Initial cranial CT scan for the assessment of prognosis in head injury

Summary A total of 208 multiple trauma patients with head injury (HI) were investigated who had been treated in the period from 1990 to 1995. The average age was 35.2 ± 17.7 years; the injury severity according to ISS was 30.2 ± 8.6 points; 20.5 % died as a result of the HI; the mortality of all patients was 26.5 %. The Glasgow Coma Scale (GCS) was determined at an average of 22 min after trauma (8.0 ± 4.3 points) at the scene of accident. The patients were classified according to GCS into minor HI (group 1: 14–15 points), moderate HI (group 2: 9–13 points) and severe HI (group 3: 3–8 points). Patient outcome was assessed by the Glasgow Outcome Scale (GOS) and was classified as good (GOS 4 and 5) and poor (GOS 1, 2 and 3) outcome. At the latest, 2 h after trauma, a CT scan of the head (CCT) was done. The HI groups are compared regarding frequency of types of injury. In all HI groups the fractures of the bony face occurred at the same frequency (36.0–38.9 %). The frequency of calotte fractures (Kal-Fx) increased from group 1 (8.0 %) to 2 (19.2 %) and 3 (25.6 %); fractures of the skull base significantly differed between group 1 (16.0 %), 2 (7.8 %) and 3 (33.4 %). Epidural hemorrhage (EDB) appeared only in group 2 (7.8 %) and 3 (6.7); subdural hemorrhage was found in group 1 (2.7 %), 2 (7.8 %) and 3 (10.0 %). Subarachnoid hemorrhage (SAB) was significantly more frequently seen, dependent on HI severity, in group 3 (26.7 %) compared to group 2 (11.7 %) and 1 (8.0 %). Intracerebral contusion (ICK) significantly increased from group 1 (12.0 %) to 2 (27.3) and 3 (45.6 %). Brain swelling (BS) also significantly increased from group 1 (8.0 %) to 2 (19.5 %) and 3 (49.0 %) and lesions of ventricles (VL) from group 1 (2.7 %) to 2 (11.7 %) and 3 (20.0 %). Midline shift (13.4 %) and signs of herniation (4.5 %) only occurred in group 3. The analysis of correlation/regression and receiver operating characteristics was able to predict 79 % of patients' outcome accurately using GCS (r 0.54; P < 0.0001) alone, using CCT (r 0.65; P < 0.0001) 87 % were correctly predicted with significant variables Cal-Fx, EDB, SAB and BS. CCT with GCS (r 0.74; P < 0.0001) were able to predict 88 % accurately with significant variables Cal-Fx, EDB, BS and GCS. The combination of CCT with GCS, age and ISS (r 0.78; P < 0.0001) was able to predict only 87 % correctly, although the r value was the highest; significant variables were Kal-Fx, EDB, BS, VL, GCS, age and ISS.      

The laboratory performance of the enFLOW®, buddy lite™ and ThermoSens® fluid warmers

We measured heating of isotonic saline by three fluid warmers in six experiments: saline at 5 °C or 20 °C delivered at 30, 50 or 100 ml.min^?1. At the three flow rates, the enFLOW^®, buddy lite^? and ThermoSens^® systems heated 5 °C saline to mean (SD) temperatures of: 41.1 (0.5) °C, 37.7 (0.6) °C and 39.1 (0.6) °C; to 40.3 (0.8) °C, 33.9 (1.6) °C and 39.3 (0.7) °C; and to 37.1 (0.8) °C, 24.0 (1.3) °C and 37.6 (1.0) °C, respectively, p < 0.0001 for each experiment. The mean (SD) times taken to heat 5 °C saline were: 16.6 (1.7) s, 258.4 (58.9) s and 134.2 (79.6) s; 16.9 (1.8) s, 256.2 (62.2) s and 182.5 (74.5) s; and 21.5 (1.5) s, 275.9 (49.3) s and 313.5 (18.0) s, respectively, p < 0.0003 for each experiment. The results for saline at 20 °C were similar. The enFLOW system heated saline above 36 °C faster than the ThermoSens system, whereas the buddy lite often failed to achieve 36 °C.     

