bluuebunny/crossref_metadata_2025 huggingface dataset:
Peptic ulceration in general practice in England and Wales 1994–98: period prevalence and drug management
Authors: Kang J.‐Y. , Tinto A. , Higham J. , Majeed A.
Published: March 2003

Background:

Little is known about the burden of peptic ulcer in the community.

Aims:

To examine recent time trends in the period prevalence of peptic ulceration and its drug management, in England and Wales.

Methods:

For each year between 1994 and 1998, information on patients with a diagnosis of peptic ulceration was extracted from the General Practice Research Database.

Results:

The annual age‐standardized period prevalence of peptic ulceration decreased from 3.3/1000 in 1994 to 1.5/1000 in 1998 for men, and from 1.8/1000 to 0.9/1000 for women. This decline was more evident among younger people, and among males registered with practices located in the most deprived electoral wards compared to those located in the least deprived. The proportion of patients receiving H2 receptor antagonists declined from 68% in 1994 to 41% in 1998. In contrast, the proportion prescribed proton pump inhibitors rose from 46% to 66%.

Conclusions:

Over a 5‐year period, the period prevalence of peptic ulceration has decreased markedly, especially among younger people and those from more deprived areas.
Premature discontinuation of interferon plus ribavirin for adverse effects: a multicentre survey in ‘real world’ patients with chronic hepatitis C
Authors: Gaeta G. B. , Precone D. F. , Felaco F. M. , Bruno R. , Spadaro A. , Stornaiuolo G. , Stanzione M. , Ascione T. , De Sena R. , Campanone A. , Filice G. , Piccinino F.
Published: March 2003

Background: Interferon‐α plus ribavirin therapy for chronic hepatitis C is associated with adverse effects that lead to therapy discontinuation in up to 27% of patients in randomized controlled trials.

Aim: To examine the causes and predictive factors for therapy discontinuation in patients treated in current clinical practice.

Methods: We retrospectively enrolled 441 consecutive patients, scheduled to receive interferon‐α + ribavirin for chronic hepatitis C, in five centres. Patients had been treated with 3 or 6 MU interferon‐α three times a week plus ribavirin, 800–1200 mg daily, for 6 or 12 months.

Results: One hundred and eight [24.5%; confidence interval (CI), 20.5–28.8%] patients failed to finish combination therapy because of adverse events. The discontinuation rate was higher during the first 6 months of treatment; anaemia was an important cause (36.1% of discontinuations); unexplained lipothymia resulted in discontinuation in 11 patients. Female gender [hazard ratio (HR) = 1.85; CI, 1.17–2.92], an interferon‐α dose > 15 MU/week (HR = 1.79; CI, 1.12–2.86) and no previous interferon‐α treatment (HR = 1.63; CI, 1.04–2.57) were independent factors associated with discontinuation. The simultaneous presence of these factors identified patients at high risk for discontinuation [odds ratio (OR) = 10; CI, 3.98–25.13].

Conclusions: The study identified some predictive factorsfor adverse event‐related discontinuation, which may improve the safety profile and effectiveness of interferon‐α + ribavirin combination therapy in chronic hepatitis C.
Stool antigen assay (HpSA) is less reliable than urea breath test for post‐treatment diagnosis of Helicobacter pylori infection
Authors: Bilardi C. , Biagini R. , Dulbecco P. , Iiritano E. , Gambaro C. , Mele M. R. , Borro P. , Tessieri L. , Zentilin P. , Mansi C. , Vigneri S. , Savarino V.
Published: March 2003

Background : The diagnostic yield of the stool antigen test (HpSA) in evaluating the results of Helicobacter pylori eradication therapy is controversial, but many studies have used only the 13C‐urea breath test (13C‐UBT) as a gold standard which has greatly reduced their relevance.

Aim : To compare the reliability of HpSA and 13C‐UBT in patients post‐treatment using biopsy‐based methods as reference tests.

Methods : A total of 100 consecutive dyspeptic patients (42 male and 58 female; mean age, 56 ± 18 years) were enrolled in our study. All patients were H. pylori positive on the basis of at least two biopsy‐based methods, and underwent 1 week of treatment with various triple therapies. They were again endoscoped 4 weeks after completing therapy and six biopsyspecimens were taken from the gastric antrum and corpus for rapid urease test, histology and culture. HpSA and 13C‐UBT were also performed within 3 days of the second endoscopy.

Results : On the basis of biopsy‐based tests, infection was eradicated in 77 patients but continued in 23. Three false negatives were observed with HpSA and two with 13C‐UBT. In contrast, the number of false positives was significantly higher (P < 0.01) with HpSA than with 13C‐UBT (nine vs. one), confirming the lower specificity of the former test. The overall accuracy of HpSA was 88% vs. 97% for 13C‐UBT (P < 0.02).

Conclusions : HpSA has lower diagnostic value than 13C‐UBT in the evaluation of the outcome of anti‐H. pylori therapy. 13C‐UBT remains the first‐line diagnostic method to monitor eradication results. The use of HpSA should be reserved for those settings in which 13C‐UBT is not available.
Acute and chronic pancreatitis — diseases on the rise: a study of hospital admissions in England 1989/90–1999/2000
Authors: Tinto A. , Lloyd D. A. J. , Kang J.‐Y. , Majeed A. , Ellis C. , Williamson R. C. N. , Maxwell J. D.
Published: March 2003

Background: The number of hospital admissions for acute and chronic pancreatitis increased in Britain from the 1960s to the 1980s.

