EXPERIENCE WITH FIFTY PATIENTS TREATED WITH ARTIFICIAL VENTILATION

Experience gained during the treatment of fifty patients withrespiratory failure is presented. The overall survival ratewas 44 per cent, although some pathological conditions provedmore amenable to treatment than others. The care of these patientsinvolved the use of mechanical ventilators, and to obtain thebest results the patients should be treated in a unit wherethere is a continuously high standard of nursing care and medicalsupervision. In such a unit problems which arise are more likelyto be successfully overcome—problems of humidification,of the care of the tracheostomy, of monitoring ventilation,of preventing cross infection, and of accurate instructionsfor the nursing staff. In a general hospital there is a widerange of medical and surgical disease which may result in respiratoryinsufficiency and be successfully treated ^*The Royal Marsden Hospital, London     

BLADDER CANCER IN PATIENTS WITH MULTIPLE SCLEROSIS TREATED WITH CYCLOPHOSPHAMIDE

Purpose

We define the risk of bladder cancer in multiple sclerosis related to the use of indwelling catheters and cyclophosphamide administered as an immunomodulating agent.

Materials and Methods

We retrospectively reviewed the records of 2,351 patients with multiple sclerosis referred to the National Center for Multiple Sclerosis.

Results

Of the 2,351 patients 2 women and 5 men (0.29%) had bladder cancer. Of the 850 chronically catheterized patients the incidence was 0.7%. One patient with cancer performed intermittent catheterization for a rate of 0.23% in this group. In a subgroup of 70 patients treated with cyclophosphamide 5 chronically catheterized patients (5.7%) had bladder cancer. Hematuria was the most common presenting symptom. These data were compared with those in the literature on bladder cancer in spinal cord injury.

Conclusions

These data suggest a possible synergistic role of cyclophosphamide and chronic catheterization in the induction of secondary bladder cancer. Regular cystoscopy is warranted in these patients to allow early detection of bladder tumors. Nitric oxide metabolism may be an important factor in the carcinogenesis of this type of bladder cancer.     

PARAPLEGIA WITH THALASSAEMIA

A case is reported of spinal cord compression resulting from extramedullary haemopoiesis in a patient with thalassaemia. A 28-year-old woman with beta thalassaemia intermedia presented with a two week history of paraparesis with bladder and bowel incontinence. Recovery followed laminectomy and the removal of haemopoietic tissue in the spinal epidural space. This is a rare complication and only eight cases have been reported in the literature.     

PETHIDINE COMPARED WITH PETHIDINE PLUS LEVALLORPHAN AND WITH A PLACEBO

The analgesic properties of intravenous pethidine and pethidineplus levallorphan were compared in a group of seventy-two fitobstetric patients. The assessment was made by graded pressureon the tibia. A double blind four-point assay plus placebo techniquewas used. The trial failed to distinguish between the analgesiceffect of the narcotic and the placebo. It is concluded thatthis method of assessment is inapplicable to the pregnant patient.The commonest side dect noted was dizziness but the incidenceof side effects was related more to increased dosage of drugsrather than Werences between pethidine and pethidine plus levallorphan. Present address: Anaesthesia Research, Providence Hospital,Seattle, Washington, U.S.A.     

OUR EXPERIENCE WITH PUBOVAGINAL SLINGS IN PATIENTS WITH STRESS URINARY INCONTINENCE

Purpose

Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling.

Materials and Methods

A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency.

Results

The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence.

Conclusions

Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.     

应用显微外科带血管自体部分脾移植治疗外伤性脾破裂

１３例外伤性脾破裂患者脾切除后，即选正常一极脾叶动脉插管。４℃肝素平衡液灌洗。切除伤脾部分。保留带有脾叶血管部分正常脾。将叶动静脉显微镜下分别与胃网膜右动静脉端端吻合。术后第２周，８例患者分别行ＤＳＡ及ＥＣＴ检查，移植脾血管及实质显影正常。术后第４周血清ＩｇＭ、ＩｇＡ、ＩｇＧ及Ｃ＿３检测结果与术前自身对照无统计学意义（Ｐ＞０．０５）。证明移植脾存活并具有免疫功能。     