Total Joint Arthroplasty Outcomes in Patients With a Previously Failed Toxicology Screen: A Propensity Score–Matched Analysis

BackgroundThe purpose of this study is to review the outcomes of a consecutive series of arthroplasty patients who had previously failed a urine toxicology test. Specifically, we assessed (1) mortality at last follow-up; (2) 90-day readmission and reoperation; (3) rate of complications; and (4) hospital length of stay (LOS) and rates of nonhome discharge.MethodsA single-institution, electronic medical record database was queried for primary arthroplasty patients from 2006 to 2017 who had previously failed a day-of-arthroplasty urine toxicology screen. Patients were matched in a 2:1 ratio with toxicology-negative controls.ResultsThe mortality rate among toxicology-positive THA patients was 1 of 20 (5%) compared to 0 of 40 among controls (P = .333); the rate of readmission was 3 of 20 (15%) vs 0 of 40 (P = .033); the rate of reoperation was 1 of 20 vs 0 of 40 (P = .333); the rate of surgical complications was 6 of 20 (30%) vs 1 of 40 (2.5%) (P = .004); the rate of medical complication was 4 of 20 (20%) vs 1 of 40 (2.5%) (P = .038); the average LOS was 4 days (range, 1-8 days) vs 2 days (range, 1-10) (P = .002); and the rate of nonhome discharge was 5 of 20 (25%) vs 2 of 40 (5%) patients in the control group (P = .013). The mortality rate among toxicology-positive TKA patients was 1 of 19 (5.3%) compared to 0 of 38 among controls (P = .333); the rate of readmission was 5 of 19 (26.3%) vs 2 of 39 (5.3%) (P = .033); the rate of reoperation was 3 of 19 (15.8%) vs zero (P = .033); the rate of surgical complications was 4 of 21 (21.1%) vs 1 of 38 (2.6%) (P = .038); the rate of medical complications was 5 of 19 (26.3%) vs 2 of 38 (5.3%) (P = .035); the average LOS was 4 days (range, 2-6 days) vs 2 days (range, 1-8 days) (P = .001), the rate of nonhome discharge was 7 of 19 (36.8%) compared to 2 of 38 (5.3%) in the control group (P = .004).ConclusionThese results suggest that toxicology-positive patients require a careful discussion of goals of care before undertaking total hip arthroplasty or total knee arthroplasty.     

Prednisone inhibits formation of cortical bone in sham-operated and ovariectomized female rats

Prednisone inhibits bone formation and causes bone loss. To investigate possible mechanisms and sites, the effects of sham operation, ovariectomy, and prednisone were determined on bone and mineral metabolism in 7-week-old growing female rats. Forty animals were divided into groups of 10 each. Sham operation and ovariectomy were performed. One week later, pellets containing 5 mg prednisone or drug free were implanted S.C. at the back of the neck. Four weeks later, animals were sacrificed and tibiae were removed for histomorphometric analysis of the middiaphysis and proximal metaphysis. In both sham-operated and ovariectomized rats, prednisone (1) reduced weight gain (P<0.02) and did not alter uterine weight; (2) lowered serum magnesium (Mg) (P<0.001) and did not change serum calcium (Ca), phosphate (P), 25-hydroxyvitamin D (25OHD), or 1,25-dihydroxyvitamin D [1,25(OH)₂D]; (3) produced striking increases in calcified cartilage, reduced cross-sectional area (P<0.05) and cortical area (P<0.01) and did not change medullary area of the tibial diaphysis; (4) lowered periosteal and endocortical bone formation and apposition rates; and (5) increased mean cancellous bone area (P<0.05) and cancellous bone perimeter (P<0.01) of the tibial metaphysis. In both control and prednisone-treated rats, ovariectomy (1) reduced uterine weight (P<0.001); (2) did not change serum Ca, P, Mg, 25OHD, or 1,25(OH)₂D; (3) did not change mean cross-sectional, medullary, or cortical areas; (4) increased periosteal bone formation and apposition rates (P<0.01) and did not alter endosteal bone formation and apposition rates, and (5) decreased cancellous bone area (P<0.01) and cancellous bone perimeter (P<0.01). Thus, in short-term studies, prednisone increased calcified cartilage and inhibited the formation of cortical bone at periosteal and endosteal surfaces and reduced cortical bone of the tibia in both sham-operated and ovariectomized, rapidly growing animals.     

Skills among young and elderly laypersons during simulated dispatcher assisted CPR and after CPR training

Background

Dispatcher assisted cardiopulmonary resuscitation (DA‐CPR) increase the rate of bystander CPR. The aim of the study was to compare the performance of DA‐CPR and attainable skills following CPR training between young and elderly laypersons.