Aims: To determine time trends in acute and chronic pancreatitis for hospital admissions from 1989/90 to 1999/2000, mortality from 1979 to 1999, and various indices of alcohol consumption.

Methods: Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data from the Office for National Statistics. Alcohol consumption data were obtained from the General Household Survey.

Results: Between 1989/90 and 1999/2000, age‐standardized hospital admission rates for acute pancreatitis increased by 43%, whilst those for chronic pancreatitis rose by 100%. The proportions of admissions requiring surgical operations increased for acute pancreatitis, but declined for chronic pancreatitis. Case fatality rates for acute pancreatitis declined, but mortality statistics showed no significant change. The proportion of women who drank more than 14 units of alcohol a week also increased.

Conclusions: There has been a steady increase in admission rates for both acute and chronic pancreatitis over the study period, and these conditions will become an increasingly important part of the workload of the gastroenterologist.
Haemochromatosis
Authors: Whittington C. A. , Kowdley K. V.
Published: March 2003

Hereditary haemochromatosis is the prototype disease for primary iron overload. The disorder is very common, especially amongst subjects of Northern European extraction. It is characterized by an autosomal recessive mode of inheritance, and most cases are homozygous for the C282Y mutation in the HFE gene. Haemochromatosis is now recognized to be a complex genetic disease with probable significant environmental and genetic modifying factors. The early diagnosis of individuals at risk for the development of haemochromatosis is important, because survival and morbidity are improved if phlebotomy therapy is instituted before the development of cirrhosis. The cost‐effectiveness and utility of large‐scale screening for haemochromatosis have been questioned given that many individuals with the homozygous C282Y mutation do not have iron overload or end‐organ damage. However, the use of phenotypic tests, such as serum transferrin‐iron saturation, for initial screening avoids the problem of the identification of non‐expressing homozygotes. Liver biopsy remains important in management to determine the presence or absence of cirrhosis, particularly amongst patients with serum ferritin levels greater than 1000 ng/mL or elevated liver enzymes. Those with non‐HFE haemochromatosis who cannot be identified on genotypic testing should have a liver biopsy to establish diagnosis. Patients with end‐stage liver disease may develop liver failure or primary liver cancer, and liver transplantation may be required. Liver transplantation for haemochromatosis is associated with a poorer outcome compared with other indications because of infections and cardiac complications.
Rabeprazole‐based therapy in Helicobacter pylori eradication
Authors: Barth J. , Hahne W.
Published: March 2003

Rabeprazole's favourable pharmacodynamic profile is a result of its rapid onset and its 24‐h control of gastric parietal secretion. These qualities, and its antimicrobial properties, make it particularly effective in the treatment of Helicobacter pylori (H. pylori), which is a short course of treatment compared to other conditions treated with proton pump inhibitors. Recently completed trials in combination with amoxicillin, clarithromycin and metronidazole for 7 days achieved high eradication of H. pylori. An additional study assessing the efficacy of combined rabeprazole and antibiotic treatments of 3, 7, and 10 days' duration vs. FDA‐approved 10‐day omeprazole triple therapy is under way to address the possibility of shorter duration therapies in the USA.
An evaluation of the clinical implications of acid breakthrough in patients on proton pump inhibitor therapy
Authors: Nzeako U. C. , Murray J. A.
Published: March 2003

Background : Some patients with gastro‐oesophageal reflux disease continue to experience symptoms despite therapy with proton pump inhibitors. One recently proposed cause is the occurrence of nocturnal acid breakthrough.

Aim : To investigate the relationship between acid breakthrough occurrence (nocturnal and daytime) and refractory symptoms among patients with gastro‐oesophageal reflux disease on proton pump inhibitors.

Methods : Fifty‐two consecutive patients with persistent symptoms of gastro‐oesophageal reflux disease despite proton pump inhibitor therapy underwent 24‐h pH study at the Mayo Clinic between January 1 and November 10, 1999. Relevant data were extracted and analysed.

Results : Fifty‐two patients, 18 males and 34 females, were eligible for the study. The mean age was 53 ± 2.2 years. Thirty‐seven patients (71%) had nocturnal acid breakthrough, and 36 (69%) had daytime acid breakthrough. Sixty per cent of patients experienced both nocturnal and daytime acid breakthrough, whereas 19% had neither. Among those with nocturnal and daytime acid breakthrough, only 36% and 33% of symptoms, respectively, were associated with gastro‐oesophageal reflux episodes. The proportion of patients with symptoms and the mean symptom scores were not significantly different between those with and without acid breakthrough.

Conclusions : Gastric acid breakthrough occurs nocturnally and during the daytime in patients on proton pump inhibitor therapy. With less than 36% of refractory symptoms associated with gastro‐oesophageal reflux, gastric acid breakthrough cannot explain symptom refractoriness to proton pump inhibitor therapy in a significant majority of patients evaluated by 24‐h pH study.
Baclofen decreases acid and non‐acid post‐prandial gastro‐oesophageal reflux measured by combined multichannel intraluminal impedance and pH
Authors: Vela M. F. , Tutuian R. , Katz P. O. , Castell D. O.
Published: March 2003

Background : Omeprazole controls acid but not non‐acid reflux. The GABA B agonist baclofen decreases acid reflux through the inhibition of transient lower oesophageal sphincter relaxations (TLESRs) and should similarly decrease non‐acid reflux. Using combined multichannel intraluminal impedance and pH (MII/pH), we compared acid and non‐acid reflux after placebo and baclofen.

