bluuebunny/crossref_metadata_2025 huggingface dataset:
The treatment of irritable bowel syndrome
Authors: Thompson W. G.
Published: March 2003

The efforts of clinical researchers, lay organizations and pharmaceutical companies have increased the public profile of irritable bowel syndrome and made it a respectable diagnosis. Diagnostic symptom criteria encourage a firm clinical diagnosis, which is the foundation of a logical management strategy. This begins with education. Reassurance that no structural disease threatens should be tempered with the reality that symptoms are likely to recur over many years. Patients expect diet and lifestyle advice, even if this is not specific to irritable bowel syndrome. Only a few of those with irritable bowel syndrome see doctors, and even fewer see specialists. Therefore, the treating physician should ascertain the reason for the visit, the patient's fears and the presence of any comorbid illness, such as depression, that might require treatment in its own right. No drug treatment is useful for all of the symptoms of irritable bowel syndrome, and many patients require no drug at all. If used, drugs should target the predominant symptom. Alosetron, a 5‐HT3 antagonist, is effective in treating women with irritable bowel syndrome who also have diarrhoea. Tegaserod, a 5‐HT4 agonist, is useful for women with irritable bowel syndrome who are constipated. Most patients with irritable bowel syndrome need psychological support. Reassurance, discussion and relaxation techniques can be provided by the family doctor. Difficult psychopathology may require referral to a mental health professional, and the gastroenterologist can settle diagnostic uncertainties. In all cases, successful treatment depends on a confident diagnosis and the strength of the doctor–patient relationship.
Meta‐analysis: ribavirin‐induced haemolytic anaemia in patients with chronic hepatitis C
Authors: Chang C. H. , Chen K. Y. , Lai M. Y. , Chan K. A.
Published: March 2003

Aim : To use meta‐analysis to study the risk of anaemiarelated to ribavirin therapy for chronic hepatitisC.

Methods : The MEDLINE database up to January 2001 was searched for randomized controlled trials of ribavirin (monotherapy or combined with interferon) for chronic hepatitis C. The outcomes evaluated were withdrawal from the study due to anaemia, ribavirin dosage reduction due to a decrease in haemoglobin and haemoglobin levels below 10 g/dL.

Results : Based on 17 studies, the overall risk difference (ribavirin vs. no ribavirin) for anaemia was 0.09 [95% confidence interval (CI), 0.04–0.13]. Two Asian studies reported risk differences of 0.29 and 0.22, greater than the pooled risk difference of 0.07 (95% CI, 0.03–0.12) for 15 non‐Asian studies. The risk associated with 1 g or more of ribavirin per day was higher (risk difference, 0.09; 95% CI, 0.04–0.14) than that for 0.8 g of ribavirin per day (risk difference, 0.01; 95% CI, − 0.04–0.06).

Conclusions : Chronic hepatitis C patients treated with 1 g or more of ribavirin per day were at a higher risk of developing anaemia. Reported risks were higher among Asian studies, which may be due to differences in study entrance criteria, dosage titration strategy or ethnic vulnerability.
Dynamics of Helicobacter pylori infection in early childhood in a high‐risk group living in Germany: loss of infection higher than acquisition
Authors: Rothenbacher D. , Bode G. , Brenner H.
Published: March 2003

Background : The dynamics of Helicobacter pylori infection in early childhood are not yet well understood.

Aim : To conduct a prospective study in a population of children known to be at high risk of H. pylori infection to elucidate the incidence and loss of infection in childhood.

Methods : Asymptomatic Turkish children [aged 1 (n = 56 children), 2 (n = 55 children) and 4 years (n = 69 children)] at baseline, on whom participating paediatricians had performed routine health screening examinations between September 1997 and October 1998, were included in the study. A follow‐up was performed about 1 year later. The infection status was defined by means of an antigen‐based stool assay.

Results : In total, for 137 of 180 (76%) children, follow‐up information was available. At baseline examination, the prevalence of infection in children with follow‐up information was 27%[95% confidence interval (CI), 20–35%]. The incidence of H. pylori infection amongpreviously uninfected children was 7% (95% CI, 3–14%) and the loss of infection among previously infected children was 35% (95% CI, 20–54%) during follow‐up.

Conclusions : This prospective cohort study in a high‐risk group of children living in Germany showed that H. pylori colonization may often not persist at an early age. Furthermore, the use of penicillins and macrolides may be associated with the loss of infection at an early age.
Thiopurine methyltransferase activity and the use of azathioprine in inflammatory bowel disease
Authors: Ansari A. , Hassan C. , Duley J. , Marinaki A. , Shobowale‐Bakre E. ‐M. , Seed P. , Meenan J. , Yim A. , Sanderson J.
Published: March 2003

Background : Azathioprine therapy is discontinued in one‐third of patients with inflammatory bowel disease because of toxicity or a lack of clinical response. Patients with thiopurine methyltransferase (TPMT) deficiency are intolerant to azathioprine, whilst carriers are at increased risk of side‐effects.

Aim : To evaluate the importance of TPMT activity in the management of azathioprine therapy in inflammatory bowel disease.

Methods : Clinical response, adverse effects and haematological parameters were determined and correlated with TPMT enzyme activity and genotype in 106 patients with inflammatory bowel disease.

Results : Ninety‐six patients had high TPMT activity, and 10 had intermediate activity. Nineteen patients (18%) were intolerant to azathioprine. Fifteen (16%) of those with high TPMT activity were intolerant, compared with five (50%) with intermediate activity [odds ratio (OR), 5.4; 95% confidence interval (CI), 1.5–19.8]. Complete remission was achieved in 63% of cases, and complete or partial remission in 79%. Interestingly, very high TPMT activity (> 14 units/mL red blood cells) was significantly associated with non‐response, irrespective of the time on azathioprine (OR, 0.21; 95% CI, 0.07–0.68). TPMT gene mutations correlated with TPMT activity.

