) also showed at least one form of gastrointestinal or genitourinary toxicity, respectively. Of these patients, 8 with gastrointestinal toxicities, and 1 with genitourinary toxicity, experienced acute complications higher than grade 3.

Conclusion: The experimental findings objectively suggested the use of neoadjuvant androgen withdrawal prior to radiation therapy. Although our clinical experience is preliminary, combined androgen ablation and radiation therapy may also be effective in controlling locally advanced prostate cancer, with tolerable side‐effects.
Factors associated with failure of extracorporeal shock‐wave lithotripsy for ureteral stones using Dornier lithotripter U/50
Authors: Shiroyanagi Yoshiyuki , Yagisawa Takashi , Nanri Masayuki , Kobayashi Chika , Toma Hiroshi
Published: March 2003

Background : In the present series of 170 patients who underwent extracorporeal shock‐wave lithotripsy (SWL) treatment for ureteral stones, the authors determine which patients with ureteral stones had an unsuccessful outcome.

Methods: The records of 170 patients with ureteral stones who were treated with SWL using the Dornier lithotriptor U/50 (EMSE 140) between January 1998 and December 1999 were retrospectively investigated. One hundred and thirty‐one patients were treated with SWL alone (single session, n = 98; multiple session, n = 33) and 39 patients required auxiliary treatment due to failure of SWL (33 with transurethral ureterolithotripsy (TUL), one with open lithotomy, and five with residual fragments who were followed up). These two groups were compared using multivariate logistic regression analysis.

Results : Lower ureteral stones and stones more than 12 mm in diameter were associated with a poor outcome of SWL. There were no significant differences in age, gender, number of stones, JJ stent placement, and degree of ureteral obstruction due to the stone between the two groups. The odds ratios of lower ureteral stones and stones ≥ 12 mm were 4.18 and 2.57, respectively.

Conclusion : Patients with distal ureteral stones and/or stones more than 12 mm in diameter were difficult to treat successfully with SWL. Alternatives such as TUL should possibly be considered as a first‐line therapy for these stones.
Surgical reconstruction of exstrophy–epispadias complex: Analysis of 13 patients
Authors: Sujijantararat Phichaya , Chotivichit Areesak
Published: March 2003

Background : Because exstrophy–epispadias complex is uncommon and satisfactory surgical reconstruction outcomes are difficult to achieve, the surgical repairs by one surgeon (PS) were analysed over a 14‐year period.

Methods : Retrospective analysis was performed on 13 patients with the complex who underwent surgery between January 1986 to August 2000. Cosmesis and continence were evaluated. Complications including wound dehiscence and urethrocutaneous fistula were reported.

Results : Of six patients with classical exstroply who underwent functional bladder closure, all had good cosmesis except one who had partial dehiscence. Four patients with isolated epispadias had satisfactory cosmesis. Urethrocutaneous fistula was found in one boy in the classical exstrophy group. Continence was achieved in three out of four patients who had bladder neck reconstruction. One girl whose bladder neck was severely obstructed after functional bladder closure, had continent catheterizable stoma.

Conclusion : Functional bladder closure yielded satisfactory cosmetic outcome. Bladder neck reconstruction made the patient dry in 75% of cases.
Massive hematuria after cystoscopy in a patient with an internal iliac artery aneurysm
Authors: Honma Ichiya , Takagi Yoshio , Shigyo Masanori , Sunaoshi Kenichi , Inaoka Masami , Miyao Noriomi
Published: March 2003

An unusual case is reported here of a patient with internal iliac artery aneurysm who developed massive hematuria after cystoscopic examination. A 75‐year‐old man presented with asymptomatic gross hematuria. Cystoscopic examination revealed that the bladder neck was congested and that the right‐side wall was being pressed on by an extrinsic mass. Computed tomography showed a right internal iliac artery aneurysm and tortuous perivesical vessels. Three days after the cystoscopic examination the patient suffered massive hematuria. Hemorrhage due to an arteriovesical or arterio‐ureteral fistula secondary to rupture of the internal iliac artery aneurysm was suspected, and an emergency operation was performed. At operation the aneurysm had not ruptured but overswelling perivesical vessels were found to have developed, and these fed a high blood flow to the bladder neck. In the present case cystoscopic examination injured the mucosa and led to massive hemorrhage from the bladder neck.
Health‐related quality of life of ileocecal rectal bladder compared with ileal conduit diversion: A questionnaire survey
Authors: Satoh Shigeru , Sato Kazunari , Habuchi Tomonori , Matsuo Shigeki , Sasaki Shuhei , Kato Tetsuro
Published: March 2003

Background : The ileocecal rectal bladder (IRB) after cystectomy has been devised, in which continence is controlled by the anal sphincter. To assess how this procedure influences postoperative health‐related quality of life (QOL), IRB patients were compared with ileal conduit (IC) patients using a questionnaire mail‐out.

Methods : The questionnaire consisted of 35 questions. The questions were multiple choice and the answers were rated on a Linkert rank‐type four‐point scale. The IRB operation was performed on 29 patients between March 1990 and July 1998. The questionnaire was mailed to 21 of 29 IRB and 34 IC patients, who underwent either operation during the same period and had no persistent or recurrent tumor. Statistical analysis was performed by Mann–Whitney U‐test.