Methods : Nine healthy volunteers and nine heartburn patients underwent two 2‐h studies of combined MII/pH in right lateral decubitus after a refluxogenic meal in random order: on placebo and after baclofen 40 mg p.o. Tracings were analysed for acid and non‐acid reflux episodes, re‐reflux and symptoms in the heartburn patients.

Results : In normal subjects baclofen significantly reduced the median number of episodes of acid (7 vs. 1, P = 0.02), non‐acid (2 vs. 0, P = 0.005), and all reflux combined (10 vs. 2, P = 0.006); re‐reflux was not reduced (0 vs. 0, P = N.S.). In heartburn patients, baclofen significantly decreased the median number of episodes of acid (15 vs. 6, P = 0.004), non‐acid (4 vs. 2, P = 0.003), re‐reflux (2 vs. 0, P = 0.02), and all reflux combined (23 vs. 8, P = 0.004); it also reduced the median number of acid‐related (9 vs. 1, P = 0.008) and non‐acid‐related (1 vs. 0, P = 0.04) symptoms.

Conclusions : Baclofen reduces post‐prandial acid and non‐acid reflux and their associated symptoms. GABA B agonists may have a role in treating GERD.
Thiopurine methyltransferase genotype distribution in patients with Crohn's disease
Authors: Reuther L. O. , Sonne J. , Larsen N. , Dahlerup J. F. , Thomsen O. O. , Schmiegelow K.
Published: March 2003

Background : Inter‐individual response to azathioprine is partly due to inter‐individual variation in the thiopurine methyltransferase (TPMT) activity. The TPMT genotype, which reflects the TPMT activity, has previously been studied in healthy Caucasians, with the most common variant allele being TPMT*3A. TPMT genotyping in adult patients with Crohn's disease has never been performed systematically.

Aim : To determine the TPMT genotype distribution in adult patients with Crohn's disease.

Methods : One hundred and twenty randomly selected Danish patients (64 females and 56 males) with azathioprine‐dependent Crohn's disease were included, and a polymerase chain reaction assay was used for TPMT genotyping. The patients were genotyped for the low‐level genotype G460→A and A719→G transitions.

Results : One hundred and nine patients (90.3%; 95% confidence interval, 84.1–95.3) had a wild‐type/ wild‐type genotype, whereas 10 patients (8.3%; 95% confidence interval, 4.1–14.8) had one non‐functional mutant allele and one patient (0.8%; 95% confidence interval, 0.02–4.6) had two non‐functional mutant alleles. Only the TPMT*3A variant allele was found.

Conclusions : The study showed a TPMT genotype distribution amongst adult Danish patients with Crohn's disease which was similar to the distribution of TPMT variant alleles normally found in healthy Caucasians.
Treatment of active Crohn's disease with onercept (recombinant human soluble p55 tumour necrosis factor receptor): results of a randomized, open‐label, pilot study
Authors: Rutgeerts P. , Lemmens L. , Van Assche G. , Noman M. , Borghini‐Fuhrer I. , Goedkoop R.
Published: March 2003

Background : Monoclonal antibodies to the pro‐inflammatory cytokine tumour necrosis factor‐α have shown efficacy in treating Crohn's disease, but can be immunogenic. Soluble tumour necrosis factor‐binding proteins are being studied as potential alternative anti‐tumour necrosis factor agents in Crohn's disease.

Aim : To investigate the safety and efficacy of onercept, a recombinant form of the natural human soluble p55 tumour necrosis factor receptor, in the treatment of patients with active Crohn's disease.

Methods : In a pilot study, 12 patients with active Crohn's disease were randomized to receive onercept at either 11.7 or 50 mg three times weekly for 2 weeks. Patients were followed up for 6 months after the end of treatment.

Results : The Crohn's disease activity index decreased rapidly during treatment in both groups. Seven responses (Crohn's disease activity index decrease of 100 points) were observed over the first 6 weeks of the study, including five remissions (Crohn's disease activity index decrease of 150 points). Improvement was sustained for 2–4 months after stopping treatment. Treatment was well tolerated. No patients developed antibodies to onercept.

Conclusions : Neutralizing the activity of tumour necrosis factor‐α with its soluble p55 receptor may be valuable in the treatment of patients with Crohn's disease. Larger placebo‐controlled trials are indicated.
Epidural anaesthesia as a method of pre‐emptive analgesia for abdominal hysterectomy
Authors: Richards J. T. , Read J. R. M. , Chambers W. A.
Published: March 2003

The effect of pre‐ versus postincisional epidural blockade without the use of systemic opioids was investigated in a randomised, double‐blind study of two groups of 25 patients undergoing abdominal hysterectomy performed under general anaesthesia. The first group received, via a lumbar epidural catheter, 0.9% saline (16 ml) 15 min prior to surgical incision and 0.5% bupivacaine (15 ml) and fentanyl 50 μg (1 ml) 15 min prior to skin closure. The second group of 25 patients received the same amount of bupivacaine and fentanyl 15 min pre‐incision and saline prior to skin closure. Visual analogue pain scores and patient‐controlled morphine consumption were measured at specified times for 48 h. We were unable to detect any significant difference in either of the outcome measures for the two groups and thus were unable to demonstrate that epidural blockade using local anaesthetic and opioid has a pre‐emptive effect.
A portable self‐learning fuzzy logic control system for muscle relaxation
Authors: Edwards N. D. , Mason D. G. , Ross J. J.
Published: March 2003