Conclusions : Inflammatory bowel disease patients with intermediate TPMT activity have an increased risk of azathioprine toxicity. Conversely, very high TPMT activity predicts treatment failure. TPMT genotype predicted TPMT phenotype in this study.
Prophylactic lamivudine prevents hepatitis B reactivation in chemotherapy patients
Authors: Lim L. L. , Wai C. T. , Lee Y. M. , Kong H. L. , Lim R. , Koay E. , Lim S. G.
Published: March 2003

Background : Chronic hepatitis B virus carriers receiving chemotherapy develop a high hepatitis B virus reactivation rate (38–53%) with a high mortality (37–60%). Few studies have characterized the efficacy of lamivudine in the treatment of chemotherapy‐induced hepatitis B virus reactivation.

Aim : To determine whether lamivudine prophylaxis reduces chemotherapy‐induced hepatitis B virus reactivation and mortality.

Methods : The medical records of all hepatitis B surface antigen‐positive patients with malignancy treated with chemotherapy since 1995 at the National University Hospital of Singapore were identified, and divided into those who received lamivudine prophylaxis before chemotherapy (P) and those who did not (NP).The parameters examined included gender, age, malignancy type, steroid usage, number of chemotherapy courses and regimens, follow‐up duration and hepatitis B virus status. The outcome measures were hepatitis B virus reactivation (abrupt rise of serum alanine aminotransferase to > 200 IU/L) and reactivation death. Patients with primary hepatoma or liver metastasis were excluded.

Results : Thirty‐five patients were identified: 16 in the P group and 19 in the NP group. The baseline characteristics of the two groups were similar. Seven of the 19 patients in the NP group and none of the 16 patients in the P group developed reactivation (36.8% vs. 0%, P=0.009). Six of the seven patients in the NP group who developed reactivation received lamivudine at that time, but five died (mortality, 71.4%), whilst no patient in the P group died from reactivation (P=0.064).

Conclusions : Prophylactic lamivudine appears to prevent hepatitis B virus reactivation and its associated mortality in patients treated with chemotherapy. This should be confirmed with prospective studies.
Clinical effectiveness of a new antacid chewing gum on heartburn and oesophageal pH control
Authors: Collings K. L. , Rodriguez‐Stanley S. , Proskin H. M. , Robinson M. , Miner P. B.
Published: March 2003

Background : Oesophageal acid neutralization with antacids depends on the duration of oesophageal antacid exposure and acid neutralizing capacity. A gum that releases antacid as it is chewed could take advantage of both mechanisms to enhance heartburn relief.

Methods : Twenty‐four subjects were crossed over to four regimens: placebo, chewable antacid tablets (1000 mg CaCO3), lower dose gum (600 mg CaCO3) and higher dose gum (900 mg CaCO3). A dual pH probe was placed, subjects ate a standardized provocative meal and self‐dosed once as needed. Symptoms were recorded every 15 min using visual analogue and Likert scales.

Results : Symptoms: Both gums decreased heartburn compared to placebo for 120 min. Higher dose gum decreased heartburn more than chewable antacids up to 120 min post‐dose. pH: Active chewable antacid and gums immediately increased oesophageal pH, with significant improvement 15–30 min post‐dose.

Summary: (i) both gums promptly decreased heartburn and elevated oesophageal pH; (ii) both gums provided sustained relief for 120 min; (iii) antacid gums provided faster and more prolonged symptom relief and pH control than chewable antacids.

Conclusions : Calcium carbonate gum effectively neutralizes oesophageal acidity and relieves symptoms following a meal, and is superior to chewable antacids in terms of the duration of heartburn relief.
Helicobacter pylori and nonulcer dyspepsia
Authors: Talley N. J. , Quan C.
Published: March 2003

Although up to 50% of patients diagnosed with nonulcer dyspepsia (NUD) have Helicobacter pylori infection and underlying chronic gastritis, it remains controversial whether any causal relationship exists. The results of worldwide epidemiological studies have been unconvincing. No clear‐cut link has been documented between H. pylori and any specific symptom profile or pathophysiological mechanism in NUD. In the randomized controlled trials, methodological weaknesses may explain in part the conflicting results, but even in the well‐conducted trials controversy persists. Although meta‐analyses have attempted to resolve the issue, inherent methodological difficulties with meta‐analysis remain a problem. Moreover, even the methodologically sound meta‐analyses have reported conflicting results. In addition, predictors of treatment response remain obscure, and there continue to be theoretical concerns about the treatment of H. pylori infection in all patients with NUD. Hence, the management of these patients is challenging, but eradication of H. pylori infection may be beneficial in a small subgroup of cases with NUD that cannot be identified before treatment.
Pharmacokinetics of budesonide controlled ileal release capsules in children and adults with active Crohn's disease
Authors: Lundin P. D. P. , Edsbäcker S. , Bergstrand M. , Ejderhamn J. , Linander H. , Högberg L. , Persson T. , Escher J. C. , Lindquist B.
Published: March 2003

Background : Systemic glucocorticosteroid therapy is effective in Crohn's disease, but is associated with side‐effects. Budesonide has high topical anti‐inflammatory activity, but considerably lower systemic activity than other oral glucocorticosteroids.

Aim : To evaluate the systemic exposure to budesonide (controlled ileal release capsules) in children and adults with active Crohn's disease, and to assess the suppression of plasma cortisol.

