Comparison of oral and vaginal misoprostol for cervical ripening before manual vacuum aspiration of first trimester pregnancy under local anesthesia: a randomized placebo-controlled study

The objective of this prospective randomized placebo-controlled study was to determine the effectiveness of 400 mug oral and 400 mug vaginal misoprostol administration for cervical priming 3 h prior to manual vacuum aspiration (MVA) under local anesthesia for voluntary termination of pregnancy before 10 weeks of gestation in comparison with placebo oral or placebo vaginal administration (n=40 in each group). Postmedication cervical dilatation was similar in the oral (mean, 6.6+/-1.5) and vaginal (mean, 7.2+/-0.8) misoprostol groups but significantly higher compared with the oral (mean, 3.4+/-0.2) and vaginal (mean, 3.6+/-1.9) placebo groups. Duration of the procedure was also significantly shorter in the misoprostol groups in comparison with their placebo counterparts. Preoperative bleeding and side effects were more common in the misoprostol groups, but none required medical intervention. Intraoperative bleeding was less in the vaginal misoprostol group compared with the placebo groups. There was no significant difference in terms of visual analogue scores during the procedure, patient satisfaction, days of postoperative bleeding and rate of postoperative complications among the groups. Cervical priming with misoprostol administered orally or vaginally 3 h before MVA for termination of pregnancy under local anesthesia facilitates the procedure by decreasing the need for cervical dilatation and by shortening its duration without improving patients' pain perception and satisfaction mainly due to side effects.     

Serum ECP and total IgE levels in children with acute laryngotracheobronchitis

OBJECTIVE: Eosinophilic cationic protein (ECP) and immunoglobulin E (IgE) are important mediators of allergic inflammation and they are commonly used in the diagnosis and follow-up of allergic diseases. But serum levels of these molecules can also be elevated by some other diseases including viral infections. Acute laryngotracheobronchitis (ALTB) is an important viral infection of upper airway and serum levels of ECP and IgE may increase in patients with ALTB. METHODS: In the present study serum ECP and IgE levels were measured before treatment and on the third day and third week after treatment in 27 patients with ALTB aged 10 months to 5 years and were compared with a age matched healthy controls. All patients were treated with nebulized budesonide. RESULTS: We found that pre-treatment ECP levels were significantly higher than post-treatment third days and third weeks (28.3+/-2.3 ng/ml versus 20.2+/-3.2 ng/ml and 11.4+/-1.1 ng/ml, respectively). Similarly, the mean pre-treatment serum IgE values were significantly higher than post-treatment values (131.6+/-17.5 IU/ml versus 83.6+/-12.4 IU/ml and 68.2+/-6.7 IU/ml). A positive correlation was found between serum ECP and IgE values for pre-treatment and post-treatment third week values (r=062, p=0.01 and r=0.64, p=0.01, respectively). The pre-treatment serum ECP and IgE levels were significantly higher than those of controls (10.8+/-1.5 ng/ml and 43.8+/-6.6 IU/ml, respectively p<0.05). CONCLUSION: In this study it was shown that, serum ECP and IgE levels increase in the acute phase of infection and return to normal after treatment in patients with ALTB such as in allergic patients. This effect of ALTB on serum ECP and total IgE levels should be kept in mind and these parameters should not be used in the diagnosis and follow-up of allergic diseases in children who had had ALTB in recent weeks.     

A case of rhabdomyolysis associated with thyrotoxicosis

Rhabdomyolysis is found to be associated with trauma; alcohol; drugs; viral infections, such as HIV, Epstein-Barr virus, cytomegalovirus and influenza; metabolic disorders; dermatomyositis; polymyositis; and hypothyroidism. Few cases of rhabdomyolysis associated with thyrotoxicosis have been reported. A patient who presented with delirium to the emergency department and was diagnosed with thyrotoxicosis and rhabdomyolysis is hereby presented.     