Results : All 21 IRB patients (100%) and 24 IC patients (71%) responded to the questionnaire. The mean age and follow‐up time of both groups were not significantly different. The IRB group had better scores in many items, especially, in those of self‐care, turning over freely during sleep, and tension. However, 43% of IRB patients used pads for small amounts of incontinence (spotting) and worried about flatus.

Conclusion : These findings show that many functional and symptomatic health‐related QOL sores are better after IRB and support the use of this procedure of urinary diversion for selected patients.
Potential benefits of combining cytosine deaminase/5‐fluorocytosine gene therapy and irradiation for prostate cancer: Experimental study
Authors: KATO HIROAKI , KOSHIDA KIYOSHI , YOKOYAMA KUNIHIKO , MIZOKAMI ATSUSHI , NAMIKI MIKIO
Published: March 2003

Background:  The purpose of this study was to investigate the potential of combining cytosine deaminase/5‐fluorocytosine (CD/5‐FC) gene therapy and radiation therapy (either external beam radiation or radioimmunotherapy [RIT]), for the treatment of prostate cancer.

Methods: Tumor xenografts of CD‐transduced LNCaP cells grown in the testes of severe combined immunodeficiency (SCID) mice were used to evaluate antitumor effect. The mice were injected intraperitoneally with 500 mg/kg of 5‐FC, or with 5, 15 or 30 mg/kg of 5‐fluorouracil (5‐FU), for 9 days. The tumors were treated with fractionated radiation at a dose of 1 or 3 Gy/day for 3 days, or I‐131 labelled anti‐prostate specific antigen (anti‐PSA) monoclonal antibody (mAb) administration at a subtherapeutic dose of 20 or 80 µCi. Intratumoral and serum concentrations of 5‐FU were measured using high performance liquid chromatography.

Results: Mice treated with CD/5‐FC gene therapy presented a significant tumor growth inhibition comparable to that obtained with 15 mg/kg, 5‐FU systemic administration without marked weight loss. Treatment with CD/5‐FC gene therapy resulted in higher tumor but lower serum concentrations of 5‐FU than treatment with systemic 5‐FU chemotherapy. An additive antitumor effect was obtained when CD/5‐FC therapy was combined with 1 Gy irradiation, which by itself did not produce a significant antitumor effect. However, the efficacy of CD/5‐FC therapy was not enhanced when combined with RIT, probably due to poor accumulation of the mAb as the tumor/blood ratio never exceeded 1.

Conclusion: These findings indicate that CD/5‐FC gene therapy for prostate cancer may function with enhanced antitumor effect when combined with external beam radiation. However, combining CD/5‐FC gene therapy and RIT using an anti‐PSA mAb may not be effective because of insufficient accumulation of the mAb at the target tumors.
Feasibility and usefulness of laparoscopic radical prostatectomy: Kobe University experience
Authors: Hara Isao , Kawabata Gaku , Miyake Hideaki , Hara Shoji , Fujisawa Masato , Okada Hiroshi , Arakawa Soichi , Kamidono Sadao
Published: March 2003

Objectives: The objective of this study was to present the clinical outcomes of 26 patients who underwent laparoscopic radical prostatectomy at our institution.

Methods: We performed laparoscopic prostatectomy on patients who were clinical stage T1 or T2. The mean age was 70 years old (range: 52–76). The mean level of pre‐treatment prostate‐specific antigen (PSA) was 8.7 ng/mL (range: 3.3–45). The Gleason score of the needle biopsy was < 7 in 21 patients and ≥ 7 in five patients. Clinical stage was T1c in 17 patients, T2a in 6 patients and T2b in 3 patients. Operative techniques followed those of the French groups. Five trocars were introduced into the peritoneal cavity. The vas deferens and seminal vesicles were dissected to reach the posterior wall of the prostate and the retroperitoneal space was dissected around the urinary bladder. Incision of endopelvic fascia and dorsal vein complex (DVC) ligation were performed. The bladder neck and prostate were divided, then the distal urethra was cut. The lateral pedicles of the prostate were cut and the entire prostate was removed. Vesico‐urethral anastomosis was performed at eight points.

Results: Mean operation time was 7 h 30 min. Mean bleeding volume (including urine volume) was 850 mL (range: 32–3135). All patients underwent autologous blood transfusion. Only one patient required further blood transfusion. Gleason scores of resected specimens were < 7 in 10 patients, and ≥ 7 in 16 patients. Pathological stage was T0 in 1 patient, T2a in 6 patients, T2b in 13 patients, T3a in 5 patients and T3b in 1 patient. The PSA value was undetectable in all patients one month after surgery. Ten patients who survived for 6 months after surgery had complete urinary continence without a pad. In 7 of the 12 patients who were potent before surgery, neurovascular bundles were preserved, and 5 of them (71%) achieved complete or incomplete erection 3 months after surgery. However, only one patient (14%) could have sexual intercourse.