Methods : In an open label study, patients (eight children and six adults) with active Crohn's disease received 9 mg budesonide (Entocort capsules) orally once daily for 7 days. Plasma concentrations were determined on the seventh day of administration, and pharmacokinetic parameters were calculated. For reference, 0.5 mg budesonide was given intravenously separately. Plasma cortisol levels were compared with the pre‐treatment baseline values.

Results : Systemic exposure to budesonide (AUC0−24 h) after 1 week of oral administration was 41 ± 21 nmol/L × h (mean ± s.d.) in children and 35 ± 20 nmol/L × h in adults. The estimated systemic availability in children was 9 ± 5% and in adults 11 ± 7%. The mean plasma cortisol (AUC0−24 h) decreased by 64 ± 18% in children and by 50 ± 27% in adults.

Conclusions : The systemic exposure, systemic availability and cortisol suppression after oral administration of 9 mg budesonide were similar in children and adults with active Crohn's disease. Budesonide was well tolerated and no clinically important safety‐related findings were identified.
A rapid‐release 50‐mg tablet‐based 13C‐urea breath test for the diagnosis of Helicobacter pylori infection
Authors: Wong W. M. , Lam S. K. , Lai K. C. , Chu K. M. , Xia H. H. X. , Wong K. W. , Cheung K. L. , Lin S. K. , Wong B. C. Y.
Published: March 2003

Background : Recently, a rapid‐release 100‐mg 13C‐urea tablet with citrate supplement (Diabact UBT) showed excellent performance in a European population.

Aim : To investigate the accuracy of a 50‐mg tablet‐based 13C‐urea breath test protocol.

Methods : Consecutive dyspeptic patients referred for upper endoscopy were recruited. 13C‐Urea breath test was performed using a 50‐mg 13C‐urea tablet (Diabact UBT) and compared with the gold standard (rapid urease test and histology). Baseline, 10‐min, 20‐min and 30‐min breath samples were collected in all cases. The cut‐off values at each measurement interval were determined by three standard deviations above the mean excess δ13CO2 excretion of Helicobacter pylori‐negative patients.

Results : Two hundred patients (150 before therapy and 50 after therapy) were available for analysis, with a mean age of 48.4 years, and 99 patients (50%) were H. pylori positive. The sensitivity and specificity of the 50‐mg tablet‐based 13C‐urea breath test at 10 min, 20 min and 30 min were 100% and 98%, 100% and 100%, and 100% and 98%, respectively.

Conclusion : A 20‐min, 50‐mg tablet‐based 13C‐urea breath test (Diabact UBT) protocol is highly accurate for the diagnosis of H. pylori infection.
Non‐erosive reflux disease (NERD) — acid reflux and symptom patterns
Authors: Martinez S. D. , Malagon I. B. , Garewal H. S. , Cui H. , Fass R.
Published: March 2003

Background: Recent reports suggest that patients with non‐erosive reflux disease (NERD) treated with anti‐reflux medications show lower symptom improvement rates than patients with erosive oesophagitis treated with the same medications.

Aim: To determine the acid reflux and symptom patterns of patients with NERD in comparison with those with erosive oesophagitis and Barrett's oesophagus, and to identify different NERD subgroups.

Methods: One hundred and forty‐nine consecutive patients seen for classic heartburn symptoms were evaluated for the study. Oesophageal mucosal injury was assessed by upper endoscopy and classified by Hetzel–Dent criteria. Patients with Hetzel–Dent grades 0–1 were considered to have NERD. The extent of oesophageal acid exposure was determined by ambulatory 24‐h oesophageal pH monitoring.

Results: Seventy‐one patients were found to have NERD, 36 erosive oesophagitis and 42 Barrett's oesophagus. Compared with patients with erosive oesophagitis (75%) and Barrett's oesophagus (93%), those with NERD (45%) were significantly less likely to have an abnormal pH test (P = 0.0001). Patients with Barrett's oesophagus had the highest mean number of acid reflux events (210 ± 17.7), compared with those with erosive oesophagitis (139.7 ± 15.2) and NERD (95.3 ± 9.4) (P = 0.0001); however, the rate of perceived acid reflux events was similar and very low in all groups (NERD, 3.6%; erosive oesophagitis, 2.9%; Barrett's oesophagus, 2.17%). NERD‐positive patients (abnormal pH test) had a similar extent of oesophageal acid exposure to those with erosive oesophagitis. NERD‐positive patients were more likely to demonstrate a symptom index greater than 75% than NERD‐negative patients (normal pH test) (61.9% vs. 10.5%; P = 0.0001). In the NERD‐negative group, those with a negative symptom index reported having heartburn at pH < 4 only 12.7% of the time, compared with 70.7% of the time in those with a positive symptom index, despite a similar mean number of heartburn episodes.

Conclusions: Patients with NERD commonly demonstrate a negative pH test. Acid reflux characteristics and symptom patterns suggest a heterogeneous group of patients.
Efficacy and safety of single‐triple capsules of bismuth biskalcitrate, metronidazole and tetracycline, given with omeprazole, for the eradication of Helicobacter pylori: an international multicentre study
Authors: O'Morain C. , Borody T. , Farley A. , De Boer W. A. , Dallaire C. , Schuman R. , Piotrowski J. , Fallone C. A. , Tytgat G. , Mégraud F. , Spénard J.
Published: March 2003

Background : The high prevalence of Helicobacter pylori resistance to metronidazole demands treatments more effective than standard bismuth‐based triple therapy against these strains.

