Study on the effects of the hypocholesteremic agents, cholestyramine and compactin on the induction of renal tumors in rats by N-ethyl-N-hydroxyethyl nitrosamine]

Male Wistar rats were administered with 0.1% N-ethyl-N-hydroxyethyl nitrosamine (EHEN)-containing diet for 2 weeks, and were then Rept for further 23 weeks on basal diet. At 25 weeks, the rats were divided into three groups. Group I was fed on basal diet to 40 weeks. Group II was fed on 2% cholestyramine-containing diet to 40 weeks. Group III was fed on 0.02% compactin-containing diet to 40 weeks. At 40 weeks after the start of experiment, the rats were sacrificed and examined histologically for the incidence of renal cell tumors (RCT) and dysplastic foci (DF) of the kidney. The serum levels of total cholesterol at 40 weeks were 108.9 +/- 23.4, 78.8 +/- 12.5, 95.6 +/- 43.4 mg/dl in Groups I, II and III, respectively. The levels were significantly lower in Groups II and III (p less than 0.01, 0.05, respectively, Wilcoxon test) than Group I. The average numbers of DF were 4.5 +/- 4.1, 1.3 +/- 0.3, 2.3 +/- 2.0 per cm2 of kidney slices in Groups I, II and III, respectively. DF were significantly less in Group II than Group I (p less than 0.025, Wilcoxon test), and less in Group III than Group I (not statistically significant). There was no statistical difference between Groups II and III. RCT were observed in 9 of 34 kidneys (26%), 2 of 18 (11%), 1 of 20 (5%) in Groups, I, II and III, respectively. The ratios of kidneys with RCT were lower in Group II than Group I (not statistically significant), and lower in Group III than Group I (p less than 0.05, qui-square test). There was no statistical difference between Groups II and III. RCT were classified into gross and microscopic lesions. Four gross RCT were found in 4 rats of Group I; no gross RCT was in Groups II and III. There were 5 microscopic RCT in 5 rats, 3 in 2, 1 in 1 in Groups I, II and III, respectively. In Group I, serum levels of total cholesterol were compared between the following subgroups; the rats with RCT and/or with more than 10 DF per kidney, and the rats without RCT and with less than 10 DF per kidney. The mean level was 120.8 +/- 21.8 mg/dl in the former subgroup, which was significantly higher than that (94.1 +/- 19.6 mg/dl) in the latter subgroup (p less than 0.025, Wilcoxon test). The serum cholesterol was suggested to act as a promoter in the development of DF and RCT.     

The importance of appropriate concentrations of inspired carbon dioxide on induced hypothermia under halothane-ether azeotrope anesthesia

Thirty adult mongrel dogs were divided into 3 equal groups and studied to define the optimal PCO2 level with azeotrope (halothane-diethyl ether) anesthesia under surface hypothermia (Groups I, II and III = F1CO2 0%, 5% and 10%, respectively). All animals were cooled to 18-20 degrees C and were subjected to 30 (Group I) or 60 minutes (Groups II and III) of total circulatory arrest. Group I animals had frequent arrhythmic episodes during cooling and postoperative motor disturbances occurred in 80% despite only 30 minutes of circulatory arrest. By contrast Group II animals were less arrhythmic during cooling; were easily resuscitated following 60 minutes of arrest and only 30% developed moderate reversible motor disturbances postoperatively. Hemodynamics were similar between Groups II and III during cooling but resuscitation using an F1CO2 of 10% (Group III) was extremely difficult and required massive cardiotonic support throughout rewarming. Furthermore, two dogs in Group III died within the first two postoperative days. However, none of the 8 survivors displayed neurological abnormalities. On balance, a ventilatory regimen utilizing 5% CO2 during surface-induced hypothermia under azeotrope anesthesia resulted in optimum intraoperative management and a satisfactory postoperative course and although some CNS disturbance (high-stepping gait) was noted, all animals recovered completely.     

Does prostaglandin E1 and superoxide dismutase prevent ischaemic spinal cord injury after thoracic aortic cross-clamping?

The beneficial use of prostaglandin E1 (PGE1) and superoxide dismutase (SOD) on the tolerance to ischaemia of the spinal cord was evaluated following thoracic aortic cross-clamping in dogs. Aside from spinally evoked somatosensory potential (SEP) by means of a bipolar epidural catheter, postoperative evaluation of motor deficits was used to determine the efficiency of pharmacological protection when compared with controls. The animals were divided into four groups. Group I (n = 12) served as controls. The dogs of Group II (n = 12) were treated with PGE1 (100 ng/kg/min) during clamping and the first hour after declamping. In the third group (n = 12) SOD was given as an intra-arterial bolus (1 mg/kg) prior to declamping which was followed by a continuous perfusion (0.4 mg/kg/min) into the carotid artery for 25 min. In Group IV (n = 12) the dogs were treated with a combination of PGE1 and SOD in the same manner as in Groups 3 and 4. Results after pharmacological protection were significantly better than controls. In Group I all animals but one (92%) were paraplegic, as were five in Group II (42%) and eight in Group III (67%). In contrast no dog in Group IV developed paraplegia. There was a close correlation of SEP and postoperative recovery. The group with combination therapy (PGE1 plus SOD) was characterised by a loss of the evoked potential for a mean of 15 min, the PGE1 group for 45.8 min and the SOD group for 58.5 min. While the control group was characterised by a loss of 72.7 min.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effects of tramadol and fentanyl on gastrointestinal motility in septic rats