Conclusion: Although longer follow‐up is necessary to evaluate this surgical technique, laparoscopic prostatectomy seems to be a reasonable option in the treatment of organ‐confined prostate cancer.
Advanced renal cell carcinoma in which a combination of IFN‐α and meloxicam was thought to be effective
Authors: YOSHINO SHUJI , OKABE TADASHI
Published: March 2003

An 83‐year‐old man with left renal cell carcinoma (RCC; pT4N0M0) was treated with postoperative combined subcutaneous injection therapy of alpha interferon (IFN‐α) and IFN gamma‐1a (IFN‐γ‐1a). Metastasis to the pleura occurred 3 months after surgery. The metastatic lesion grew while the treatment was changed to intramuscular injection of IFN‐α‐2b due to the presence of severe general malaise, which seemed to be caused by IFN‐α and IFN‐γ therapy. As melosalgia associated with sciatica was also severe, treatment with meloxicam, which is known as a potent cyclooxigenase‐2 inhibitor among commercially available non‐steroidal anti‐inflammatory drugs, was combined, resulting in significant improvement in activity of daily life, 43.2% decrease in the size of the pleural metastasis and complete regression of retroperitoneal residual tumor.
Cyclooxygenase inhibitors: any reservations?
Authors: Penglis P. S. , James M. J. , Cleland L. G.
Published: March 2003

The discovery of two cyclooxygenase isozymes, constitutive COX‐1 and inducible COX‐2, has resulted in the rapid development of selective inhibitors of COX‐2, such as celecoxib and rofecoxib. Compared with traditional non‐steroidal anti‐inflammatory drug agents, use of COX‐2 selective inhibitors is associated with decreased incidence of adverse gastric events as a result of minimal inhibition of gastroprotective COX‐1, but with equivalent anti‐inflammatory benefit through inhibition of COX‐2. However, there is evidence to suggest that the ‘COX‐1 = constitutive, COX‐2 = inflammatory’ paradigm is less distinct than originally proposed. Futhermore, selective COX‐2 inhibitors may have other consequences as a result of the change in the eicosanoid profile. Thus, despite the relatively safe gastrointestinal profile, vigilant post‐marketing surveillance for other adverse effects is required. (Intern Med J 2001; 31: 37–41.
Checking the scoreboard: the impact of cancer genetics on clinical practice
Authors: Ward R. L. , Hawkins N. J.
Published: March 2003

Improvements in cancer care have historically been predicated on significant scientific and technological advances, such as antisepsis in surgery, and the discovery of the therapeutic benefits of radiation and chemotherapeutic drugs. The past 30 years have seen an exponential increase in our knowledge of the biology and genetics of cancer, built on a massive and sustained research effort worldwide. Yet over the same period, significant changes in cancer outcomes have occurred largely as a result of public health measures and through incremental advances in existing technologies. The present paper examines the extent to which the new knowledge of cancer genetics has impacted on current patient care. It considers some of the issues that may have served to lessen this impact, as well as some of the reasons for this apparent imbalance between action and outcome. (Intern Med J 2001; 31: 249–253)
The oratory of addiction: a 30‐year perspective on alcohol and drug misuse
Authors: Mackay I. R.
Published: March 2003

The annual Leonard Ball Orations illustrate changing perspectives in Australia over 30 years on medical and social effects of misuse of alcohol and other substances. The first oration, in 1968, examined causal factors in the context of ‘agent’, ‘purveyor’ and ‘host’ and provided themes for subsequent orators. In regard to the agent (alcohol), it was proposed that availability (and cost) determined not only overall consumption within the community, but also numbers of users at hazardous levels. This principle seemed applicable to substance misuse and addictive behaviours overall. The influence of purveyors (and advertisers) was discussed with expectedly different perspectives from the liquor industry and social and health‐care providers. The role of host was examined in terms of genetic predisposition, foreshadowing current experimental applications of gene transfer and disruption technologies in mice to substance misuse and the promise of the Human Genome Project in clarifying inheritance of substance misuse. Individual successes in harm reduction were described in the context of alcohol and road trauma, smoking prevention and heroin addiction. Government intervention was introduced with the 1987 National Campaign Against Drug Abuse. The focus shifted during the 1980s from alcohol to addictive drugs, in line with community concerns. The 1996 oration on the aborted Canberra trial of supervised heroin administration illustrated the need for, and problems associated with, such studies. The prescience and achievements of the Ball orators provide optimism and direction for efforts in the future. (Intern Med J 2001; 31: 357–363)
Human immunodeficiency virus–hepatitis C coinfection: swapping new problems for newer ones
Authors: Sasadeusz J.
Published: March 2003

Abstract Recent successes in HIV therapy have uncovered other health problems for HIV‐infected individuals. Hepatitis C has become an especially significant problem, partly due to its faster progression in an immunocompromised setting. In addition, the higher viral loads in coinfected patients likely result in more efficient perinatal and perhaps even sexual transmission. Therapy has largely been neglected, despite data suggesting its efficacy in HIV–HCV coinfected patients. Studies of combination interferon and ribavirin studies are lacking, although underway. A major concern is the potential inactivation of certain thymidine analogues by ribavirin. Some antiretroviral therapies, such as ritonavir, indinavir and nevirapine, may enhance liver toxicity in coinfected patients and should be avoided if possible. The role of chronic low‐grade liver function abnormalities remains uncertain and requires further investigation. (Intern Med J 2001; 31: 418–421)
Severe bronchial hyperreactivity as a sequel to(r)congenital diaphragmatic hernia
Authors: Skousgaard Søren G
Published: March 2003