Aim : To evaluate the H. pylori eradication rate in both metronidazole‐sensitive and ‐resistant strains following quadruple therapy using single‐triple capsules of bismuth biskalcitrate, metronidazole and tetracycline, given with omeprazole.

Methods : One hundred and seventy valid patients with duodenal ulcer, gastric ulcer or non‐ulcer dyspepsia were treated in eight centres located in five countries. H. pylori was confirmed at baseline using 13C‐urea breath test, histology and/or culture. Patients received three single‐triple capsules q.i.d. and omeprazole, 20 mg b.d., for 10 days. Each capsule contained bismuth biskalcitrate, 140 mg (as 40 mg Bi2O3 equivalent), metronidazole, 125 mg, and tetracycline, 125 mg. 13C‐Urea breath test was repeated at least 4 and 8 weeks post‐treatment.

Results : Overall eradication rates were 93% (158/170) by modified intention‐to‐treat analysis and 97% (142/146) by per protocol analysis. Eradication rates were 93% (40/43) and 95% (38/40) for strains resistant to metronidazole and 95% (82/86) and 99% (75/76) for strains sensitive to metronidazole by modified intention‐to‐treat and per protocol analysis, respectively.

Conclusion : This omeprazole–bismuth biskalcitrate–metronidazole–tetracycline 10‐day regimen is a very effective and well‐tolerated treatment, which overcomes metronidazole resistance.
Effect of frequent consumption of a Lactobacillus casei‐containing milk drink in Helicobacter pylori‐colonized subjects
Authors: Cats A. , Kuipers E. J. , Bosschaert M. A. R. , Pot R. G. J. , Vandenbroucke‐Grauls C. M. J. E. , Kusters J. G.
Published: March 2003

Background : Several studies have reported inhibitory effects of lactic acid bacteria on bacterial pathogens.

Aim : To test whether a drink containing Lactobacillus casei strain Shirota inhibits Helicobacter pylori growth.

Methods : The in vitro growth inhibition of H. pylori was studied when L. casei was added to plates previously inoculated with H. pylori reference strain NCTC 11637. In an intervention study, 14 H. pylori‐positive subjects were given Yakult drink (108 colony‐forming units/mL L. casei) thrice daily during meals for 3 weeks. Six untreated H. pylori‐positive subjects served as controls. H. pylori bacterial loads were determined using the 13C‐urea breath test, which was performed before and 3 weeks after the start of L. casei supplementation.

Results : In vitro, L. casei inhibits H. pylori growth. This effect was stronger with L. casei grown in milk solution than in DeMan–Rogosa–Sharpe medium. No growth inhibition was shown with medium inoculated with lactic acid, Escherichia coli strain DH5α or uninoculated medium. Filtration of L. casei culture before incubation with H. pylori completely abolished the inhibitory effect. Urease activity decreased in nine of the 14 (64%) subjects with L. casei supplementation and in two of the six (33%) controls (P = 0.22).

Conclusions : Viable L. casei are required for H. pylori growth inhibition. This does not result from changes in lactic acid concentration. In addition, a slight, but non‐significant, trend towards a suppressive effect of L. casei on H. pylori in vivo may exist.
The pharmacological properties and clinical use of valdecoxib, a new cyclo‐oxygenase‐2‐selective inhibitor
Authors: Alsalameh S. , Burian M. , Mahr G. , Woodcock B. G. , Geisslinger G.
Published: March 2003

Cyclo‐oxygenase‐2‐selective inhibitors produce less gastric damage than conventional non‐steroidal anti‐inflammatory drugs. Valdecoxib is a new orally administered cyclo‐oxygenase‐2‐selective inhibitor, recently approved for use in osteoarthritis, rheumatoid arthritis and primary dysmenorrhoea in the USA. The drug has been evaluated in more than 60 clinical studies involving more than 14 000 patients and healthy volunteers. The analgesic efficacy of valdecoxib at a dose of 10 mg once daily in both osteoarthritis and rheumatoid arthritis is superior to that of placebo and similar to that of traditional non‐steroidal anti‐inflammatory drugs. Valdecoxib is effective in single doses of up to 40 mg for the alleviation of acute menstrual pain and has a rapid onset of action (within 30 min) and a long duration of analgesia (up to 24 h). Valdecoxib is well tolerated and has safety advantages compared with traditional non‐steroidal anti‐inflammatory drugs in terms of less gastrointestinal toxicity and a lack of an effect on platelet function. The incidence of adverse effects involving the kidney (fluid retention, oedema and hypertension) is similar to that of non‐selective, non‐steroidal anti‐inflammatory drugs.
The theoretical ideal fresh‐gas flow sequence at the start of low‐flow anaesthesia
Authors: Mapleson W. W.
Published: March 2003

A spreadsheet model of a circle breathing system and a 70‐kg anaesthetised ‘standard man’ has been used to simulate the first 20 min of low‐flow anaesthesia with halothane, enflurane, isoflurane, sevoflurane and desflurane in oxygen. It is shown that, with the fresh‐gas flow set initially equal to the total ventilation and the fresh‐gas partial pressure to 3 MAC, the end‐expired partial pressure can be raised to 1 MAC in 1 min with desflurane and sevoflurane, 1.5 min with isoflurane, 2.5 min with enflurane and 4 min with halothane. Sequences of lower fresh‐gas flow and partial pressure settings are given for then maintaining 1 MAC end‐expired partial pressure, with a minimum usage of anaesthetic, e.g. 13 ml of liquid desflurane in 20 min (of which only 33% is taken up by the patient) if the minimum acceptable flow is 1 lmin−1, or 8 ml (with 57% in the patient) if the minimum is 250 mlmin−1.
Clinical utility of EEG parameters to predict loss of consciousness and response to skin incision during total intravenous anaesthesia
Authors: Schraag S. , Mohl U. , Bothner U. , Georgieff M.
Published: March 2003