Methods

Volunteer laypersons (young: 18–40 years; elderly: > 65 years) participated. Single rescuer CPR was performed in a simulated DA‐CPR cardiac arrest scenario and after CPR training. Data were obtained from a manikin and from video recordings. The primary endpoint was chest compression depth.

Results

Overall, 56 young (median age: 26, years since last CPR training: 6) and 58 elderly (median age: 72, years since last CPR training: 26.5) participated. Young laypersons performed deeper (mean (SD): 56 (14) mm vs. 39 (19) mm, P < 0.001) and faster (median (25th–75th percentile): 107 (97–112) per min vs. 84 (74–107) per min, P < 0.001) chest compressions compared to elderly. Young laypersons had shorter time to first compression (mean (SD): 71 (11) seconds vs. 104 (38) seconds, P < 0.001) and less hands‐off time (median (25th–75th percentile): 0 (0–1) seconds vs. 5 (2–10) seconds, P < 0.001) than elderly. After CPR training chest compressions were performed with a depth (mean (SD): 64 (8) mm vs. 50 (14) mm, P < 0.001) and rate (mean (SD): 111 (11) per min vs. 93 (18) per min, P < 0.001) for young and elderly laypersons respectively.

Conclusion

Despite long CPR retention time for both groups, elderly laypersons had longer retention time, and performed inadequate DA‐CPR compared to young laypersons. Following CPR training the attainable CPR level was of acceptable quality for both young and elderly laypersons.     

EFFECTS OF PROPOFOL AND OF THIOPENTONE ANAESTHESIA ON THE REGIONAL KINETICS OF PETHIDINE IN THE SHEEP

We have examined the extraction ratios, net fluxes and clearancesof pethidine by the liver, kidneys and hindquarters in sheepbefore, during and after continuous anaesthesia (70 min) withpropofol or thiopentone. Before anaesthesia, the overall meanrespective regional pethidine extraction ratios were 0.98 (SD0.01), 0.20 (0.06) and 0.44 (0.13), the corresponding net fluxeswere 47 (7), 5 (2) and 20 (10)% dose min^–1 and the clearances1.44 (0.22), 0.17 (0.07) and 0.80 (0.39) litre min^–1.During propofol anaesthesia, arterial blood concentrations ofpethidine approximately doubled (P < 0.05), mean pethidinehepatic extraction ratio was unchanged, flux was increased to145 (20)% and clearance decreased to 79 (10)% (P < 0.05)of baseline values; mean pethidine renal extraction ratio, fluxand clearance were 73 (34), 112 (43) and 69 (31)% of baselinevalues; mean hindquarter pethidine extraction ratio decreasedto 65 (25)% (P < 0.05) of baseline values. During thiopentoneanaesthesia, arterial blood concentrations of pethidine approximatelydoubled (P < 0.01), mean pethidine hepatic extraction ratiowas 97 (2)% of baseline values and flux and clearance were unchanged,mean pethidine renal extraction ratios, flux and clerance decreasedto 37 (21), 54 (18) and 27 (19)% (all P < 0.05) of baselinevalues and mean pethidine hindquarter extraction ratio was 81(20)% of baseline values. In spite of only modest changes inhepatic and renal blood flow during anaesthesia, blood concentrationsof pethidine doubled and pethidine kinetics were disturbed forseveral hours after anaesthesia. Overall, however, the changeswere of smaller magnitude and shorter duration than those thathave been described for anaesthesia with the volatile anaestheticagents. ^*Present address: Department of Anaesthesia and Intensive Care,Royal Adelaide Hospital, The University of Adelaide, AdelaideSA 5000, Australia.     

Improvement in quality of colorectal cancer pathology reporting with a standardized proforma – a comparative study