We have assessed the practicality and performance of the Vital Signs Paragraph neuromuscular blockade monitor as part of a ‘self‐learning’ fuzzy logic control feedback system used to administer atracurium to a required depth of neuromuscular blockade. Fifteen patients undergoing surgery expected to last longer than 90 min entered the study. A Vital Signs Paragraph was used to measure the degree of neuromuscular blockade and control it such that the first twitch of the train‐of‐four was kept at 10% of its baseline value. The controller instructed a Graseby Medical 3400 infusion pump to administer an atracurium infusion to maintain this level of blockade. Five patients (33%) were withdrawn from the study due to inadequate piezo‐electric sensor function. In the remaining 10 patients, the system achieved stable control of neuromuscular blockade with a mean (range) error for the first twitch of the train‐of‐four of −0.45 (−1.06 to 0.13)%. The mean atracurium infusion rate ranged from 0.13 to 0.67 mg.kg−1.h−1. These results compare reasonably well with previous results using the Datex Relaxograph, whilst the system itself was portable and easy to use. However, the reliability of the system was limited due to variability in the sensitivity of piezoelectric sensors.
A change in resistance? A survey of epidural practice amongst obstetric anaesthetists
Authors: Howell T. K. , Prosser D. P. , Harmer M.
Published: March 2003

Five hundred members of the Obstetric Anaesthetists Association were surveyed regarding their technique for identification of the epidural space. Eighty‐one per cent of the questionnaires were returned completed. Fifty‐nine per cent of respondents first learned a loss of resistance to air technique, 33.4% to saline and 7.4% another technique. Presently, 37.1% and 52.7% use only a loss of resistance to air or saline, respectively. Six per cent use both techniques and 3.2% use other techniques. Twenty‐eight per cent taught a loss of resistance to air, 57.2% taught a loss of resistance to saline and 12.9% taught both techniques. Twenty‐three per cent changed from a loss of resistance to air, to a saline technique, and 4.2% vice versa. Forty‐seven per cent of those using air felt that loss of resistance to air was not associated with a clinically significant difference in the incidence of accidental dural puncture compared with saline.
The cuffed oropharyngeal airway as an aid to fibreoptic intubation
Authors: Pigott D. W. , Kay N. H. , Greenberg R. S.
Published: March 2003

The cuffed oropharyngeal airway is a new disposable airway based on the Guedel oral airway. It has an asymmetrical cuff which provides a seal as well as lifting the base of the tongue forwards, and a 15‐mm connector allowing attachment to an anaesthetic breathing system. The device does not extend beyond the vallecula, so that the laryngeal inlet can be visualised with a fibreoptic laryngoscope passed between the cuff of the device and the pharyngeal wall. The advantage is that ventilation is maintained throughout the intubating sequence. We describe its use in a patient with oropharyngeal carcinoma.
Anaesthesia for chronic spinal cord lesions
Authors: Hambly P. R. , Martin B.
Published: March 2003

Increasing numbers of patients with spinal cord injury present for surgery or obstetric care. Spinal cord injury causes unique pathophysiological changes. The most important peri‐operative dangers are autonomic dysreflexia, bradycardia, hypotension, respiratory inadequacy and muscle spasms. Autonomic dysreflexia is suggested by headache, sweating, bradycardia and severe hypertension and may be precipitated by surgery, especially bladder distension. Patients with low, complete lesions, undergoing surgery below the level of injury, may safely do so without anaesthesia provided there is no history of autonomic dysreflexia or troublesome spasms. An anaesthetist should be present to monitor the patient in this situation. General anaesthesia of sufficient depth is effective at controlling spasms and autonomic dysreflexia but hypotension and respiratory dysfunction are risks. There is a growing consensus that spinal anaesthesia is safe, effective and technically simple to perform in this group of patients. We present a survey of 515 consecutive anaesthetics in cord‐injured patients and a review of the current literature on anaesthesia for patients with chronic spinal cord lesions.
The effect of education, assessment and a standardised prescription on postoperative pain management The value of clinical audit in the establishment of acute pain services
Authors: Harmer M. , Davies K. A.
Published: March 2003

A study involving 2738 patients in 15 hospitals in the United Kingdom was undertaken to evaluate the effect of simple methods of pain assessment and management on postoperative pain. The study consisted of four parts: a survey of current practice in each hospital; a programme of education for staff and patients regarding pain and its management; the introduction of formal assessment and recording of pain and the use of a simple algorithm to allow more flexible, yet safe, provision of intermittent intramuscular opioid analgesia; and a repeat survey of practice. One hospital from each of the former health regions of England and Wales was selected for inclusion in the project. Hospitals included representatives of different size units (university, large and small district general hospitals). As a result of the study, there was an overall reduction in the percentage of patients who experienced moderate to severe pain at rest from 32% to 12%. The incidence of severe pain on movement decreased from 37% to 13% and moderate to severe pain on deep inspiration from 41% to 22%. Similar decreases were seen in the incidence of nausea and vomiting. There was also a slight reduction in the incidence of postoperative complications. This study shows that simple techniques for the management of postoperative pain are effective in reducing the incidence of pain both at rest and during movement and should form part of any acute pain management strategy.
The effect of intrathecal administration of magnesium sulphate in rats
Authors: Karasawa S. , Ishizaki K. , Goto F.
Published: March 2003