We studied 30 female patients undergoing elective surgery, to assess the reliability of electroencephalogram spectral edge frequency and median frequency to predict loss of consciousness and movement in response to skin incision during total intravenous anaesthesia. Each patient received a different combination of propofol (1, 2, 3, 4, 5 or 6 μgml−1) and sufentanil (0.1, 0.2, 0.3, 0.5 or 1.0 ngml−1) target concentrations for induction of anaesthesia using target controlled infusions, assigned randomly. In a logistic regression model, spectral edge frequency was a significant determinant of both loss of consciousness (p = 0.0006) and movement to skin incision (p = 0.0044), whereas for median frequency no significant prediction model could be established. The probabilities of 50% and 95% no response for spectral edge frequency were 13.4 Hz and 6.8 Hz, respectively. The variability of the data limited the predictive value, so that spectral edge frequency was a poor predictor and median frequency was no predictor of response in the individual patient during total intravenous propofol/sufentanil anaesthesia.
Pre‐operative fasting for paediatric anaesthesia A survey of current practice
Authors: Emerson B. M. , Wrigley S. R. , Newton M.
Published: March 2003

There has recently been much debate about pre‐operative fasting for paediatric anaesthesia. There is no consensus about the optimum fasting times for children undergoing elective surgery. In order to establish a standard for paediatric pre‐operative fasting times, we undertook a postal survey, targeting members of the Association of Paediatric Anaesthetists resident in the United Kingdom and Ireland in 1995. One hundred and sixty‐three questionnaires were despatched, 131 (80%) were returned and 110 (67%) were complete. The results show that the following guidelines for duration of fast are acceptable to the majority of respondents — neonates: 2 h for clear fluids, 4 h for breast and formula milk; infants: 2 h for clear fluids, 4 h for breast milk, 6 h for formula milk and solids; children: 2 h for clear fluids, 6 h for milk and solids. We suggest that these times be used as guidelines and audited for pre‐operative fasting in paediatric anaesthesia.
Prolonged impairment in activities of daily living due to postdural puncture headache after diagnostic lumbar puncture
Authors: Tohmo H. , Vuorinen E. , Muuronen A.
Published: March 2003

To assess the incidence of postdural puncture headache and its effects on patients' activities of daily living, we interviewed 325 adult patients subjected to a diagnostic lumbar puncture during a 1‐year period. Two hundred and eighteen (67%) of the subjects replied to the questionnaire; 41 (19%) of these were diagnosed as having suffered a postdural puncture headache. Impairment of the activities of daily living persisting for 1 week or more was experienced by 16 (7%) of the subjects.
Caudal epidurals: the whoosh test
Authors: Eastwood D. , Williams C. , Buchan I.
Published: March 2003

Caudal epidural injection is a simple procedure that carries a low risk of complications. The whoosh test (injection of air into the caudal epidural space with simultaneous auscultation over the thoracolumbar spine) has been recommended as an aid to correct needle placement. A 1‐year prospective study, using fluoroscopic imaging to identify needle position, was conducted to compare the sensitivity and specificity of the whoosh test with that of clinical impression alone in assessing correct needle placement in the caudal space. Of 131 patients studied, correct needle placement was achieved in 121 on the first attempt (92%). Clinical impression alone had a sensitivity of 94% and a specificity of 20%. The whoosh test had a sensitivity of 80% and a specificity of 60%. The whoosh test is superior to clinical judgment in detecting incorrect caudal needle placement.
Systemic mastocytosis presenting as profound cardiovascular collapse during anaesthesia
Authors: Vaughan S. T. A. , Jones G. N.
Published: March 2003

Mastocytosis is a rare disorder with serious anaesthetic implications. Anaesthetic management is hazardous since trauma, stress, extremes of temperature and drugs may precipitate intra‐operative mast cell degranulation. Release of histamine and other mast cell mediators can lead to profound cardiovascular collapse and even death. We present a case report of a patient with mastocytosis who suffered cardiac arrest during anaesthesia. Anaphylactoid/anaphylactic shock may be delayed and lack supporting signs of histamine release such as cutaneous flushing and bronchospasm.
Gamma‐hydroxybutyric acid: an emerging recreational drug
Authors: Kam P. C. A. , Yoong F. F. Y.
Published: March 2003

Gamma‐hydroxybutyric acid (GHB) is no longer used as an anaesthetic induction agent because of the high incidence of myoclonic seizures and vomiting. However, it is used occasionally in Europe for the treatment of narcolepsy, alcohol dependence and opiate dependence. Since the early 1990s, GHB has become a drug of abuse in youths for its euphoric, sedative and anabolic effects. Common adverse effects include a rapid onset of drowsiness, nausea, vomiting, myoclonic seizures and coma of short duration. Clinicians should be alert for these adverse effects and consider the possibility of GHB abuse in young adults with unusual clinical presentations in the emergency department.
Influence of anaesthesia on defibrillation threshold
Authors: Moerman A. , Herregods L. , Tavernier R. , Jordaens L. , Struys M. , Rolly G.
Published: March 2003