Outcome following radiotherapy for loco-regionally recurrent non-small cell lung cancer

Local and regional recurrence of non-small cell lung cancer is reported to occur in 13-20% of treatment failures after resection. Reported post-recurrent median survival following radiotherapy ranges from 9 to 14 months. This study examines survival following radiotherapy alone for patients with loco-regionally recurring non-small cell lung cancer after initial surgery. Fifty-five patients, receiving radiotherapy at Westmead Hospital between 1979 and 1997, were eligible for study. Data were collected retrospectively by reviewing patient records. The end-point was overall survival. Symptom control was also recorded. Prognostic factors for analysis included age, sex, original presenting stage, disease-free interval (DFI), performance status, site of recurrence, treatment intent and dose. The median overall survival was 11.5 months (95% confidence interval: 8.1-13.0). Survival following treatment with radical intent was 26 months compared to 10.5 months for patients treated with palliative intent (P = 0.025). There was no significant difference in survival for short (< or = 2 years) or long DFI, performance status, radiation dose, age, sex, site of recurrence or stage. Most patients (55%) had partial or complete resolution of symptoms. Radiotherapy results in overall post-recurrence median survival of nearly 1 year, consistent with previous published data. Radical treatment intent predicts better prognosis as a result of patient selection and higher dose. Radiotherapy is effective at palliating symptoms of this disease.     

Osteoarthritis--a rare indication for atlantoaxial fusion. A case report and review of the literature

The authors report a case of C1-C2 fusion which was performed in a 64-year-old woman with unilateral atlantoaxial osteoarthritis, who consulted because of incapacitating occipital pain and decreased cervical rotation without neurological deficit. The diagnosis of unilateral C1-C2 osteoarthritis was confirmed by an open-mouth radiograph, a bone-scan, a computerised tomography scan, and magnetic resonance imaging. C1-C2 fusion was performed using a computer assisted navigation system and posterior instrumentation. This resulted in marked relief of pain, and distinct improvement in quality of life. The prevalence of atlantoaxial osteoarthritis is about four per cent in patients suffering from peripheral or spinal osteoarthritis. However, many primary-care providers are not familiar with this entity. C1-C2 fusion remains rare, due to the difficulties related to the diagnosis of atlantoaxial osteoarthritis, its established non-operative treatment options, and the fact that it has not received adequate attention in the orthopaedic literature. However, based on review of the literature, it can be stated that C1-C2 fusion is an effective and safe procedure providing distinct reduction of pain and increased quality of life in case of failure of conservative treatment.     

Primary adenocarcinoma of the epididymis: case report

Primary epididymal malignancies are uncommon and usually benign. Benign paratesticular tumors are most commonly adenomatoid, while the most common malignant paratesticular tumors are rhabdomyosarcomas. Approximately 25% of all epididymal tumors are malignant, and of the benign tumors, 60% to 78% are adenomatoid tumors. According to a recent MEDLINE search using epididymis and adenocarcinoma as key words, reports of a primary epididymal adenocarcinoma are extremely rare with only 23 cases in the literature. We report a case of epididymal adenocarcinoma with clinical follow up and metastatic natural history of this rare malignancy.     

Vertebral body replacement with expandable titanium cages

OBJECTIVES: The aim of vertebral body replacement is the stabilisation and restoration of the anterior column of the spine with removal of the diseased region. We present our results of stabilisation, pain reduction and neurological improvement using vertebral-body replacement systems METHODS: Between April 1997 and December 2002, 53 patients with malignant vertebral destruction or instability due to traumatic and osteoporotic fracture were treated. We evaluated the results after vertebrectomy and vertebral body replacement by using expandable titanium cages in a retrospective study. RESULTS: The average follow-up time was 18.9 +/- 19.9 months. The mean operation time was 173.2 +/- 77.4 minutes. Intraoperatively, we saw no implant-related complications. Perioperatively, complications appeared in 18 patients (34.0 %). 4 of them were severe, with 2 patients dying. In the total follow-up, 16 patients died, 10 of them (62.5 %) due to tumour progression. Pain reduction was reported in 52.7 %, neurological improvement in 48.0 %. One patient had a loosening of his posterior instrumentation in the further follow-up due to tumour growth with dislocation of the cage and a deterioration of his neurological deficit. CONCLUSION: By using vertebral body replacement systems, sufficient stabilisation of the vertebral column, pain reduction and neurological improvement can be achieved with an acceptable perioperative risk.     

Can indications for lower limb replantation and revascularization be expanded with simultaneous free-flap transfer for limb salvage?

High-energy trauma from road accidents and work-related injuries is the most common cause of lower-limb traumatic amputations. Many of these cases require extensive debridement and substantial bone shortening for primary closure because of crushing and/or avulsion of the involved parts. Since 1998, the authors have replanted or revascularized five lower limbs in five patients. Free tissue transfers have been used to cover soft-tissue defects during replantation and revascularization in all patients. The numbers and kinds of free flaps include one latissimus dorsi muscle, two transverse rectus abdominis musculocutaneous (TRAM), and two anterolateral thigh fasciocutaneous flaps. Survival of the replanted and revascularized limbs and transferred flaps was obtained in four patients. Below-knee amputation was performed because of flap necrosis and extensive infection in one patient. Simultaneous free-tissue transfers may be used simultaneously with lower limb replantation or revascularization to obtain functional extremities in appropriately selected patients. The indications for lower limb salvage may be enhanced and successful results may be obtained in one stage, with low complication rates and shorter hospital stays. The authors report their experience with simultaneous free tissue transfers and lower limb replantation or revascularization.     