CLONIDINE COMBINED WITH SUFENTANIL AND BUPIVACAINE WITH ADRENALINE FOR OBSTETRIC ANALGESIA

Clonidine produces analgesia via a non-opioid mechanism andit may be used as an interesting adjuvant to local anaestheticsand opioids in obstetric analgesia. To examine the effects ofthe addition of clonidine to bolus injections of bupivacaine,adrenaline and sufentanil, we enrolled 50 women receiving extraduralanalgesia for vaginal delivery into a double-blind study. Theywere allocated randomly to two groups: group A received a 10-mlextradural solution of bupivacaine 12.5 mg combined with adrenaline25 µg and sufentanil 10 µg; group B received thesame solution with clonidine 30 µg Each patient was allowedtwo subsequent injections of the chosen solution. Subsequently,if still in the first stage of labour, analgesia was augmentedwith additional 10-ml injections of bupivacaine 12.5 mg withadrenaline 25 µg. without sufentanil or clonidine. Thelatter solution was used for perineal analgesia in group A;clonidine 30 µg was added in group B. During the firstand second stages of labour, there was no difference betweenthe two groups in duration of analgesia after the first injection(142 min in group A; 127 min in group B), number of injections(1.8 in group A; 1.9 in group B) and the total bupivacaine requirements(33.9mg in group A; 34 mg in group B). The quality of analgesiawas evaluated as very good in both groups (23/25 in group A;24/25 in group B). The degree of motor block or the frequencyof other side effects were not enhanced by clonidine. Analgesiawas greater for episiotomy in group B (15/20 in group A; 21/21in group B) (P < 0.05). Within the limits of this study,the total dose of extradural clonidine 90 µg appearedto be safe for the mother and the child. (Br. J. Anaesth. 1993;71: 657–660)     

巨大肝癌并肝硬化患者的围手术期处理

74例巨大肝癌合并肝硬化患者实施半肝或肝左三叶切除,围手术期处理包括①纠正贫血和低蛋白血症及低氧血症,纠正水与电解质平衡失调;②手术前后肠外营养支持;③术前按结肠手术的要求准备肠道;④术中不阻断肝门血流;⑤术后适当限制水盐摄入量及利尿治疗。结果:71例半肝切除患者中,术前肝功A级58例,B级13例,术后1～2周评定肝功A级22例,B级30例,C级12例(其中1例于术后17天死于消化道出血);术后3～4周评定肝功A级43例,B级23例,C级4例,3例肝左三叶切除的术前肝功均为A级,但3例均于术后1个月内死于肝衰竭。表明在充分的围手术期处理下,绝大多数肝功能处于代偿期的肝癌合并肝硬化患者可以安全耐受半肝切除术,但不能耐受肝三叶切除手术。     

异体软骨细胞复合Pluronic修复关节软骨缺损

目的 探讨运用同种异体软骨细胞复合Pluronic修复关节软骨缺损的可行性，并应用^3H—TdR放射自显影方法鉴别软骨缺损修复的细胞来源。方法 取同种异体软骨细胞体外培养至第2代，用^3H—TdR标记后复合Pluronic植入兔关节软骨缺损区作为实验组，并采用单纯Pluronic植入作为材料对照组，不作任何处理组为空白对照组，分别于4、8及16周取材，观察其修复效果，并应用放射自显影方法鉴别修复组织的细胞来源。结果 实验组术后8周，缺损表面可见新生软骨形成，术后16周缺损完全修复，表面光滑，与周围界限模糊，放射自显影证实所修复组织的细胞来源于植入细胞。材料对照组及空白对照组缺损均未见明显修复。结论 ①同种异体软骨细胞复合Pluronic修复关节软骨缺损是可行的；②^3H—TdR标记细胞可作为鉴别细胞来源的一种简便可行的方法。     

REVERSAL OF CURARIZATION WITH ATROPINE-NEOSTIGMINE MIXTURE IN PATIENTS WITH CONGENITAL CARDIAC DISEASE

Electrocardiographic changes during reversal of curarizationwith an atropine-neostigmine mixture were studied in 41 paediatricpatients with congenital cardiovascular disease. A slight statisticallysignificant rise in heart rate was observed 1 minute followingthe injection of the mixture. There was an inverse relationshipbetween the initial heart rate and maximum increase in rate.Normal sinus rhythm was maintained throughout the period ofreversal in 29 patients while 12 patients exhibited some e.c.g.changes. Electrocardiographic findings did not indicate theoccurrence of serious arrhythmias, but it is suggested thatthe incidence of arrhythmia may actually be higher in cyanoticthan acyanotic patients.     

THE IGNITION RISK WITH MIXTURES OF OXYGEN AND NITROUS OXIDE WITH HALOTHANE

To enable the effect of pressure on the flammability of halothanewith oxygen and with mixtures of oxygen and nitrous oxide tobe studied, the work at atmospheric pressure already reportedin the literature has been extended to find the effect of differenttypes of ignition sources. Particular attention has been paidto those types of ignition most likely to be present when halothaneis in use, such as the cautery and the diathermy knife. Theresults indicate that even with the most flammable mixturesthere is no risk of ignition provided the concentrations ofhalothane recommended for use are not gready exceeded. Furtherwork designed to determine the limiting conditions more preciselywill be reported at a later date. ^*Dr. G. Morris died before submission of this paper.