Bronchial hyperreactivity may be a sequel to congenital diaphragmatic hernia (CDH). V/Q‐mismatch in these patients may aggravate the condition. A case history is presented of a 20‐month‐old girl, who on the second day of life survived surgery for a left CDH. Adrenaline intratracheally via the nasotracheal tube was given to break a condition of refractory bronchospasm and desaturation. In the case of refractory bronchospasm and desaturation adrenaline may be helpful due to its alpha‐receptor stimulation as this may inhibit bronchoconstriction, improve the V/Q mismatch and reduce pulmonary vascular resistance and mucosal swelling.
An unusual case of obstructive pulmonary oedema
Authors: Dillon  , Dearlove
Published: March 2003

A four‐year‐old boy was admitted to intensive care via casualty having suffered an apnoeic episode due to compression of his chest by a heavy cattle bar. A petechial rash was noted on the upper chest and arms. A chest radiograph showed pulmonary oedema which resolved over a few hours following positive pressure ventilation and positive end expiratory pressure. We believe this to be an unusual presentation of obstructive pulmonary oedemia (Negative Pressure Pulmonary Oedema).
Paediatric day case anaesthesia: estimate of its quality at home
Authors: Grenier  , Dubreuil  , Siao  , Meymat
Published: March 2003

The aim of this clinical audit was to evaluate the home recovery and complications of 104 daycase anaesthetized children, as well as parent satisfaction. A questionnaire, explained at the time of preoperative visit, was given to parents at hospital discharge and returned by mail. Opioids were administered in 19% of the children whereas regional anaesthesia was performed in 28% of cases. In the recovery room, 8% of them suffered pain. At home, pain was the main problem (25%) and vomiting and agitation were found in 9% and 6% of the cases respectively. Parents reported anxiety in 45% of cases, and 14% called their general practitioner. Nevertheless, 94% were satisfied with the anaesthetic. A clinical audit is useful in detecting management deficiencies. Quality of home recovery may be improved by: wider use of perioperative analgesia, systematic prescription of take‐home analgesia, designation of a hospital practitioner for advice, and closer collaboration with general practitioners.
Sublingual midazolam premedication in children: a dose response study
Authors: Khalil Samia , Philbrook Lisa , Rabb Mary , Wagner Kari , Jennings Chris , Chuang Alice Z , Lemak Noreen A
Published: March 2003

The purpose of this study was to evaluate various doses of sublingual midazolam premedication in children. In our prospective, double‐blind, placebo‐controlled trial, children (n=102, age range 12 to 129 months) scheduled for day surgery were randomized to receive either midazolam in one of three doses (0.25, 0.5, or 0.75 mg·kg−1) or placebo. Injectable midazolam was mixed with a thick grape syrup and placed under the tongue; the patient was asked to hold it as long as possible before swallowing. Children readily accepted the mixture. Analysing all patients randomized, none of the children receiving placebo vs 28% receiving 0.25 mg·kg−1 (P=0.02), 52% receiving 0.5 mg·kg−1 (P<0.001), and 64% receiving 0.75 mg·kg−1 (P<0.001) of midazolam showed satisfactory sedation (drowsy) at 15 min after administration. Children receiving the two higher doses of midazolam (0.5 and 0.75 mg·kg−1) accepted mask induction willingly, while the group receiving 0.25 mg·kg−1 resembled the placebo group (P<0.05).
Epidural analgesia for major neonatal surgery
Authors: Bösenberg Adrian T
Published: March 2003

Safe effective analgesia for neonates undergoing major surgery remains a challenge particularly in institutions where resources are limited. The experience in the use of epidural analgesia in 240 neonates weighing between 0.9–5.8 kg body weight (lumbar n=211, thoracic n=29) is reviewed. Dural puncture (n=1), convulsion(r)(n=1) and intravascular migration of catheter (n=1) were the only complications. In all cases effective analgesia was established intraoperatively. Postoperatively analgesia was maintained by intermittent ‘top‐ups’ (n=170) and continuous infusion (n=10). Skin epidural distance ranged between 3 and 12 mm (mean 6.0±1.7 mm) and did not correlate with the patients’ weight. Patients remained haemodynamically stable except occasional bradycardia below 100 (n=15) which was successfully managed with anticholinergics. The potential risks and benefits of epidural analgesia in this age group are discussed and arguments for intermittent ‘top‐up’ doses rather than continuous infusions presented.
Epidural anaesthesia and Familial Dysautonomia (the Riley Day syndrome). Three case reports
Authors: CHALLANDS J. , FACER E.
Published: March 2003

Epidural anaesthesia in Familial Dysautonomia (FD) or the Riley Day syndrome has not previously been reported. Three children with FD presenting for redo Nissen fundoplication were managed with epidural anaesthesia. Cases 1 and 2 had had their original Nissen fundoplication without epidural anaesthesia. In Case 3, FD had not yet been diagnosed when she had her first operation, and it was performed with epidural anaesthesia. The anaesthetic management of these cases with and without epidural anaesthesia is described and discussed.
Sevoflurane for controlled hypotension during spinal surgery: preliminary experience in five adolescents
Authors: TOBIAS JOSEPH
Published: March 2003

