Inter-scalene block in day-case shoulder surgery

This study looked at the potential of using a combination of general anaesthesia and inter-scalene block (balanced anaesthesia) for providing day-case shoulder surgery services. One hundred and four patients undergoing shoulder surgery were audited using a questionnaire immediately after operation. All patients underwent shoulder surgery under a combination of general anaesthesia and inter-scalene block. The blocks were performed by a single anaesthetist experienced in the procedure. The pain scores were recorded based on visual analogue scale at 6, 12 and 48 h after operation. At 48 h overall pain control was assessed and patients were asked their opinion about having their operation done as a day-case. There were 52 males and 52 females with mean age of 49 years (range 18–85). Mean operation time was 47 min (range 25–90). Ninety-seven (93%) patients were pain free immediately after the operation. Seventy-six (73%) patients were pain free at 6 h and 39 (38%) at 12 h. Mean pain scores at 6 h was 3 and at 12 h was 4. One hundred and one patients said their pain was well controlled throughout the first 48 h by simple oral analgesics. Eighty-four (83%) patients expressed the opinion that they could have been managed as day case provided they were adequately counselled about the procedure. Six (5.7%) patients showed signs of Horner’s syndrome that resolved by 12 h. No other complications related to inter-scalene block occurred. This study has shown that inter-scalene block is a safe procedure providing sustained adequate pain relief after shoulder surgery. It could allow a high percentage of patients undergoing shoulder surgery to be discharged home on the day of the surgery.     

Pediatric valve replacement, 15 years experience in Oman

Background Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group. Methods 42 children under the age of 13 years who underwent valve replacement were included in this study. Totally, 50 valves were implanted in 42 patients: 48 were mechanical prostheses, two were bioprosthetic both in pulmonary position. 37 (74%) valves were implanted in mitral position, 10 (20%) in aortic position, 1 (2%) in tricuspid position and 2 (4%) in pulmonary position. Preoperatively, 14 (33,3%) patients were in New York Heart Association (NYHA) class IV, while 27 (64.2%) were in NYHA class III. Results There were 2 (4.7%) hospital deaths and 2 (4.7%) late deaths while 2 (4.7%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (83.3%) patients are in NYHA Class I and free of all medications except warfarin. 3 (7.1%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.3%) patient. Conclusions In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.     

Larvicidal effect of perbendazole on experimental infection of Angiostrongylus cantonensis in mice

Perbendazole was given orally and subcutaneously to mice infected with Angiostrongylus cantonensis at different stages of infection. The subcutaneous route of administration was more effective than the oral one. On the 5th day after infection, the perbendazole had a higher efficacy than on the 10th day postinfection. This finding shows that perbendazole had complete larvicidal effect at early stages of infection.     

An unusual cause of adult onset cerebellar ataxia with hypogonadism

We report an unusual case of sporadic adult onset cerebellar ataxia with hypogonadism. A 40-year-old unmarried man presented with progressive ataxia and dysarthria along with complaints of non-development of secondary sexual characteristics and erectile dysfunction. There were complaints of intermittent diarrhea. Clinical examination revealed a pan-cerebellar syndrome with features of hypoandrogenism. No eye movement abnormalities were evident. There were signs of malabsorption. Investigations confirmed the presence of auto-antibodies found in celiac disease, and a duodenal biopsy confirmed the same. Hypoandrogenism was postulated to be due to hypergonadotropic hypogonadism which has been mentioned in a few patients of celiac disease. However, the pattern seen in our patient was of a hypogonadotropic hypogonadism. This is probably secondary to an autoimmune hypophysitis seen in some patients in the absence of other clinical manifestations. Autoantibody testing should be a diagnostic necessity in any adult with a sporadic cerebellar ataxia.     

Danazol administration after gonadotrophin-releasing hormone analogue reduces rebound of uterine myomas [published erratum appears in Hum Reprod 1998 Mar;13(3):780]

We report the results of administration of danazol after suspension of gonadotrophin-releasing hormone analogue (GnRHa) therapy for uterine myomas. A total of 21 women with uterine myomas was treated with 100 mg danazol for 6 months after GnRHa therapy. Uterine volume and endocrine status were monitored monthly by ultrasound and assay of plasma gonadotrophins, oestradiol and progesterone. The results show a rebound of uterine volume about 30% less than in controls at the end of danazol therapy. Menstrual cyclicity returned after 65 +/- 3 days in 16 subjects and five patients remained amenorrhoeic. Hormone assays confirmed renewed ovarian function in the women whose menstrual periods returned. Bone mineral content was substantially reduced during GnRHa treatment but improved significantly during danazol therapy even in the women who remained amenorrhoeic. These results show the utility of danazol in prolonging the therapeutic effects of GnRHa. The mechanism by which danazol inhibits rebound of uterine volume may be due to its antiprogesterone effects on uterine myomas.      

Cryptococcal Meningitis in Patients with the Acquired Immunodeficiency Syndrome

The optimum therapy for cryptococcal meningitis in patients with the acquired immunodeficiency syndrome (AIDS) remains unresolved. Traditional therapy consists of amphotericin B with or without flucytosine. Obstacles exist in administering these agents to patients with AIDS. Mortality rates during initial therapy are relatively high. Given the lack of proved benefit, we do not recommend adding flucytosine to amphotericin B routinely. The search for more efficacious and less toxic agents continues. The oral triazoles, especially fluconazole, have increased the options for treatment of this disease. New strategies and novel approaches in managing cryptococcal meningitis in patients with AIDS continue to be developed.