Somatosensory evoked potential, locomotion and vocalisation upon tail pinch in rats was studied in order to determine whether intrathecal magnesium sulphate administration causes spinal anaesthesia. In Wistar rats with indwelling intrathecal catheters, cortical somatosensory evoked potential was recorded following stimulation via electrodes inserted into the hind paw under chloral hydrate anaesthesia before and after intrathecal administration of 10 μl of either magnesium sulphate (12.3% or 24.6%) or lignocaine (4% or 8%). Locomotion and vocalisation after tail pinch were tested following intrathecal administration of the same two drugs in conscious rats. Somatosensory evoked potential amplitude was diminished after administration of lignocaine (p < 0.05) but did not change after magnesium sulphate. Latency of P1 was increased by lignocaine and by magnesium sulphate 12.3% (p < 0.05). Although lower extremity paralysis was observed in both groups, its duration with magnesium sulphate was much longer than with lignocaine. Vocalisation was recognised after magnesium sulphate 12.3%, but was not observed after lignocaine 8% during paralysis (p < 0.05). We believe that magnesium sulphate caused motor paralysis, but not complete analgesia.
Use of the McCoy laryngoscope or fingers to facilitate fibrescope‐aided tracheal intubation
Authors: Asai T. , Matsumoto S. , Shingu K.
Published: March 2003

In fibrescope‐aided tracheal intubation, it can be difficult to advance a tube over a fibrescope, because its passage may be impeded by the epiglottis, arytenoids or pyriform fossa. In two patients with difficult intubation, after successful insertion of a fibrescope into the trachea, it was impossible to advance the tube over the fibrescope. Fibrescope‐aided tracheal intubation was accomplished by shifting the epiglottis anteriorly and ‘opening up’ the glottis either by fingers or the McCoy laryngoscope.
Induced hypothermia in the postoperative management of refractory cardiac failure following paediatric cardiac surgery
Authors: Deakin C. D. , Knight H. , Edwards J. C. , Monro J. L. , Lamb R. K. , Keeton B. , Salmon A. P.
Published: March 2003

Postoperative low cardiac output states are a major cause of postoperative mortality in infants and children following corrective cardiac surgery for congenital heart defects. In this unit, whole body hypothermia has been used since 1979 in the management of these low output states when they are refractory to conventional modes of therapy. Twenty cases treated in this way between July 1986 and June 1990 were reviewed in 1992. The current report reviews the 50 further cases treated with moderate hypothermia between July 1990 and December 1995. The median (range) age of patients was 8 months (0 days — 16 years) with a median weight of 4.1 kg (2.5–33 kg). Following cooling, there was a decrease in heart rate (p < 0.001), an increase in mean arterial pressure (p < 0.001) and a decrease in mean atrial pressure (p < 0.001). Significant increases in pH and urine output were also noticed, the increase in urine output being greater in the surviving group (p = 0.02). A decrease in platelet count occurred (p < 0.001) but white blood cell count remained unchanged (p = 0.18). Twenty‐five of the 50 patients survived to leave hospital. Induced hypothermia does not appear to be associated with any complications and after the failure of all conventional treatment, it seems likely that the technique may have been beneficial to outcome in some patients.
Recovery characteristics using single‐breath 8% sevoflurane or propofol for induction of anaesthesia in day‐case arthroscopy patients
Authors: Dashfield A. K. , Birt D. J. , Thurlow J. , Kestin I. G. , Langton J. A.
Published: March 2003

We studied the induction and recovery characteristics following inhalational induction with 8% sevoflurane in nitrous oxide and oxygen compared with intravenous propofol in 40 patients presenting for arthroscopy of the knee. Patients were randomly allocated to receive either induction agent, and anaesthesia was then maintained with sevoflurane in oxygen and nitrous oxide. A computerised test of hand–eye co‐ordination and a p‐deletion test were used to measure psychomotor recovery. The sevoflurane group had a faster onset of anaesthesia time. No significant differences between the groups were found in time to eye opening or psychomotor tests. Nausea and vomiting scores were significantly higher at 30 min in the sevoflurane group (p = 0.04); this difference was no longer significant by 90 min. We conclude that inhalational induction with sevoflurane in these patients has no important clinical advantages and causes more nausea and vomiting than propofol.
Cortical responses to auditory stimuli during isoflurane burst suppression anaesthesia
Authors: Hartikainen K. , Rorarius M. G. F.
Published: March 2003

The cortical responses to auditory stimuli were studied in 12 patients during isoflurane anaesthesia producing burst suppression (ETisof (SD) 1.4 (0.2) vol.%). Earphones were used to give 3‐s trains of auditory click stimuli (60 clicks, 20 clicks per second, 80 dB, 0.1 ms) at irregular intervals. In 10 patients, the electroencephalography (EEG) showed a burst suppression pattern consisting of high‐amplitude activity intermingled with suppressed background activity. In eight patients with burst suppression patterns, there was a strong cortical reactivity to the termination, not to the beginning, of auditory stimuli: 80 (20)% of all stimuli presented during EEG suppression evoked high amplitude cortical response, offset‐burst. The latency of these auditory offset evoked bursts was 540 (60) ms. Auditory offset evoked bursts suggest that in spite of cortical suppression during deep anaesthesia the brain retains its ability to respond to changes in the acoustic environment.
Acute cardiac herniation after radical pleuropneumonectomy
Authors: Self R. J. , Vaughan R. S.
Published: March 2003

Acute cardiac herniation after radical pneumonectomy is extremely rare and is associated with an immediate mortality greater than 50%. We report a patient in whom cardiac herniation produced no signs or symptoms. The heart was returned to its correct position and the pericardial defect was repaired.
Peribulbar anaesthesia: a double‐blind comparison of three local anaesthetic solutions
Authors: Bedi A. , Carabine U.
Published: March 2003