Background Histopathological evaluation is a critical component in the management of patients with colorectal cancer (CRC). It is the single most powerful prognostic indicator in CRC and determines if adjuvant chemotherapy is indicated. The aim of this study was to assess if the introduction of a comprehensive standardized pathology proforma improved the quality of histopathology reporting. Methods A standardized pathology proforma, based on the 1996 minimum dataset for colorectal histopathology reporting, was introduced in our pathology department in 1998. Pathology reports for all colonic resection specimens for 1996 (n = 85) and 2000 (n = 86) were identified, retrieved and entered on to database. Comparison was made with the minimum dataset published in the 1996 guidelines for the management of colorectal cancer. Results Demographic details were complete in all cases. Clinical data was incomplete in 57 (67%) patients in 1996 and 63 (73%) in 2000 (ns; χ²). There were 24 (28%) (7 Abdomino‐perineal resections (APER)) and 40 (47%) (17 APER's) rectal specimens for 1996 and 2000, respectively. The presence or absence of pathological background abnormalities were commented on in 18 (21%) reports in 1996 and 80 (93%) reports in 2000 (P < 0.01; Fishers exact test (Fisher)). Histological differentiation was commented on in 73 (86%) and 86 (100%) in 1996 and 2000, respectively (P < 0.01; Fisher). Dukes' stage was stated in 33 (39%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher) but Dukes' stage was calculable in 84 (99%) in 1996 and 86 reports (100%) for 2000 (ns; Fisher). The apical node was commented on in 34 (40%) reports in 1996 and 85 (99%) reports in 2000 (P < 0.01; Fisher). The median (IQR) number of nodes assessed in 1996 was 8 (5–12) compared to 12 (8–17) in 2000 (P < 0.001; Mann–Whitney (MW)). Complete resection was mentioned in 74 (87%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher). Regarding rectal specimens, the circumferential resection margin (CRM) was commented on in 19 of 24 specimens in 1996 and 38 of 40 specimens in 2000 (ns; Fisher). Relationship to the peritoneal reflection was commented on in 1 (1%) rectal specimen in 1996 and 30 (35%) in 2000 (P < 0.001; Fisher). Conclusion The introduction of a standardized proforma for reporting CRC resection specimens improves the quality of histopathological reporting. This aids decision‐making regarding adjuvant chemotherapy or radiotherapy and further surveillance.     

Temporary Right Ventricular Mechanical Support in High‐Risk Left Ventricular Assist Device Recipients Versus Permanent Biventricular or Total Artificial Heart Support

Early planned institution of temporary right ventricular assist device (RVAD) support with the CentriMag (Levitronix LLC, Waltham, MA, USA) in left ventricular assist device (LVAD) recipients was compared with permanent biventricular assist device (BVAD) or total artificial heart (TAH) support. Between 2007 and 2011, 77 patients (age range: 25–70 years) with preoperative evidence of biventricular dysfunction (University of Pennsylvania score >50; University of Michigan score >5) were included. Forty‐six patients (38 men; median age 54.5 years, range: 25–70 years) underwent LVAD placement combined with temporary RVAD support (group A); in 31 patients (25 men; median age 56.7 years, range: 28–68 years), a permanent BVAD or TAH implantation (group B) was performed. Within 30 days, 12 patients from group A (26.08%) and 14 patients from group B (45.1%) died on mechanical support (P = 0.02). Thirty patients (65.2%) in group A were weaned from temporary RVAD support and three (6.5%) underwent permanent RVAD (HeartWare, Inc., Framingham, MA, USA) placement. A total of 26 patients (56.5%) were discharged home in group A versus 17 (54.8%) in group B (P = 0.56). Three patients (8.5%) received heart transplantation in group A and six (19.3%) in group B (P = 0.04). In group A, 90‐day and 6‐month survival was 54.3% (n = 25) versus 51.6% (n = 16) in group B (P = 0.66). In group A, 1‐year survival was 45.6% (n = 21) versus 45.1% (n = 14) in group B (P = 0.81). The strategy of planned temporary RVAD support in LVAD recipients showed encouraging results if compared with those of a similar permanent BVAD/TAH population. Weaning from and removal of the temporary RVAD support may allow patients to be on LVAD support only despite preoperative biventricular dysfunction.     

Simultaneous measurement of cardiac output by thermodilution, thoracic electrical bioimpedance and Doppler ultrasound

To evaluate the accuracy of two non-invasive techniques forcardiac output (CO) measurement, we have measured CO simultaneouslyby thoracic electrical bioimpedance (TEB), pulsed Doppler ultrasound(DU) and standard thermodilution methods (TD) under differentclinical conditions. Measurements were made in 10 patients:(I) during steady state anaesthesia with controlled IPPV ventilation(n = 131), spread over the entire ventilatory cycle; (II) duringapnoea (n = 56); (III) during spontaneous breathing (n = 152)in the intensive care unit. Mean (SD) cardiac output valueswere: (I) CO_TD 3.5 (1.0) litre min^–1, CO_TEB 3.4 (0.7)litre min^–1 CO_DU 2.8 (0.7) litre min^–1; (II) CO_TD3.6 (0.6) litre min^–1, CO_TEB 3.5 (0.4) litre min^–1,CO_DU 2.9 (0.7) litre min^–1; (III) CO_TD 7.7 (1.5) litremin^–1, CO_TEB 7.6 (1.9) litre min^–1, CO_DU 5.2 (1.4)litre min^–1. The mean percentage deviation of TEB fromTD ranged from –2.2% to 1.4% and that of DU from TD wasfrom –16% to –32%. There were no statistically significantdifferences between TD and TEB, but TD and DU differed significantlyduring IPPV, apnoea and spontaneous ventilation (P < 0.0001).(Br. J. Anaesth. 1994; 72:133–138) ^*Department of Anaesthesiology, Caritas Krankenhaus, Werkstr.1, 66763 Dillingen/Saar, Germany      