Internal cardioverter–defibrillator implantation can be performed under local or general anaesthesia. Whether the technique of general anaesthesia influences the defibrillation threshold remains a matter of debate. We therefore compared, in a prospective, randomised clinical study, the effect of intravenous anaesthesia using propofol with inhalational anaesthesia using isoflurane on the defibrillation threshold in 68 patients scheduled for transvenous single‐lead internal cardioverter–defibrillator implantation. Defibrillation threshold was measured at implantation and at device testing 1 week and 1 month after implantation. Patients acted as their own controls. Neither the anaesthetic technique nor the duration of anaesthesia was associated with significant changes in the defibrillation threshold. We conclude that in this group of high‐risk patients, both types of anaesthesia are acceptable techniques for internal cardioverter–defibrillator implantation and testing.
Comparison of supine and upright positions on autonomic nervous activity in late pregnancy: the role of aortocaval compression
Authors: Chen Gau‐Yang , Kuo Cheng‐Deng , Yang Ming‐Jie , Lo Huey‐Ming , Tsai Yuh‐Show
Published: March 2003

In order to understand the effect of aortocaval compression on autonomic nervous activity, we compared the effects of supine and upright postures on measures of heart rate variability in late pregnancy. Thirty‐two women in late pregnancy and 23 nonpregnant age‐matched women were studied. Both time and frequency domain heart rate variability measures were compared between the supine and upright positions, and between pregnant women and controls. The pregnant women had smaller mean RR interval, standard deviation of RR intervals and normalised high‐frequency power, and a larger low‐ to high‐frequency power ratio than nonpregnant women in the supine position. When the position was changed from upright to supine in nonpregnant women, the percentage change in the mean RR interval and normalised high‐frequency power were increased, whereas the percentage change in the coefficient of variation of RR interval and low‐ to high‐frequency power ratio were decreased. In contrast, the percentage change in normalised high‐frequency power was decreased and the percentage change in low‐ to high‐frequency power ratio was increased in pregnant women when the position was changed from upright to supine. These results indicate that the vagal enhancing effect seen in normal subjects when changing position from upright to supine was reversed in women in late pregnancy. Aortocaval compression in the supine position in pregnant women might be responsible for this reversal in the autonomic response to lying down.
The use of tramadol following day‐case oral surgery
Authors: Broome I. J. , Robb H. M. , Raj N. , Girgis Y. , Wardall G. J.
Published: March 2003

This prospective, randomised double‐blinded study was designed to assess the analgesic efficacy and occurrence of nausea when tramadol is added to a nonsteroidal anti‐inflammatory drug to provide analgesia following day‐case third molar teeth extraction. All patients received oral diclofenac pre‐operatively and one of four treatments intra‐operatively: fentanyl and metoclopramide, tramadol and metoclopramide, fentanyl and ondansetron, or tramadol and ondansetron. There were no significant differences between groups in scores for pain in the early postoperative period. However, there were significant differences in nausea scores at this time, with the fentanyl–ondansetron group having the lowest and the tramadol–ondansetron group having the highest scores. There were no significant differences in the incidence of pain or nausea in the following 24 h. We conclude that the addition of tramadol to diclofenac results in no useful improvement in analgesic effect, and that the use of ondansetron fails to reduce the nausea associated with tramadol.
A comparison of the antibacterial activity of levobupivacaine vs. bupivacaine: an in vitro study with bacteria implicated in epidural infection
Authors: Hodson M. , Gajraj R. , Scott N. B.
Published: March 2003

The purpose of the study was to compare the antibacterial activity of bupivacaine with levobupivacaine against a range of bacteria implicated in epidural infection to determine whether any differences existed between the two drugs. Concentrations of 0.125%, 0.25% and 0.5% bupivacaine and levobupivacaine were inoculated with suspensions of either Staphylococcus epidermidis, Staphylococcus aureus or Enterococcus faecalis. After incubation, the mixtures were plated onto blood agar and colony counts were recorded after a further period of incubation. The minimum bactericidal concentration of local anaesthetic against the three bacteria studied was found to be 0.25% for bupivacaine and 0.5% for levobupivacaine showing racemic bupivacaine to have a more potent antibacterial action than levobupivacaine. This finding suggests that the dextrobupivacaine isomer of racemic bupivacaine has a more potent antibacterial action than the levobupivacaine isomer.
THIS ARTICLE HAS BEEN RETRACTED Nefopam and clonidine in the prevention of postanaesthetic shivering
Authors: Piper S. N. , Suttner S. W. , Schmidt C. C. , Maleck W. H. , Kumle B. , Boldt J.
Published: March 2003

Postanaesthetic shivering affects up to 70% of patients after general anaesthesia, and may be very distressing. Various drugs have been used to treat or prevent postanaesthetic shivering, but the ideal one has not yet been found. Sixty patients undergoing elective abdominal or orthopaedic surgery under general anaesthesia were included in a randomised, double‐blind study. Patients received clonidine (3 μg.kg−1), nefopam (0.15 mg.kg−1) or saline 0.9% as a placebo at the end of surgery, prior to extubation. Nefopam and clonidine significantly reduced the incidence and severity of shivering in comparison with the placebo. The recovery time, between the end of anaesthesia and extubation, was significantly longer in the clonidine‐treated patients [13.6 (5.2) min] than in either the nefopam [9.6 (2.8) min] or the placebo [10.0 (5.4) min] groups. Mean arterial blood pressure and heart rate were significantly lower in the clonidine group compared with both other groups. Our results suggest that nefopam and clonidine are effective in the prevention of postanaesthetic shivering. However, following clonidine administration the recovery time was prolonged and hypotension was significantly greater than after nefopam.
The story of the gauge
Authors: Pöll J. S.
Published: March 2003