The physical properties of sevoflurane suggest that it may be a suitable agent for controlled hypotension. With its low blood:gas partition coefficient of 0.69, it has a rapid onset of action making it easy to rapidly control blood pressure. The current report outlines preliminary experience with sevoflurane for controlled hypotension during posterior spinal fusion in five adolescents. The patients ranged in age from 12 to 16 years and in weight from 49 to to 72 kg. The duration of controlled hypotension varied from two to three h. The expired sevoflurane concentration required to maintain the mean arterial pressure (MAP) at 55 to 65 mmHg varied from 2 to 4%. With sevoflurane, there was an increase in heart rate from baseline of 74±7 beats·min−1 to a maximum of 83±13 beats·min−1 (P=0.038). One patient required three intravenous doses of esmolol (10 mg each) for a heart rate in excess of 100 beats·min−1. Estimated blood loss varied from 300 to 850 ml. No patient received homologous blood. No excessive hypotension was noted with sevoflurane. No patient required calcium, alpha adrenergic agonists, or ephedrine for excessive hypotension. When controlled hypotension was no longer necessary, the sevoflurane concentration was decreased to 1%. After decreasing the sevoflurane to 1%, the time to return of the MAP to baseline varied from 4 to 8 min (5.6±1.8 min).
Transcutaneous CO2 tension effects of clonidine in paediatric caudal analgesia
Authors: DUPEYRAT ALINE , GOUJARD ETIENNE , MURET JANE , ECOFFEY CLAUDE
Published: March 2003

In adults, clonidine when added to bupivacaine, results in no detectable respiratory depressant effect except when carbon dioxide challenge is performed. However, to date no investigations have quantified this in children. Twenty‐four children (nine months to seven years) were randomized in a double‐blind study into two groups. After induction, a caudal block was performed with 1 ml·kg−1 0.25% bupivacaine. Clonidine 1 μg·kg−1 was added in the clonidine group, and 1 ml normal saline in the placebo group. Patients were monitored in the recovery room for three h from arrival to discharge with continuous pulse oximetry, respiratory rate, a trancutaneous CO2 tension (tcPCO2) every 15 min, and a four point sedation score every 30 min. Mean tcPCO2 and respiratory rate values were not different between the two groups. Apnoea and desaturation less than 97% were not observed. The sedation score decreased with time in both groups, and the score time interval was significantly higher in the clonidine group (P<0.05). All the patients left the recovery room with a sedation score of 1, excepting four in the clonidine group with a sedation score of 2. Clonidine 1 μg·kg−1 with 0.25% bupivacaine mixture in caudal analgesia in children did not induce an increase in tcPCO2 despite prolonged sedation.
Anaesthetic management of a patient with erythropoietic protoporphyria for ventricular septal defect closure
Authors: Asokumar Buvanendran , Kierney Catherine , James Timothy W. , Amato Joseph , Tumanmd Kenneth J.
Published: March 2003

Erythropoietic protoporphyria (EPP) is due to a deficiency in ferrochelatase required for haem synthesis. We describe the anaesthetic management of a seven‐year‐old with EPP undergoing closure of a haemodynamically significant ventricular septal defect. Photosensitivity in EPP patients is triggered at wavelengths near 400 nm and light‐excited porphyrins generate free radicals and singlet oxygen that lead to erythrocyte deformity and haemolysis. Stimuli that could trigger a porphyric crisis during anaesthesia and surgery were reduced by avoiding exposure to the sensitive 400 nm spectrum and using light sources covered with yellow acrylate filters in the operating room. Anaesthetic agents not previously associated with porphyric crisis were chosen. Whole blood priming of the extracorporeal circuit was performed to ensure adequate haemoglobin concentrations during the perioperative period.
Spinal anaesthesia and meningitis in former preterm infants: cause–effect?
Authors: Luz G , Büchele H , Innerhofer P , Maurer H
Published: March 2003

Meningitis associated with spinal anaesthesia is a rare but well‐known complication. We report on a case of fatal bacterial meningitis following spinal anaesthesia in a former preterm infant. The aetiology of this meningitis could not be established. Former preterm infants represent a high‐risk population because of their susceptibility to group B streptococcal meningitis at this age as documented in a second case. Therefore we discuss whether meningitis was consequential or coincidental with spinal anaesthesia and could have been prevented by more comprehensive preoperative laboratory screening or prophylactic antibiotics.
Guillain–Barré Syndrome: delayed diagnosis following anaesthesia
Authors: Jones Gareth D. , Wilmshurst Jo M. , Sykes Kim , Murdoch Ian A.
Published: March 2003

Guillain–Barré syndrome following anaesthesia or surgery is rare. Diagnosis is often delayed, which may lead to an increase in morbidity. There is now good evidence that early diagnosis and treatment reduces this morbidity. The two cases highlight the difficulties with diagnosis in the perioperative period and further discuss the aetiology, diagnostic features and complications of childhood Guillain–Barré syndrome.
Propofol‐nitrous oxideversussevoflurane‐nitrous oxide for strabismus surgery in children
Authors: Gürkan Yavuz , Kiliçkan Levent , Toker Kamíl
Published: March 2003