DISPOSITION OF MEPIVACAINE AND BUPIVACAINE ENANTIOMERS IN SHEEP

Mepivacaine and bupivacaine are used clinically as racemic mixturesof enantiomers. In these studies the enantiomers of each agentwere administered separately to sheep by i.v. bolus injectionon separate occasions. Enantioselective disposition was deemedif the R:s ratio of the relevant pharmacokinetic parameter differedsignificantly from unity. Both enantiomers of both agents werecleared principally by the liver; urinary excretion of unmetabolizedagents accounted for < 2% of the doses. For R(–)- andS( +)-mepivacaine. respective mean (SEM) values of parameterswere: total body clearance 1.20 (0.29) litre min^–1 and0.97 (0.20) litre min^–1 (ns); total volume of distribution144 (39) litre and 80 (21) litre (P < 0.05); slow half-life120 (40) min and 84 (22) min (ns); mean hepatic extraction ratio0.50 (0.14) and 0.52 (0.09) (ns); mean hepatic clearance 0.75(0.23) litre min1 and 0.75 (0.18) litre min1 (ns). For R(+)-and s(–)-bupivacaine, respective values were: total bodyclearance 0.77 (0.33) litre m nd 0.53 (0.26) litre min (P<0.05);total volume of distribution 40 (10) litre and 43 (10) litre(ns); slow half-life 57 (10) min and 104 (21) min (P<0.05);mean hepatic extraction ratio 0.46 (0.15) and 0.29 (0.13) (P< 0.05); mean hepatic clearance 0.85 (0.31) litre min and0.54 (0.26) litre min (P < 0.05). Thus there was enantioselectivedistribution of mepivacaine and enantioselective clearance ofbupivacaine, but the magnitude of the effect was relativelysmall. This paper is dedicated to the memory of friend and colleagueDr Peter J. Meffin (1943-1987), who made major contributionsto our knowledge of the disposition of mepivacaine and of otherenantiomeric drugs before his untimely death     

Effects of ischaemia and reperfusion on vasoactive neuropeptide levels in the canine infrarenal aortic revascularization model

Infrarenal aortic cross-clamping is associated with remote vascular events, including myocardial infarction and renal insufficiency. The purpose of this study was to determine whether hindlimb ischaemia and reperfusion associated with infrarenal aortic cross-clamping results in the production of vasoactive regulatory neuropeptides. A canine model of infrarenal aortic cross-clamping was used for the study. Serial blood samples were drawn, prior to, at the time of, and serially following placement of the clamp and subsequent release of the clamp and reperfusion. Ischaemia resulted in increased mean (s.e.m.) plasma levels of neuropeptide Y (NPY) (initial 10.0(1.8) pmol/l versus ischaemia 24.7(2.3) pmol/l, P<0.001) and vasoactive intestinal polypeptide (VIP) (initial 2.53(0.5) pmol/l versus ischaemia, 7.3(1.3) pmol/l, P<0.05). Reperfusion produced three-fold elevation of VIP (initial 2.5(0.5) pmol/l versus reperfusion 9.6(1.5) pmol/l, P<0.001), two-fold elevation in the plasma levels of endothelin-1 (initial 1.3(0.1) pmol/l versus reperfusion maximum 2.5(0.3) pmol/l, P<0.01) and NPY (initial 10.0(0.8) pmol/l versus reperfusion maximum 23.9(2.3) pmol/l, P<0.001). Ischaemia and reperfusion did not alter calcitonin gene-related peptide (CGRP) (a potent vasodilator) levels. Endothelin-1 (ET-1) plasma levels were also increased following haemorrhagic shock (initial 1.3(0.1) pmol/l versus exsanguination 3.4(0.4) pmol/l, P<0.001), but not during ischaemia (initial 1.3(0.1) pmol/l versus ischaemia maximum 1.7(0.2) pmol/l, P=0.7). It was concluded that vasoactive regulatory peptides are released following ischaemia, reperfusion and shock in the canine infrarenal aortic revascularization model and, therefore could contribute to remote vascular events observed with infrarenal aortic cross-clamping. Copyright © 1996 The International Society for Cardiovascular Surgery.     