Gauges are old measures of thickness. They originated in the British iron wire industry at a time when there was no universal unit of thickness. The sizes of the gauge numbers were the result of the process of wire‐drawing and the nature of iron as a substance. Gauges were measured and described in fractions of an inch during the 19th century. In the UK, one gauge was standardised and legally enforced as the Standard Wire Gauge. One important reason for the standardisation of the gauge was the convenience of craftsmen. In the 20th century, the gauge was to be replaced with the introduction of the International System of Units. However, within the field of anaesthesia at the threshold of the 21st century, the gauge seems hard to remove from the minds of craftsmen like anaesthetists.
Retracted: Comparison of the effects of desflurane and isoflurane anaesthesia on hepatocellular function assessed by alpha glutathione S‐transferase
Authors: Schmidt C. C. , Suttner S. W. , Piper S. N. , Nagel D. , Boldt J.
Published: March 2003

The purpose of this study was to investigate the influence of isoflurane and desflurane on hepatocellular function. Twenty male patients undergoing elective surgery were randomly assigned to receive either isoflurane or desflurane anaesthesia. Alpha glutathione S‐transferase concentrations and aminotransferase activities were measured at induction of anaesthesia (t0), 15 min (t1), 90 min after induction (t2), end of surgery (t3) and 2 h thereafter (t4). A significant increase in alpha glutathione S‐transferase concentration was observed only in the isoflurane group. Alpha glutathione S‐transferase levels increased significantly from 2.3 μg.l−1 at t0 to 6.1 (1.9) μg.l−1 at t2 and to 7.8 (2.1) μg.l−1 at t3. A significant difference in alpha glutathione S‐transferase concentration between the two groups was found at t2 and t3. The significant increases in alpha glutathione S‐transferase concentrations in patients receiving isoflurane suggest a transient disturbance of hepatocellular function.
A survey of pre‐operative fasting regimens before regional ophthalmic anaesthesia in three regions of the United Kingdom
Authors: Morris E. A. J. , Mather S. J.
Published: March 2003

A postal and telephone survey of the practice of fasting before regional ophthalmic anaesthesia with and without sedation was sent to 50 hospitals in three regions of the United Kingdom. Responses were received from 100% of hospitals. In most hospitals (58%), local anaesthetic blocks were performed by both surgeons and anaesthetists, with surgeons alone providing ophthalmic anaesthesia in only 14%. Eighty‐six per cent of hospitals surveyed had a formal policy regarding pre‐operative fasting, with 44% allowing patients to eat and drink freely until their operation. In those hospitals where a fast was imposed, the most common fasting periods were 6 h for food and 2 h for fluids. Twenty‐six per cent of respondents would be prepared to give intravenous sedation to a non‐fasted patient during eye surgery: small doses of benzodiazepine were the most frequently suggested method. National evidence‐based guidelines for ophthalmic regional anaesthesia are needed.
‘Speaking in tongues’Paradoxical fixation on a non‐native language following anaesthesia
Authors: Ward M. E. , Marshall J. C.
Published: March 2003

An intriguing case of transient language disturbance following anaesthesia is described which may throw some light on the way languages are stored in the brain. A review of the existing literature and its relevance to this unique case is discussed.
A comparison of patient‐controlled epidural analgesia following gynaecological surgery with and without a background infusion
Authors: Wong K. , Chong J. L. , Lo W. K. , Sia A. T. H.
Published: March 2003

We conducted a randomised, controlled study to investigate the effect of adding a background infusion to patient‐controlled epidural analgesia for postoperative pain relief. Forty‐two patients scheduled for elective lower abdominal gynaecological surgery received patient‐controlled epidural analgesia postoperatively using a mixture of 0.2% ropivacaine and 2.0 μg.ml−1 fentanyl. Patients in group B (n = 20) were given a background infusion of 5 ml.h−1, whereas those in group N (n = 21) were not. There was no difference in pain scores or patient satisfaction scores between the two groups. Patients in group B had a higher total drug consumption (156.8 ± 34.8 ml vs. 89.5 ± 41.0 ml; p < 0.0001) and incidence of side‐effects (71.4% vs. 30.0%; p = 0.007). Motor blockade during the 24‐h study period was also greater in group B (median [range] area under the curve 7.5 [0.0–39.0] h vs. 3.0 [0.0–36.0] h; p = 0.035). We conclude that the addition of a background infusion to patient‐controlled epidural anaesthesia is not recommended as it confers no additional benefits.
Risk factors for pressure sores in the critically ill
Authors: Theaker C. , Mannan M. , Ives N. , Soni N.
Published: March 2003

Pressure sore development in the critically ill is a well‐recognised problem and several risk factors have been put forward as being relevant; however, none has been proved valid in this population. This study examines the effects of specific risk factors for the development of pressure sores in the critically ill. Data on 22 specific risk factors were recorded every 8 h. Of 286 patients who were identified as having a minimum set of three predetermined risk factors, 77 developed pressure sores. Using univariate regression analysis, 18 of the 22 specific factors were identified as being significant (p < 0.05) in the development of pressure sores. Multivariate analysis identified five of these 18 specific risk factors as being independently significant (p < 0.05) in pressure sore development. These five factors were norepinephrine infusion, APACHE II score, faecal incontinence, anaemia and length of stay.
An investigation into the quantity of secretions removed by inflated and deflated laryngeal mask airways
Authors: Deakin C. D. , Diprose P. , Majumdar R. , Pulletz M.
Published: March 2003