Vomiting is a common problem following strabismus surgery. We compared the effects of propofol‐N2O and sevoflurane‐N2O on the incidence of oculocardiac reflex and postoperative nausea and vomiting. Forty unpremedicated children, aged 3–15 years were randomly assigned to two groups of 20 patients. In group 1, anaesthesia was induced and maintained with propofol infusion(173 ± 41 μg·kg−1·min−1). In group 2, anaesthesia was induced with N2O (66%) in O2and incremental sevoflurane via face mask and maintained with sevoflurane. Both groups received 66% N2O in O2throughout surgery. The overall incidence of vomiting and antiemetic requirement in the first 24 h was significantly higher in sevoflurane‐N2O group than propofol‐N2O group (P< 0.05). The propofol‐N2O group had significantly more episodes of oculocardiac reflex than sevoflurane‐N2O group (P< 0.05). Propofol‐N2O anaesthesia results in a significantly lower incidence of postoperative vomiting, yet a significantly higher incidence of oculocardiac reflex.
Anaesthetic implications of thoracoscopic surgery in children
Authors: TOBIAS JOSEPH D.
Published: March 2003

As the equipment and technique have improved, minimally invasive surgery is being applied to younger and younger children. With the advent of this valuable surgical technique, there are also specific modifications necessary in the anaesthetic technique. When considering the anaesthetic implications of these patients, one must account for both the patient's underlying status as well as physiological derangements induced by the surgical procedure. The following article attempts to address and review the specific anaesthetic implications of thoracoscopic procedures in neonates, infants, and children including the preoperative evaluation, intraoperative care and monitoring, and postoperative issues including analgesia. The techniques of one‐lung anaesthesia, commonly required for thoracoscopy, are reviewed as well as consideration of the adverse effects which can occur during thoracoscopy including inadvertent intravascular CO2 embolism.
Preoperative hypoglycaemia, propranolol and the Jervell and Lange‐Nielsen syndrome
Authors: BAINES DAVID B. , MURRELL DAVID
Published: March 2003

The Jervell and Lange‐Nielsen syndrome is an autosomal recessive trait characterized by deafness and electrocardiographic changes. These changes include prolongation of the QT interval and T‐wave inversion. Treatment may include the use of β‐blockers to prevent the development of malignant ventricular arrhythmias and sudden death. We report a patient with this syndrome, who was receiving propranolol orally and who became hypoglycaemic during the preoperative fasting period prior to cochlear implantation.
The efficacy of pre‐ versus postsurgical axillary block on postoperative pain in paediatric patients
Authors: Altintas Fatiş , Bozkurt Pervin , İpek Neval , Yücel Akin , Kaya Güner
Published: March 2003

We compared the effects of pre‐ and postsurgical axillary block on pain after hand and forearm surgery in 55 children in a double‐blind randomized study. The successful blocks are reported here (n=49). Children aged 1–11 years and ASA I or II were allocated randomly to receive axillary block with 2 mg.kg−1 of 0.25% bupivacaine, either after induction but before the surgery (presurgical group, n=25) or immediately after surgery, before the end of anaesthesia (postsurgical, n=24). In all patients, a standard general anaesthesia technique was used. The Faces Pain Scale (FPS) and analgesic requirements were recorded for 24 h at various times after operation. Eight patients (32%) in the presurgical group and 20 patients (83.33%) in the postsurgical group did not require additional analgesic within the first 24 h after operation (P< 0.05). In patients who had pain during the observation period, the pain started 13.66±2.61 h in the presurgical group and 13.14±2.34 h in the postsurgical group after performing block (P> 0.05). The FPS scores were similar in both groups during the first 8 h in the postoperative period (P> 0.05). There was a significant difference at 10 h after surgery (P< 0.05). Cumulative FPS score was higher in the presurgical group (10.50±1.06) than in the postsurgical group (9.45±1.28) (P< 0.05), but both groups had effective analgesia overall, the mean FPS score being less than 2. Additional analgesic consumption was similar in these patients in both groups. A lower isoflurane concentration was used in the presurgical group (0.68%vs 1.72%, P< 0.001). We did not demonstrate the superiority of preemptive analgesia, but our results indicate that presurgical axillary block with 0.25% bupivacaine allows the use of inhalational anaesthetics at lower concentrations while providing a reasonably painless postoperative period.
Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery
Authors: Bridge Hilary S. , Montgomery Carolyne J. , Kennedy Ross A. , Merrick Pamela M.
Published: March 2003

This prospective double‐blind study was designed to assess the analgesic efficacy of ketorolac 0.5% ophthalmic solution compared with placebo in 30 healthy children undergoing extraocular muscle recession for correction of strabismus. After paracetamol 20 mg·kg–1 preoperatively, a standard anaesthetic was given. There were no significant differences in Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) and faces pain scale (FPS) scores, requirement for supplementary analgesia or in postoperative vomiting between the two groups over the following 24 h. This study did not demonstrate improved postoperative analgesia when topical ketorolac eye drops were given in addition to paracetamol. This observed lack of efficacy may reflect difficulties in the use of CHEOPS and FPS in this age group with this pain model.
Successful airway control with the laryngeal mask in an infant with Beckwith–Wiedemann syndrome and hepatoblastoma for central line catheterization
Authors: Goldman Luis J. , Nodal Concepción , Jimenez Esperanza
Published: March 2003