Guided Active Play Promotes Physical Activity and Improves Fundamental Motor Skills for School-Aged Children

Reports show that children’s physical activity (PA) levels are related to FMS proficiency; however, whether PA levels directly improve FMS is uncertain. This study investigated the responses of PA levels and FMS proficiency to active play (AP) and guided active play (GAP) interventions. Three community programs (seven-weeks; 4d·wk^-1) were randomly assigned to: i) active play (CON); ii) locomotor skills (LOC) guided active play (GAP); and iii) object control skills (OC) GAP groups. Children’s (n = 52; 6.5 (0.9) yr) interventions included continuous and/or intermittent cooperative games focused on either locomotor skills (i.e. blob tag, red-light-green-light) or object control skills i.e., hot potato, racket balloons, 4-way soccer). PA levels (accelerometers) were assessed on 2 of 4 sessions per week throughout the program. The Test of Gross Motor Development-2 (TGMD-2) was used to assess FMS scores. The changes for CON and LOC interventions for locomotor standard scores were -0.83 (2.61) vs. 2.6 (2.64) (α = 0.022), for locomotor percentiles -9.08 (36.7) vs. 20.1 (30.4) (α = 0.033) and for gross motor quotient percentiles -4.3 (30.3) vs. 24.1 (29.6) (α = 0.022). Children’s PA levels averaged 158.6 (6.6) kcal·55min^-1 for CON vs. 174.5 (28.3) kcal.55min^-1 for LOC (α = 0.089) and 170.0 (20.1) kcal·55min^-1 for OC (α = 0.144). Moderate-Vigorous PA was 18.4 (8.0) %, 47.9 (7.8) % (α = 0.000) and 51.9 (6.0) % (α = 0.000) for CON, LOC and OC, while time at sedentary/very light PA was 36.4 (9.8) %, 15.1 (4.9) % (α = 0.000) and 14.9 (15.9) %Sed/VL (α = 0.001) during the 7-week program. The OC intervention showed more upper body movement experiences compared to the LOC program (p = 0.020). A guided active play program using LOC cooperative games showed increases in energy expenditure and %MVPA and improved FMS proficiency, but active play did not. For school-aged children (5-7 yr) guided active play using cooperative games may be an effective strategy to improve FMS and promote health and fitness benefits.Key points

• Using multiple accelerometer placements (waist, wrist and ankle) during motor skill intervention programs are effective in quantified varying amounts of lower body versus upper body movement patterns, which are useful in designing children’s motor skill programs.
• Children’s active play in community-based settings can elicit self-paced energy expenditures of >170 kcal/hour and intensity levels between 40-60% MVPA.
• During early childhood the energy expenditure and moderate-vigorous nature of physical activity drives improvements fundamental motor skill proficiency.

Key words: Play, exercise movement techniques, performance of complex motor acts     

Inhibition of nitric oxide synthesis augments pulmonary oedema in isolated perfused rabbit lung

The role of nitric oxide (NO) in precipitating pulmonary oedemain acute lung injury remains unclear. We have investigated themechanism of involvement of NO in the maintenance of liquidbalance in the isolated rabbit lung. Thirty pairs of lungs wereperfused with colloid for up to 6 h, during which pulmonaryvascular resistance (PVR) and capillary pressure (PCP) weremeasured frequently, and time to gain 5 g in weight (t₅) wasrecorded. Four protocols with different perfusate additiveswere studied: (i) none (control, n=11); (ii) 10 mmol N^G-nitro-L-argininemethyl ester (L-NAME) (n=6); (iii) 10 mmol L-NAME with 100 µmollodoxamide, an inhibitor of mast cell degranulation (n=7); (iv)10 mmol L-NAME with 10 µmol 8-bromo-3',5'-cyclic guanosinemonophosphate (8Br-cGMP), an analogue of cGMP that may reducevascular permeability by relaxing contractile elements in endothelialcells (n=6). Neither PVR nor PCP differed between protocols.L-NAME markedly reduced t₅ from 248 (27) min (mean (SEM)) inprotocol (i) to 144 (5) min in protocol (ii) (P<0.05). Bothlodoxamide (t₅=178 (7) min) and 8Br-cGMP (t₅=204 (10) min) substantiallycorrected the effect of L-NAME (P<0.005). Results suggestthat maintenance of a low permeability by NO may involve mastcell stabilization and endothelial cell relaxation. Br J Anaesth 2000; 85: 570–6 ^* Corresponding author     