A prospective, randomised, double‐blinded study comparing three agents for peribulbar anaesthesia is reported. Sixty patients undergoing extracapsular cataract extraction under local anaesthesia were randomly allocated to receive peribulbar anaesthesia with lignocaine 2% with adrenaline; prilocaine 3% with felypressin 0.03 IU.ml−1 or 2% lignocaine and 0.5% bupivacaine in a ratio of 1:1, using a standardised two‐injection technique. The pain of injection, time of onset of the block and the operating conditions at the start and finish of surgery were assessed. Peribulbar anaesthesia using lignocaine 2% was significantly more painful than the other solutions. The onset of anaesthesia adequate for surgery was similar in all three groups. Prilocaine 3% with felypressin was associated with the greatest number of blocks providing total akinesia of the eye. Inadequate duration of anaesthesia was seen in only one case; the solution used for this block was 2% lignocaine.
A comparison of hospital and critical‐care activity
Authors: Ridley S. A. , Burchett K. , Burns A. , Gunning K.
Published: March 2003

When compared with changes in hospital activity, corresponding fluctuations in critical‐care activity are not clear. Therefore, trends in hospital activity were compared with those of the critical‐care services and simple patient demographic details. The results suggest that while the size of hospitals remained static, hospital admissions and outpatient attendances increased by 5% each year. During the same period, the number of critical‐care beds increased by 21.4%. Despite this increase in capacity, the activity of the critical‐care services continued to increase by a similar 5% per annum, indicating a huge surge in critical‐care workload. The results indicate that the increase in the rate of activity in hospitals and critical‐care services is similar but the workload of the critical‐care services is increasing much faster. This suggests that the demand for critical care may be generated from within hospitals.
The accuracy of visual estimation of weight and height in pre‐operative supine patients
Authors: Coe T. R. , Halkes M. , Houghton K. , Jefferson D.
Published: March 2003

Four observers estimated the weight and height of 38 patients who were lying covered on operating theatre trolleys. Regression analysis of the results was performed for each observer. The results showed marked variation in ability to assess these characteristics accurately.
Gas movement in the nonventilated lung at the onset of single‐lung ventilation for video‐assisted thoracoscopy
Authors: Pfitzner J. , Peacock M. J. , McAleer P. T.
Published: March 2003

To assess the potential for atmospheric nitrogen to enter the nonventilated lung following the initiation of single‐lung ventilation, the nonventilated lung of 10 patients undergoing video‐assisted thoracoscopy was connected to the air in a water‐filled spirometer, and gas movement outof and back into the lung was measured. Airway pressure from both lungs and pleural pressure from the nonventilated side were also measured. With each breath of positive‐pressure ventilation to the ventilated lung prior to the thoracic cavity being opened to the atmosphere, the pressure transmitted to the opposite hemithorax generated a mean (range) tidal movement of gas in the nonventilated lung of 134 (65–265) ml. In addition, ongoing gas exchange resulted in a progressive influx of gas from the spirometer over the 110–120 s measurement period of a mean (range) volume of155 (70–320) ml. This easily preventable influx of atmospheric nitrogen could, in theory, predispose to arterial desaturation and to delayed lung collapse after the parietal pleura is opened.
Low‐dose bupivacaine: a comparison of hypobaric and near isobaric solutions for arthroscopic surgery of the knee
Authors: Kuusniemi K. S. , Pihlajamäki K. K. , Pitkänen M. T. , Korkeila J. E.
Published: March 2003

The results of studies on the effect of volume, concentration or total dose of local anaesthetic on the spread of spinal anaesthesia are inconclusive. Most support the assumption that the total dosage is more important than the volume. We compared low‐dose bupivacaine (6 mg) in 0.5% and 0.18% solutions as sole anaesthetic to achieve predominantly unilateral spinal anaesthesia for knee arthroscopy. Sixty patients were randomly allocated to two groups to receive either 1.2 ml 0.5% bupivacaine (6 mg) (n = 30) or 3.4 ml 0.18% hypobaric bupivacaine (6.1 mg) (n = 30). Drugs were administered at the L3–4 interspace with the patient in the lateral position. Patients remained in this position for 20 min before being turned supine for the operation. Spinal block was assessed by pinprick and modified Bromage scale and compared between the operated and nonoperated sides. No significant changes were found in the spread or duration of sensory or motor block (p > 0.05). The haemodynamic changes were also similar between the groups. The same pinprick level of analgesia, degree of motor block and duration of spinal anaesthesia was obtained with bupivacaine (6 mg) in low (1.2 ml) or high (3.4 ml) volumes.
Thoracic epidural infusions for post‐thoracotomy pain: a comparison of fentanyl–bupivacaine mixtures vs. fentanyl alone
Authors: Mahon S. V. , Berry P. D. , Jackson M. , Russell G. N. , Pennefather S. H.
Published: March 2003