We present a case of an infant with severe macroglossia, hypoglycaemia and inguinal hernia associated with hepatoblastoma (Beckwith–Wiedemann syndrome) in which a laryngeal mask airway (LMA) was useful to secure the airway during central line insertion. Carbon dioxide monitoring through LMA proved effective to assess airway patency during positioning for central vein puncture. In this syndrome, where a potentially difficult airway may be encountered, LMA allowed adequate ventilation, avoiding the risk and inconvenience of tracheal intubation.
Pseudopolyp of the right laryngeal ventricle following atraumatic intubation: a diagnostic dilemma
Authors: Smith O. Daniel , Callanan Vincent , Lloyd‐Thomas Adrian , Albert David M.
Published: March 2003

The traumatic effects of tracheal intubation are well recognized. Whilst these usually follow prolonged intubation, acute lesions have been described, usually following a traumatic intubation technique. We present a case of acute, localized swelling of the right laryngeal ventricle which followed an entirely atraumatic intubation by an experienced paediatric anaesthetist. The lesion was not present at the time of intubation, but developed subsequently during the surgical procedure. Although previously observed at our institution, such lesions have not been described in the literature. The potential for a diagnostic pitfall, by mistaking the lesion for a laryngeal cyst or nodule, is discussed.
A case of pneumomediastinum in paediatric ARDS: to oscillate or not?
Authors: McGinley J , Corcoran T , Canny G , O'Hare B
Published: March 2003

An 18‐month‐old was transferred (intubated and ventilated) to our hospital with staphylococcal tracheitis, which progressed to a necrotizing pneumonitis, complicated by surgical emphysema and pneumomediastinum. Maximum conventional ventilation on a Servo 300 failed. Treatment with high frequency oscillatory ventilation (for 10 days) with a permissive hypercarbia and hypoxaemia strategy to limit mean airway pressure facilitated recovery in our patient.
Propofol as a sole agent for paediatric day care diagnostic ophthalmic procedures: comparison with halothane anaesthesia
Authors: Madan Rashmi , Kapoor Indu , Balachander S. , Kathirvel S. , Kaul H. L.
Published: March 2003

Background: Our aim was to study the feasibility of total intravenous anaesthesia with propofol in spontaneously breathing children undergoing ophthalmic procedures.

Methods: Fifty‐five children (aged 6 months to 5 years) were randomly allocated to receive either propofol bolus (until loss of eyelash reflex) followed by infusion [group P (n=29)] or halothane 3–4% for induction, followed by 1–2% in 70% nitrous oxide and oxygen via face mask [group H (n=28)]. Dose for induction and maintenance, intraoperative adverse events, time to recovery (on an Observer’s Assessment of Alertness/Sedation Scale, 5 at each level) and duration of procedure were recorded. All children in both groups, were anaesthetized successfully.

Results: 4.0 ± 0.7 mg·kg–1and 5.1 ± 1.0 mg·kg–1of propofol were required for loss of eyelash reflex and tolerance of the ophthalmic speculum, respectively. An infusion rate of 8.3 ± 1.7 mg·kg–1·h–1was needed for maintenance of anaesthesia; 3.4 ± 0.5%, 3.6 ± 0.4% and 1.4 ± 0.4% halothane was needed for induction, tolerance of the eye speculum and maintenance of anaesthesia, respectively. Induction and recovery were significantly faster with halothane compared with propofol [induction – 38.3 ± 6.6 s (group H)/60.9 ± 15.2 s (group P) (P < 0.001); recovery 12.8 ± 4.6 min (group H)/27.0 ± 23.3 min (group P) (P < 0.001)]. Apnoea, coughing and breath‐holding were seen only in group H. Group P had significantly higher incidence of involuntary movements (minor degree) (n=6) (P < 0.01).

Conclusions: Propofol is a feasible option for paediatric diagnostic ophthalmic procedures with the advantage over halothane of providing complete access to the eye.
Analgesia for circumcision in a paediatric population: comparison of caudal bupivacaine alone with bupivacaine plus two doses of clonidine
Authors: Sharpe P. , Klein J.R. , Thompson J.P. , Rushman S.C. , Sherwin J. , Wandless J.G. , Fell D.
Published: March 2003

Background: Clonidine is often used to improve the duration and quality of analgesia produced by caudal epidural blockade, although the optimum dose of clonidine with bupivacaine remains uncertain.

Methods: We compared the effect of clonidine, 1 and 2 μg·kg–1, added to bupivacaine (1.25 mg·kg–1) with that of bupivacaine alone in 75 male children undergoing elective circumcision.