TIME COURSE OF NEUROMUSCULAR EFFECTS AND PHARMACOKINETICS OF ROCURONIUM BROMIDE (ORG 9426) DURING ISOFLURANE ANAESTHESIA IN PATIENTS WITH AND WITHOUT RENAL FAILURE

We have studied the onset and duration of action and pharmacokineticsof rocuronium bromide (Org 9426) during anaesthesia with nitrousoxide, fentanyl and isoflurane after a single bolus dose ofrocuronium 0.6 mg kg^–1 in nine patients with chronic renalfailure requiring regular haemodialysis, and in nine healthycontrol patients. Blood samples were collected over 390 minand concentrations of rocuronium and its putative metabolitesmeasured using HPL C. Onset time for maximum block, durationof clinical relaxation (T1₂₅) and recovery index, were 61 (SD25.0) s and 65 (16.4) s, 55 (26.9) min and 42 (9.3) min and28 (12.3) min and 19 (8.8) min, respectively, for patients withand without renal failure. The time for TOF ratio to returnspontaneously to 0.7 was 99 (41.1) min and 73 (24.2) min, respectively,in the two groups. None of these differences was significant.The pharmacokinetic data were best described by a three-exponentialequation. There were significant differences between patientswith and without renal failure in the rates of clearance (2.5(1.1) ml kg^–1 min^–1 and 3.7(1.4) ml kg^–1 min^–1respectively) and the mean residence times (97.1 (48.7) minand 58.3(9.6) min) (P<0.05). The differences in other kineticparameters were not significant. We conclude that the effectsof rocuronium may be prolonged in patients with renal disease,because of a decreased clearance of the drug.     

A systematic review & meta-analysis comparing outcomes of endoscopic treatment of primary vesico ureteric reflux in children with polyacrylate poly alcohol copolymer versus dextranomer hyaluranic acid

Background & aimsThere are conflicting reports on the efficacy of bulking agents for vesico ureteric reflux (VUR). In this meta-analysis we have compared the outcomes of endoscopic treatment with polyacrylate polyalcohol copolymer (PPC) and dextranomer hyaluronic acid (DxHA).MethodsA systematic review of publications between 2010 and 2020 was conducted covering databases like PUBMED, MEDLINE etc. for (endoscopic treatment) AND (VUR) AND (PPC OR DxHA) AND (recurrence OR complications). PRISMA guidelines were followed and only comparative studies were included. Outcomes were early success defined as absence of VUR in voiding cystourethrogram at 3-months followup, urinary tract infections (UTI) and occurrence of vesico-ureteric-junction obstruction (VUJO). Risk of bias was analysed with Robvis tool and odds-ratios were compared with Revman-3.0.ResultsAmong nine studies (heterogeneity; I 2 69–79%) all cleared the risk of bias assessment. There was no significant difference in high grade VUR (p = 0.94) between PPC (40%) and DxHA (43%). Success rate after single injection was significantly higher (p = 0.0001) at 86% (477/555) for PPC vs 69% (474/685) for DxHA. UTI rate between PPC (12%) and DxHA (14.6%) was not statistically significant (p = 0.54). VUJO rate between PPC (3.9%) and DxHA (0.8%) was also not significantly different (p = 0.47). Significantly lesser volume (p = 0.02) was used for PPC (0.7 ml) compared to DxHA (0.9 ml).ConclusionReflux resolution was significantly higher with PPC than DxHA. Postinjection UTI/VUJO incidence was not significantly different between them. Limitation of this meta-analysis was heterogeneity & small number of articles. Further studies should focus on long-term outcomes and cost-effectiveness.     

A Change in Practice from Epidural to Intrathecal Morphine Analgesia for Hepato-Pancreato-Biliary Surgery

Background  This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery. Methods  All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay. Results  During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3–11) liters vs. 5 (3–11) liters, P < 0.05) and in total (15.5 (5–48.5) liters vs. 9 (3–70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3–36) days vs. 7 (3–55) days, P < 0.01). Conclusions  In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.     

