Postoperative pseudostatus: not everything that shakes is epilepsy

Postoperative epileptic seizures are recognised but rare. Psychogenic seizures and pseudostatus epilepticus are relatively common, particularly in the peri-operative period. Our series of five cases of postoperative pseudostatus epilepticus demonstrates that the failure to recognise the psychogenic nature of this condition may cause anaesthetists to give inappropriate and potentially harmful treatment. Psychogenic 'status' is easy to diagnose once it has been considered. Convulsive episodes lasting longer than 90 s, closed eyes during a 'tonic-clonic' attack, retained pupillary response and resistance to eye opening are useful signs. Often there is a history of multiple admissions with 'status epilepticus' and of previous postoperative 'status'.     

Measuring outcomes in urogynecological surgery: “perspective is everything”

Over 10 years have passed since the first US National Institutes of Health consensus panel considered the standardization of definitions of pelvic floor conditions and the criteria utilized for reporting pelvic floor research study outcomes. The literature is replete with pelvic floor outcome studies; however, a consistent standardized approach to the evaluation of patients and characterization of outcomes is still needed. The purpose of this overview is to describe how the use of outcome measures has evolved over time and to attempt to help readers utilize the best measures for their clinical and research needs.     

Everyone is guilty in everything. The 1991 Harvey Cushing oration

In the 1991 Cushing oration, Russian poet Yevgeny Yevtushenko examines the concept of guilt and responsibility for the condition of mankind. Literature and recent history offer examples of response to shame. He discusses the importance to the future of man of the acknowledgment of guilt and the concept of global patriotism.     

Hypertonic saline attenuation of polymorphonuclear neutrophil cytotoxicity: timing is everything

BACKGROUND: The potential to modulate the inflammatory response has renewed interest in hypertonic saline (HTS) resuscitation of injured patients. However, the effect of the timing of HTS treatment with respect to polymorphonuclear neutrophil (PMN) priming and activation remains unexplored. We hypothesized that HTS attenuation of PMN functions requires HTS exposure before priming and activation. METHODS: Isolated PMN were incubated in HTS (180 mM Na+) before L-alpha-phosphatidylcholine, beta-acetyl-gamma-O-alkyl (PAF)/N-formylmethionyl-leucyl-phenylalanine (fMLP) priming/activation, after priming, or after priming/activation. Superoxide production was measured by the reduction cytochrome c, elastase release by cleavage of AAPV-pNA, and beta2-integrin expression by flow cytometry. RESULTS: HTS before priming or activation decreased beta2-integrin expression, superoxide production, and elastase release. In contrast, HTS after priming/activation augmented superoxide production and elastase release. CONCLUSION: The timing of HTS is a key variable in the attenuation of PMN cytotoxic functions. Maximal attenuation of cytotoxicity is achieved before priming, whereas HTS exposure after activation augments cytotoxicity.     

Timing of pre-emptive tenoxican is important for postoperative analgesia

PURPOSE: In this prospective randomized study, a comparison was made between the efficacy of 20 mg tenoxicam, administered either, 30 min preoperatively or at induction of anesthesia, for the relief of postoperative pain in patients undergoing ambulatory breast biopsy. METHODS: Seventy-three patients were recruited and all received a standard anesthetic consisting of induction with 2 mg x kg(-1) propofol followed by 5 microg x kg(-1) alfentanyl. No premedication was administered and at the end of the procedure the wounds were infiltrated with 10 ml of bupivacaine (0.5%). Patients were randomized to receive 20 mg tenoxicam intraveneously either 30 min before surgery or at induction of anesthesia. RESULTS: Demographic criteria were similar in both groups. There were differences in pain scores at 30, 60, 120 and 240 min postoperatively (VAS at 30 min 3.2 +/- 1.2 vs 5.5 +/- 1.8; P < 0.001: VAS at 60 min 1.8 +/- 1.2 vs 3.7 +/- 1.9; P < 0.001: VAS at 120 min 0.9 +/- 0.9 vs 1.7 +/- 1.0; P = 0.003: VAS at 240 min 0.5 +/- 0.5 vs 1.1 +/- 0.8; P < 0.001: Expressed as mean +/- SD). There was a difference in the number of patients requiring additional analgesia, in the first four hours postoperatively (12 (33%) vs 27 (73%); P = 0.001) and a difference in the time to additional analgesia in these patients (87.5 +/- 32.5 vs 55.0 +/- 26.8 min; P = 0.002). CONCLUSION: Early administration of pre-emptive tenoxicam 30 min before induction of anesthesia improves postoperative analgesia in patients undergoing ambulatory breast biopsy.