Results: There was a trend towards increasing duration of analgesia with increasing dose of clonidine [group B (bupivacaine) 280.7 (171.6) min, C1 (bupivacaine + clonidine 1 μg·kg–1) 327.8 (188.3) min and C2 (bupivacaine + clonidine 2 μg·kg–1) 382.0 (200.6) min], although this difference was not statistically significant. Mean time to arousal from anaesthesia was significantly prolonged with clonidine 2 μg kg–1 (group C2 21.3 (13–36) min, group C1 14.0 (6–25) min and group B 14.4 (2–32) min. Supplementary analgesic requirements and incidence of adverse effects were low, with no differences between the groups.

Conclusions: For paediatric circumcision, under general anaesthesia, the addition of clonidine 2 μg·kg–1 to low volume (0.5 ml·kg–1) caudal anaesthetics has a limited clinical benefit for children undergoing circumcision.
The analgesic efficacy of preoperative high dose (40 mg·kg–1) oral acetaminophen after bilateral myringotomy and tube insertion in children
Authors: BOLTON PHILLIP , BRIDGE HILARY S , MONTGOMERY CAROLYNE J , MERRICK PAMELA M
Published: March 2003

Background: The purpose of this study was to measure the plasma levels and analgesic effectiveness of a dose of 40 mg·kg–1 of preoperative oral acetaminophen.

Methods: Thirty children aged 55 (17–72) months undergoing bilateral myringotomy and tube insertion (BMT) received acetaminophen 40 mg·kg–1 p.o. preoperatively. Plasma levels were measured, at 29 (10–51) min and at 60 min in the postanaesthesia care unit (PACU). Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), for all subjects and the Poker Chip Tool (PCT) a self‐report scale for subjects aged > 4 years, were used. After discharge, 24‐h analgesic efficacy was evaluated using an observer Visual Analogue Scale (VAS) score and further acetaminophen use was recorded.

Results: Plasma concentrations were 259 (60–391) μmol·l–1 and 250 (135–450) μmol·l–1, respectively. All 60 min plasma concentrations were ≥ 70 μmol·l–1 (ED50 for adenotonsillectomy) and less than 800 μmol·l–1 (associated with toxicity). Twenty‐six subjects (87%) had adequate analgesia (CHEOPS ≤ 8). The PCT was only understood in the PACU by 13 of the 21 children > 4 years (62%). The median worst 24‐h observer VAS was 0.5 (0–5.5) (27 subjects). No further analgesic was required after discharge in 16/28 (57%). A higher plasma level was associated with fewer doses of acetaminophen after discharge (r=–0.36, P=0.05).

Conclusions: No relationship was evident between age, the 60 min plasma acetaminophen level and the CHEOPS carried out at the same time. Acetaminophen 40 mg·kg–1 p.o. results in 60 min plasma levels of 250 (135–450) μmol·l–1. The in‐hospital analgesic efficacy was 87% (CHEOPS < 9, no further analgesics) and the 24‐h efficacy was 57% (need for further acetaminophen).
Effect of general and epidural anaesthesia on thyroid hormones and immunity in neonates
Authors: GASPARONI A , CIARDELLI L , DE AMICI D , CASTELLAZZI A. M , AUTELLI M , BOTTINO R , POLITO E , BARTOLI A , RONDINI G , CHIRICO G
Published: March 2003

Background: The aim of this study was to verify if variations of thyroid hormones related to circumstances of delivery and mode of maternal anaesthesia can contribute to neonatal neutrophil respiratory burst and natural killer cell activity.

Methods: We evaluated 10 infants born by vaginal delivery (group A), 10 infants born by caesarean section after epidural anaesthesia with lidocaine (group B) and 10 infants born by caesarean section after general anaesthesia with sevoflurane (group C).

Results: A significant reduction of neutrophil respiratory burst test was found in groups A and C compared with group B. Natural killer cell (NK) activity with an effector : target ratio of 30 : 1 (NK30) and 10 : 1 (NK10) was significantly higher in group A compared with the B and C groups. In addition, thyroid stimulating hormone (TSH) concentration was significantly reduced in group A compared with the B and C groups. A significant negative correlation was found between TSH and NK30 or NK10.

Conclusions: Our results suggest that the mode of delivery and anaesthesia can significantly modify the endocrine‐immune system in the newborn. Caesarean section delivery with regional anaesthesia seems to produce fewer modifications of neonatal immune function compared with general anaesthesia.
Vincristine‐induced vocal cord paralysis in an infant
Authors: ANGHELESCU DORALINA L. , DE ARMENDI ALBERTO J. , THOMPSON JEROME W. , SILLOS ELAINE M.A. , PUI CHING‐HON , SANDLUND JOHN T.
Published: March 2003

We report the development of stridor and dysphagia in a 5‐month‐old‐infant with acute lymphoblastic leukaemia after the administration of four weekly doses of vincristine during induction therapy. Because direct laryngoscopy revealed bilateral vocal cord paralysis, the patient underwent elective intubation. Extubation was performed 7 days later, after direct laryngoscopy confirmed recovery of vocal cord mobility. Vincristine‐induced bilateral recurrent laryngeal nerve paralysis is a rare but potentially life‐threatening complication. Therefore, it should be suspected when stridor is present, and clinicians should consider visualization of the airway to establish the cause of upper airway compromize in infants receiving vincristine.