N-acetylcysteine reduces lung reperfusion injury after deep hypothermia and total circulatory arrest

OBJECTIVE: We hypothesized that the use of N-acetylcysteine would ameliorate the lung reperfusion injury observed after deep hypothermia and total circulatory arrest (DHTSA). METHODS: Experiments were carried out on 12 adult mongrel dogs of either sex weighing 25 to 30 kg. The animals were randomly divided into two groups of six animals each. All animals were cooled to an esophageal temperature of 15 degrees C during 30 minutes and underwent 60 minutes of DHTSA, followed by the reinstitution of cardiopulmonary bypass (CPB) and rewarming. Before rewarming, while 100 mL physiologic saline solution was added into the pump in group I, 50 mg/kg N-acetylcysteine(NAC) was given in group II. Heart rate, mean arterial pressure, pulmonary arterial pressure, left atrial pressure, central venous pressure, and cardiac output were recorded. To measure lung tissue malondialdehyde (MDA), water content and polymorphonuclear leukocytes (PMNs) count, lung tissue samples were taken before CPB and after weaning CPB. In addition, alveolar-arterial oxygen difference (AaDO(2))()for tissue oxygenation was calculated by obtaining arterial blood gas samples. Dynamic lung compliance (DLC) was measured before CPB and after CPB. RESULTS: MDA levels before CPB of 44.2 +/- 3.9 nmol/g tissue rose to 76.6 +/- 5.6 nmol/g tissue after weaning CPB in group I (p = 0.004). In group II also, the MDA levels increased from 43.5 +/- 4.2 to 57.4 +/- 5.6 nmol MDA/g tissue after weaning CPB (p = 0.006). The MDA increase in group II after CPB was found to be significantly lower than in group I (p = 0.006). The wet-to-dry lung weight ratio in the NAC group was 5.1 +/- 0.2, significantly less than in the control group (5.9 +/- 0.3), (p = 0.004). AaDO(2) significantly increased in the group I and II (p = 0.002 and p = 0.002, respectively); this elevation in group I was significant than in group II (p = 0.044). In histopathological examination, it was observed that neutrophil counts in the lung parenchyma rose significantly after CPB in both groups (p < 0.001). The increase in group I was significantly larger than group II (p < 0.001). CONCLUSIONS: Results represented in our study indicate that addition of NAC into the pump after DHTSA can reduce lung reperfusion injury.     

The effects of alfentanil or remifentanil pretreatment on propofol injection pain

STUDY OBJECTIVE: To compare the efficacy of alfentanil, remifentanil, and saline in minimizing the propofol injection pain. DESIGN: Randomized, double-blind study. SETTING: University hospital. PATIENTS: 175 ASA physical status I and II, adult female patients undergoing minor gynecological procedures with general anesthesia. INTERVENTIONS: Unpremedicated patients were randomly allocated to one of four groups. Patients received 2 mL (1 mg) of alfentanil (n=43), 2 mL of remifentanil 0.01 mg (n = 43), 2 mL of remifentanil 0.02 mg (n=45), or 2 mL of saline (n=44) 30 seconds prior to administration 5 mL of propofol 1%. MEASUREMENTS: Patients were asked whether they had pain due to propofol injection. Their pain scores were evaluated with a Visual Analogue Scale. In the Postanesthesia Care Unit, frequency of postoperative nausea, vomiting, hypotension, and flushing were all determined. MAIN RESULT: The remifentanil and alfentanil groups showed significantly less frequency and severity of pain than the saline group (p <0.05). When the alfentanil group was compared with the remifentanil groups, significant differences in pain relief associated with injection of propofol (p <0.001) were noted. Remifentanil 0.02 mg relieved pain associated with injection of propofol more effectively than remifentanil 0.01 mg (p <0.001). CONCLUSIONS: The remifentanil and alfentanil groups showed significantly less frequency and severity of pain than did the saline group. Remifentanil was effective in preventing propofol injection pain, and should be used at a dose of at least 0.02 mg for this purpose. Remifentanil may be an alternative drug for prevention of propofol injection pain.