A randomised double‐blind clinical trial was conducted on 106 patients scheduled for pulmonary resection. Patients received an epidural infusion containing 0.1%, 0.2% bupivacaine or saline in combination with fentanyl 10 μg.ml −1. Adequacy of analgesia was assessed at rest and during movement over 24 h. Analgesic efficacy was assessed using visual analogue scores and an observer/verbal ranking scale. Pain scores were higher in the fentanyl‐only group at the 2 h assessment (p < 0.05). Otherwise, there were no between‐group differences in pain scores or in the total amounts of epidural solution used. All patients received continuous haemodynamic monitoring. There were no between‐group differences in the number of episodes of hypotension or in the number of interventions for hypotension. However, the use of intra‐operative vasopressor and the incidence of temporary neurological complications was higher in the 0.2% bupivacaine group (p < 0.05). We conclude that, in the early postoperative period, the addition of bupivacaine 0.1% improves fentanyl epidural analgesia in patients undergoing lung resection and is not associated with the disadvantages seen with the addition of bupivacaine 0.2%.
Effect of epidural bupivacaine on the relationship between the bispectral index and end‐expiratory concentrations of desflurane
Authors: Hans  , Lecoq  , Brichant  , Dewandre  , Lamy
Published: March 2003

We compared the relationship between the bispectral index and end‐tidal desflurane concentrations in 20 patients undergoing elective surgery. Patients received epidurally either 10 ml saline (group S) or 10 ml bupivacaine 0.125% with epinephrine 1/800 000 (group B) before induction of anaesthesia with sufentanil (0.15 μg.kg−1) and propofol (2 mg.kg−1); muscle relaxation was obtained with cisatracurium (0.2 mg.kg−1). Patients lungs were ventilated to maintain end‐tidal desflurane at 3% in O2/N2O (50/50) until 5 min after skin incision, followed by two consecutive 10 min periods at end‐tidal desflurane 6% and 9%. bispectral index values were recorded before induction, at 3% desflurane before and 5 min after skin incision, and at 6% and 9% end‐tidal desflurane. Bispectral index decreased with increasing end‐tidal desflurane concentration (anova: p < 0.05). The decrease in bispectral index was significant between pre‐induction, 3% and 6% desflurane. No significant difference was observed at 3% desflurane before and after skin incision, or between 6 and 9% desflurane. The relationship between bispectral index and end‐tidal desflurane concentration was fitted by a linear regression in each group. No significant difference in bispectral index was observed between the groups at any time. We conclude that bispectral index decreases with increasing desflurane concentration and that this relationship is not affected by epidural 0.125% bupivacaine.
The use of neuromuscular blocking agents in noncardiac surgery after dynamic cardiomyoplasty
Authors: Timmerman  , Van der Maaten  , Wierda  , Broekema  , Mungroop  , Brouwer  , Van den Berg
Published: March 2003

Dynamic cardiomyoplasty is a surgical treatment to improve cardiac performance in patients with end‐stage heart failure by wrapping the latissimus dorsi muscle around the heart. The use of skeletal muscle raises concerns about the safety of neuromuscular blocking agents used during general anaesthesia in noncardiac surgery in patients after cardiomyoplasty. We describe the administration of rocuronium to a patient undergoing carotid endarterectomy 18 months after cardiomyoplasty. No clinically relevant effects on haemodynamics were observed. We conclude that the use of nondepolarising neuromuscular blocking agents for noncardiac surgery in patients after cardiomyoplasty does not compromise cardiac performance in a clinically relevant way, although the time between the cardiomyoplasty procedure and the use of nondepolarising neuromuscular blocking agents remains a concern.
Prognostic indicators following emergency aortic aneurysm repair
Authors: Urwin S. C. , Ridley S. A.
Published: March 2003

We performed a retrospective study of 135 patients presenting for emergency abdominal aneurysm repair to determine predictive factors for outcome. The outcome measures investigated were mortality in the operating theatre and intensive care, and at 28 and 100 days. Univariate analysis showed that the patient's age, hypotension on admission, aneurysmal rupture, pre‐operative cardiopulmonary resuscitation, intra‐operative blood loss and hypotension were risk factors for death either in the operating theatre or up to 100 days after surgery. Binary logistic regression identified the independent risk factors for survival. Operative survival was determined by acute factors such as pre‐operative cardiopulmonary resuscitation, aneurysmal rupture and intra‐operative hypotension. Longer term survival was determined by the patient's age, aneurysmal rupture, blood loss and blood pressure at admission. Using a binary logistic regression equation, from which a simplified risk score was derived, it is possible to predict the likelihood of survival of individual patients presenting for abdominal aortic aneurysm repair.
Exaggerated cardiovascular response to anaesthesia — a case for investigation
Authors: Jones  , Redfern  , Shaw  , Baylis
Published: March 2003

We present a case of a 40‐year‐old woman who developed major cardiovascular complications during anaesthesia for an elective clipping of a cerebral arteriovenous malformation. Postoperative investigation confirmed the diagnosis of an adrenal phaeochromocytoma. In retrospect, it became apparent that she had experienced a series of potentially life‐threatening events over a 20‐year period all of which are known complications of phaeochromocytoma. This case highlights the importance of investigating young patients who have unexpected and unexplained cardiovascular events during anaesthesia and surgery.
Complications following the use of the Combitube, tracheal tube and laryngeal mask airway
Authors: Oczenski W. , Krenn H. , Dahaba A. A. , Binder M. , El‐Schahawi‐Kienzl I. , Kohout S. , Schwarz S. , Fitzgerald R. D.
Published: March 2003