Commercial transplants in local Pakistanis from vended kidneys: a socio-economic and outcome study

Donor shortage and absence of transplant law lead to unrelated commercial transplants in Pakistan. We report the socio‐economic and outcome parameters of 126 local recipients of unrelated kidney vendor transplants presenting to our institute between 1997 and 2007. Their outcome was compared with 180 recipients of living‐related donor transplants matched for age, gender and transplant duration as controls. Age of commercial recipients was 35.63 ± 11.57 years with an M:F ratio of 2.4:1. Majority (92%) were transplanted in northern Pakistan paying US$7271 ± 2198. All were educated with 50% being graduates or above and rich earning a monthly salary of US$517 ± 518 with 44% earning >US$500. Comparison of commercial recipients with controls showed high comorbidities 35 (28%) vs. 14 (8%) (P = 0.0001) with diabetes, hepatitis‐C and cardiovascular diseases. Donor age was 29.97 ± 6.16 vs. 32.63 ± 9.3 years (P = 0.035). Biologic agents induction in 101 (80%) vs. 14 (8%) (P = 0.0001), acute rejections in 42 (33%) vs. 31 (17%) (P = 0.005), 1‐year creatinine 1.84 ± 1.28 vs. 1.27 ± 0.4 mg/dl (P = 0.0001), surgical complications 28 (22%) vs. 14 (8%) (P = 0.001), tuberculosis 14 (11%) vs. 6 (6%) (P = 0.007), acute hepatitis 20 (16%) vs. 3 (2%) (P = 0.0001), cytomegalovirus 33 (26%) vs. 21 (11%) (P = 0.001) and recurrent urinary tract infection 35 (28%) vs. 30 (16%) (P = 0.034). Overall 1‐ and 5‐year graft survival was 86% and 45% vs. 94% and 80%, respectively (P = 0.00001). Total deaths were 34 (27%) vs. 12 (6.0%) (P = 0.001). In conclusion, recipients of the vended kidneys are poor candidates, educated, rich and often self‐selecting. Their outcome is poor, which will leave them poorer still and back to dialysis if not death.     

ONSET AND RECOVERY OF ROCURONIUM (ORG 9426) AND VECURONIUM UNDER ENFLURANE ANAESTHESIA

We have studied the onset, duration of action and recovery indexof twice the ED₉₀ of rocuronium (Org 9426) (0.6 mg kg^–1)and of vecuronium (0.08 mg kg^–1) in patients during enf/uraneanaesthesia. Rocuronium had a significantly shorter mean onsettime of 1.8 (SD 0.4) min, compared with vecuronium 3.4 (0.8)min. Clinical duration (time for the first twitch in the train-of-fourto recover to 25% of control) was similar for both drugs (29(10) min vs 31 (12) min). Spontaneous recovery times (TOF ratio70%) did not differ significantly between rocuronium (47 (10)min) and vecuronium (44 (11) min). (Br. J. Anaesth. 1992;69:511–512)     

Onset/offset characteristics and intubating conditions of rapacuronium: a comparison with rocuronium

We compared onset and offset of action and tracheal intubatingconditions after rapacuronium and rocuronium in 60 patientsin a randomized, assessor-blinded study. Following inductionof anaesthesia with propofol 2.5 mg kg^–1, eitherrapacuronium 1.5 mg kg^–1 (n=30) or rocuronium0.6 mg kg^–1 (n=30) was administered to facilitatetracheal intubation. Anaesthesia was maintained with eithera propofol infusion (100 µg kg^–1 min^–1)or sevoflurane (1% end-tidal) with 66% nitrous oxide (N₂O),n=15 in each subgroup. Neuromuscular monitoring was performedusing an electromyographic (EMG) device (Datex Relaxograph).The lag times (mean 42 (SD 11) s and 44 (16) s), maximumblock (99 (2)% and 98 (3)%) and intubating conditions at 60 s(good-to-excellent in 86% and 84% of patients) were similarfor rapacuronium and rocuronium, respectively. The onset timeof rapacuronium was shorter than rocuronium (87 (20) vs 141(65) s, P<0.001), and the degree of block at 60 swas greater (69 (26) vs 50 (27)%, P<0.05). Twenty-five percent recovery was shorter with rapacuronium than rocuroniumduring propofol (15.0 (3.2) vs 39.1 (14.2) min, P<0.001)and sevoflurane (15.1 (4.2) vs 47.8 (19.0) min, P<0.001)anaesthesia. We conclude that rapacuronium 1.5 mg kg^–1had a more rapid onset, similar intubating conditions, and shorterrecovery times than rocuronium 0.6 mg kg^–1. Br J Anaesth 2000; 85: 246–50