In this study, we investigated the effects of tramadol and fentanyl on gastrointestinal transit (GIT) during acute systemic inflammation in an experimental model of cecal ligation and perforation (CLP). One-hundred-twenty male Swiss-Albino rats were divided randomly into 6 groups: Group I = sham-operated + saline; Group II = sham-operated + fentanyl; Group III = sham-operated + tramadol; Group IV = CLP + saline; Group V = CLP + fentanyl; Group VI = CLP + tramadol. Suspension of charcoal was administered as an intragastric meal to measure the GIT. GIT% (mean +/- sd) were 46.1% +/- 9.8%, 43.2% +/- 9.8%, 45.9% +/- 10.2%, 33.2% +/- 9.2%, 24.9% +/- 4.1%, and 31.8% +/- 8.4% in Groups I, II, III, IV, V, and VI, respectively. GIT% was significantly less in Group V than in Groups I, II, III, and IV (P < 0.05). The Group VI mean value was significantly lower than those of Groups I, II, and III (P < 0.05) but not different from those of Groups IV and V (P > 0.05). The antitransit effect of fentanyl was shown to have increased in the experimental sepsis model, but no decrease in GIT was obtained with tramadol. This was thought to be the result of an associated endogenic opioid system activation and receptor upregulation in sepsis.     

Medium-term results of heart transplantation using older donor organs.

BACKGROUND: Donor heart shortage has necessitated the expansion of the donor pool by the use of older hearts. PATIENTS AND METHODS: In a 13-year period, 1,070 heart transplants were performed in 1,035 adults at the German Heart Institute Berlin. We divided the patients into 3 groups: Group I, donor age <35 years (n = 524); Group II, donor age 35 to 50 years (n = 379); Group III, donor age >50 years (n = 167). We analyzed post-operative mortality (up to 30 days), cumulative survival rates, cardiac dependent morbidity, and changes in the left/right ventricular ejection fraction as well as freedom from cytomegalovirus infection and freedom from acute rejection episodes grade >/= 2 (International Society for Heart and Lung Transplantation). We also calculated the rate of cardiac interventions per patient in the groups. RESULTS: Recipients in Group III were significantly older, compared with Groups I and II. The post-operative mortality was 16.8% in Group I, 29.8% in Group II, and 23.4% in Group III. The differences were significant (p = 0. 00001) between Group I and Group II. The long-term cumulative survival rates were significantly better in Group I when compared with Groups II and III (p < 0.00001, p = 0.014), but it did not differ between Groups II and III (p = 0.18). However, cardiac morbidity in Groups I and II was significantly lower when compared with Group III (p = 0.0009, p = 0.037). Mean left and right ventricular ejection fraction was >55% and did not significantly change in groups for up to 10 years. Freedom from cytomegalovirus infection was not significantly different between Groups II and III (p = 0.09). Significantly fewer percutaneous transluminal coronary angioplasties were performed in Group I, but comparable numbers were carried out in Groups II and III (p = 0.53). For retransplantation a similar situation occurred. CONCLUSION: We did not find significant differences in the mid-term follow-up between patients who received hearts from 35- to 50-year-old donors and from those who had received hearts from donors >50 years, despite increased cardiac morbidity in Group III. Close monitoring of the coronary situation after heart transplantation and expanded indications for revascularization in Group III makes heart transplantation with older hearts a suitable option to save the lives of patients in end-stage heart failure.     

The use of esmolol and magnesium to prevent haemodynamic responses to extubation after coronary artery grafting

BACKGROUND AND OBJECTIVE: The haemodynamic responses during extubation can cause complications after open-heart surgery. In this study, we aimed to examine the effect of esmolol and magnesium before extubation on these haemodynamic responses. METHODS: Following the approval of local Ethics Committee, 120 patients having coronary artery bypass grafting with extubation in the intensive care unit were included in the study. Patients were allocated to receive esmolol 1 mg kg-1 (group I, n = 40), magnesium 30 mg kg-1 (Group II, n = 40) or normal saline (Group III, n = 40). Study medication was administered as a 20-min infusion in a volume of 20 mL. Patients were extubated just after termination of the infusion. Heart rate, blood pressure and central venous pressure were recorded prior to drug administration, before extubation, during extubation and 1 min after extubation. RESULTS: Heart rate was lower in Group I than in Groups II (P < 0.05) and III (P < 0.001) and lower in Group II than in Group III (P < 0.05) during extubation. It was also lower in Group I than in Group III (P < 0.05) after extubation. Systolic blood pressure was lower in Group I than in Groups II and III (P < 0.001) during extubation. Diastolic blood pressure was higher in Group III than in Groups I and II during extubation (P < 0.001) and after extubation (P < 0.05). Mean arterial pressure was lower in Group I than in Groups II and III (P < 0.001) during extubation, lower in Group II than in Group III (P < 0.05) during extubation and lower in Group I than in Group III (P < 0.05) after extubation. CONCLUSION: We found that using esmolol before extubation following coronary artery bypass graft surgery prevents undesirable haemodynamic responses while magnesium reduces undesirable haemodynamic responses but does not prevent them.     