In a prospective, randomised trial, 75 patients scheduled for routine surgery were randomly allocated to one of three groups to evaluate trauma and postoperative complications after insertion of the Combitube, tracheal tube or laryngeal mask airway. Insertion of the Combitube was associated with a higher incidence of sore throat (48% vs. 16% vs. 12% [p < 0.01]) and dysphagia (68% vs. 12% vs. 8% [p < 0.01]) compared with tracheal intubation or insertion of the laryngeal mask airway, respectively. Hoarseness was significantly less common in both the Combitube and the laryngeal mask groups (both 12%) than in the tracheal tube group (44%; p < 0.01). Haematoma occurred in 36% of the Combitube group compared with 4% in both the laryngeal mask and the tracheal tube groups (p < 0.01). The higher incidence of complications should be considered when using the Combitube.
Systemic stress response during operations for acute abdominal pain performed via laparoscopy or laparotomy in children
Authors: Bozkurt P. , Kaya G. , Altintas F. , Yeker Y. , Hacibekiroglu M. , Emir H. , Sarimurat N. , Tekant G. , Erdogan E.
Published: March 2003

We compared the endocrine and metabolic changes during acute emergency abdominal surgery performed using either laparoscopy or laparotomy in children. Twenty‐nine children aged 1.5–14 years were assigned to undergo laparoscopy (n = 15) or laparotomy (n = 14) with a standard anaesthesia technique. Arterial blood gases and blood prolactin, cortisol, interleukin‐6, glucose, insulin, lactic acid and epinephrine levels were determined 5 min after the induction of anaesthesia, 30 min into surgery and at the end of surgery. Intra‐operative heart rate and mean arterial pressure were stable in both groups. In the laparoscopy group, slight respiratory acidosis occurred during surgery (p < 0.01) but there were no changes in the laparotomy group. Insulin, cortisol, prolactin, epinephrine, lactate and blood glucose levels increased in both groups (p < 0.05) although there was no difference between the groups. The surgical stress and trauma imposed by laparoscopy seems similar to that caused by laparotomy in children undergoing emergency abdominal surgery.
Tourniquet pain in a volunteer study: effect of changes in cuff width and pressure
Authors: Estebe J.‐P. , Le Naoures A. , Chemaly L. , Ecoffey C.
Published: March 2003

This study examines the relationship between pneumatic tourniquet cuff size, occlusion pressure and the resulting pain. Two tourniquet cuff widths were used, a wide (14 cm) and a narrow cuff (7 cm). Twenty volunteers were divided into two groups for tourniquet application: a pressure group in which the tourniquet was inflated to a pressure equal to the systolic pressure + 100 mmHg, and a saturation group in which the tourniquet was inflated to 10 mmHg above the loss of arterial pulse, as indicated by cessation of pulse waveform on an oximeter. According to a randomised cross‐over protocol, subjects were studied using wide and narrow cuffs simultaneously and/or successively on both arms. Pain was assessed by subjects by means of a visual analogue score (0–10 cm). Occlusion pressures were similar for all volunteers in the pressure group and significantly higher than those in the saturation group with both the wide and narrow tourniquets. The wide cuff data turned out to be significantly lower than the narrow cuff results. Subjects in the pressure group could tolerate pain with the narrow cuff for significantly longer than with the wide cuff. However, in the saturation group, volunteers tolerated the wide cuff for longer. Pain intensity increased more rapidly in those in the pressure group with the wide cuff than with the narrow cuff. In contrast, volunteers in the saturation group found the narrow cuff to be more painful than the wide cuff. In conclusion, this study has shown that a wide tourniquet cuff is less painful than a narrow cuff if inflated at lower pressures and at these lower pressures it is still effective at occluding blood flow.
The relationship between change in blood pressure, blood pressure and time
Authors: Harrison M. J. , Kluger M. T. , Robertson N. N.
Published: March 2003

Physiological homeostatic mechanisms and interventions by anaesthetists attempt to moderate excessive change in many biological variables during anaesthesia. These mechanisms may have fast or slow response times. This study describes how mean arterial blood pressure changes with time and how the change is dependent upon the pre‐existing blood pressure. The results demonstrate the ‘regression towards the mean’ concept; low arterial blood pressures increase and high pressures decrease. The data are the result of all interactions and have been used to produce an ‘envelope’ into which 80% of all changes fall. Alarm systems using this envelope could warn of excessive changes that occur within short time intervals.
Pharyngeal abscess presenting with upper airway obstruction and atlanto‐axial subluxation in a small infant
Authors: Brookes A. , Moriarty A.
Published: March 2003

We describe an infant who presented with a combination of upper airway obstruction and atlanto‐axial subluxation, secondary to a pharyngeal abscess resulting from cosmetic ear piercing. This combination posed a number of difficulties for the anasthetist and a detailed plan was formulated to prepare the child for anasthesia.
Caudal ropivacaine and ketamine for postoperative analgesia in children
Authors: Lee H. M. , Sanders G. M.
Published: March 2003

In a prospective, randomised, double‐blind clinical study, we studied 32 ASA grade I and II boys aged 18 months to 12 years, scheduled for circumcision under general anaesthesia on an outpatient basis. They were randomly allocated to one of two groups: those in the ropivacaine group received caudal ropivacaine 0.2% 1 ml.kg−1 for postoperative analgesia and those in the ketamine/ropivacaine group received caudal ropivacaine 0.2% 1 ml.kg−1 plus caudal ketamine 0.25 mg.kg−1. Postoperative pain was assessed using a modified 10‐cm visual analogue scale and analgesia was administered if the pain score exceeded a value of 3. The median duration of analgesia was significantly longer in the ketamine/ropivacaine group (12 h) than in the ropivacaine group (3 h, p < 0.0001), and subjects in the ropivacaine group required significantly more doses of postoperative analgesia than those in the ketamine/ropivacaine group (p < 0.0001). There were no differences between the groups in the incidence of postoperative nausea, vomiting, sedation, emergence delirium, nightmares, hallucinations, motor block and urinary retention.