It has been suggested that removal of a laryngeal mask airway with the cuff inflated may remove more secretions than with the cuff deflated. We performed a study to determine whether this suggestion is correct. Patients were randomly allocated to removal of the laryngeal mask airway with the cuff deflated (n = 75) or inflated (n = 74). The laryngeal mask airways were weighed before insertion and after removal, the difference in these two weights being taken to be the mass of secretions adherent to the airways on removal. The mean (SD) increase in laryngeal mask airway weight was 2.45 (1.47) g with the cuff deflated and 3.03 (1.76) g with the cuff inflated (p = 0.03). We conclude that removal of the laryngeal mask airway with the cuff inflated removes approximately 0.5 g more secretions than with the cuff deflated.
A double‐blind randomised comparison of ropivacaine 0.5%, bupivacaine 0.375% – lidocaine 1% and ropivacaine 0.5% – lidocaine 1% mixtures for cataract surgery
Authors: Perello A. , George J. , Skelton V. , Pateman J.
Published: March 2003

This study evaluated the efficacy and side‐effects of plain ropivacaine compared with ropivacaine–lidocaine and bupivacaine–lidocaine mixtures for peribulbar blocks in cataract surgery. Ninety patients were randomly allocated to three groups and received peribulbar blockade using one of the three solutions. Speed of onset and quality of blockade were assessed using akinesia, surgical satisfaction and patient satisfaction. Complications and cardiovascular side‐effects were noted. There was a slower onset of akinesia using ropivacaine alone, although at 10 min after injection all groups were equal in this respect. There was no difference in surgical or patient satisfaction between the groups. There were no differences in pain on injection, preblock and postblock blood pressure, heart rate or oxygen saturation. The optimal time to surgical incision after peribulbar blockade is not less than 15 min and plain ropivacaine fulfils this criterion.
THIS ARTICLE HAS BEEN RETRACTED Acute phase response to nitroprusside‐induced controlled hypotension in patients undergoing radical prostatectomy
Authors: Piper S. N. , Suttner S. W. , Schmidt C. C. , Kumle B. , Maleck W. H. , Boldt J.
Published: March 2003

This study evaluated the effects of sodium nitroprusside‐induced controlled hypotension on the acute phase response in patients undergoing radical prostatectomy. Thirty patients were randomly allocated to two groups, a hypotension group (mean arterial blood pressure was adjusted to 50 mmHg) and a control group (mean arterial blood pressure > 70 mmHg). C‐reactive protein increased significantly in the hypotension group from 0.13 (0.23) to 9.85 (2.84) μg.ml−1 and in the control group from 0.15 (0.27) to 7.38 (3.02) μg.ml−1. In both groups, serum amyloid A increased significantly, but levels were higher in the hypotension group [585 (125) μg.l−1] than in the control group [460 (187) μg.l−1]. Interleukin‐6 increased significantly in both groups, but was higher in the hypotension group [139 (124) pg.ml−1] than the control group [56 (27) pg.ml−1]. Elastase showed no significant changes in the control group but in the hypotension group there was a significant increase from 65 (51) to 122 (75) ng.ml−1. Sodium nitroprusside‐induced hypotension was associated with a more pronounced acute phase reaction.
A pilot study to investigate the effects of an infusion of aminophylline on renal function following major abdominal surgery
Authors: Parker M. R. J. , Willatts S. M.
Published: March 2003

Acute renal failure is a frequent complication of critical illness and optimal preventive therapy remains elusive. There is increasing evidence from animal models and some human studies that adenosine receptor antagonism by aminophylline may reduce the severity of renal impairment caused by a variety of aetiologies. We studied the renal effects of intravenous aminophylline in an unblinded, within‐patient study of 20 patients admitted to a general intensive care unit following major surgery. We demonstrated that there were no adverse cardiovascular complications related to aminophylline therapy. Renal sodium and osmolar clearance increased with a non‐significant trend towards increased diuresis during treatment. Creatinine clearance, however, was unchanged but the study was not designed and did not have the power to test whether aminophylline increased renal blood flow or glomerular filtration rate. We suggest the renal actions of aminophylline in critical illness merit further investigation.
The peri‐operative complications of nasal intubation: a comparison of nostril side
Authors: Coe T. R. , Human M.
Published: March 2003

We studied 128 patients undergoing nasal intubation to see whether the nostril side used influenced peri‐operative nasal complications. In the apparently normal nostril, there is no significant difference between either nostril in difficulty of intubation (p > 0.8). Similarly, there is no significant difference in the incidence of bleeding at intubation (p > 0.2), at extubation (p > 0.5) and once the patient has returned to recovery (p > 0.1). Postoperative nostril patency is also similar between groups (p > 0.85).
The effect of intravenous dexmedetomidine premedication on the dose requirement of propofol to induce loss of consciousness in patients receiving alfentanil
Authors: Peden C. J. , Cloote A. H. , Stratford N. , Prys‐Roberts C.
Published: March 2003

Dexmedetomidine reduces the dose requirements for opioids and anaesthetic agents. We conducted a single‐centre, open‐label, noncomparative phase II study of the effect of intravenous dexmedetomidine on the dose requirement of propofol to induce loss of consciousness in 49 ASA I and II patients. The initial dexmedetomidine infusion scheme was reduced twice because of adverse events. Forty patients who received the final infusion scheme were randomly allocated to receive one of five stepped propofol infusions; loss of consciousness was assessed after 21 min. The ED50 for the final infusion rate of propofol to suppress consciousness was 3.45 mg.kg−1.h−1 (95% CL 2.7–4.2): ED95 was 6.68 mg.kg−1.h−1 (95% CL 5.1–19.1), EC50 was 1.69 µg.ml−1 (95% CL 0.95–2.5) and EC95 was 5.7 µg.ml−1 (95% CL 3.2 to > 10). Our final dose of dexmedetomidine of 0.63 µg.kg−1 caused a reduction in the overall concentration and dose of propofol required to produce loss of consciousness, but no significant shift in the dose–response curve compared with other studies.