The effect of hematoma in muscle flap microcirculation

Free radicals were first mentioned by Healey about the hematoma under skin flaps, trying to explain the blood itself has different effect beyond its space-occupying effect or infection. The aim of this study was to determine whether hematoma would have any effect on neutrophil behavior in muscle flap microcirculation. Rat cremaster muscle flap model was used for measuring intravital different parameters. We used the rat cremaster muscle flap model for direct observation and measurement of rolling and adhesion.The rats were randomized into 6 groups. Groups I and IV: only the cremaster muscle was turned to the abdominal wall (n = 4 and n = 4). Groups II and V: saline was injected under the muscle flap (n = 3 and n = 4). Group III and VI: blood was injected under the muscle flap (n = 4 and n = 5). Two sets of microcirculatory measurements were taken in each group. For the comparisons of the groups, the measurements that were taken at the second hour and at the sixth hour were standardized according to the baseline values of the same groups in the same postcapillary venules. Comparisons within the groups were made by Student t test. Between the groups, analysis of variance (ANOVA) independent test was used.Within groups, the number of adherent neutrophils in the second and sixth hour in hematoma groups were found significantly increased according to the baseline measurements, and the number of rolling neutrophils in the second hour in hematoma group was found increased according to the baseline measurements. Between groups, the number of rolling neutrophils in the second hour was found significantly increased between hematoma and sham/hematoma and control groups and the number of adherent neutrophils in the second and sixth hour was found significantly increased between hematoma and sham/hematoma and control groups.     

Effects of a bradykinin B(2) receptor antagonist, FR173657, on pulmonary ischemia-reperfusion injury in dogs.

BACKGROUND: This study investigated the effects of a bradykinin B(2) receptor antagonist, FR173657 (FR), on pulmonary ischemia-reperfusion (I/R) injury. METHODS: Twenty-four mongrel dogs were divided into four groups (n = 6 each). In Groups I, II and III, FR doses of 33, 100 and 300 nmol/kg per hour, respectively, were administered continuously beginning 30 minutes before ischemia and continuing for 2 hours after reperfusion. In Group IV, vehicle alone was administered. Warm ischemia was induced for 3 hours by clamping the left pulmonary artery and veins. Simultaneously, the left stem bronchus was bisected and then anastomosed before reperfusion. Fifteen minutes after reperfusion, the right pulmonary artery and bronchus were ligated. Left pulmonary vascular resistance (L-PVR), cardiac output (CO), arterial oxygen pressure (PaO(2)) and the alveolar - arterial oxygen pressure difference (A-aDO2) were measured for 4 hours after reperfusion. Lung tissue was harvested for wet-to-dry weight ratio (WDR) measurements, histopathologic studies and polymorphonuclear neutrophil (PMN) counts. Serum thromboxane (TX) B(2), 6-keto-prostaglandin (PG) F(1alpha) and leukotriene (LT) B(4) levels were also measured. RESULTS: PaO(2), A-aDO2, L-PVR and CO were significantly (p < 0.05) improved and WDR was significantly (p < 0.05) lower in Groups II and III than in Group IV. Histologic tissue edema was mild, and PMN infiltration was significantly (p < 0.05) reduced in Groups I, II and III compared with Group IV. TXB(2) levels were significantly (p < 0.05) lower in Group II than in Group IV, whereas 6-keto-PGF(1alpha) levels were not significantly different. LTB(4) levels were significantly (p < 0.05) lower in Groups II and III than in Group IV. CONCLUSIONS: FR appears to have a protective effect on pulmonary I/R injury stemming from the inhibition of eicosanoid release.     

Quantitative histologic study of the influence of spinal instrumentation on lumbar fusions: a canine model

Histomorphometric and microradiographic studies were performed on 28 beagle hounds 1 year of age, followed up for 6 months after an L5-L6 anterior and posterior spinal destabilization procedure--Group I (n = 7), destabilized surgical controls; Group II (n = 7), posterolateral bone grafting after destabilization; Group III (n = 7), Harrington rod instrumentation and posterolateral bone grafting after destabilization; and Group IV (n = 7), Luque instrumentation, and bone grafting after destabilization. Six months postoperatively, device-related osteoporosis occurred in spines treated with spinal instrumentation. Within the L5 vertebral body the mean trabecular width was less for the two groups with instrumentation (Groups III and IV) compared with the two groups without instrumentation (Groups I and II) (p less than 0.001). The bone formation rate [mm3/(mm3 x year)] x 10(3), which is based on the mean distance between sequenced fluorochrome labels, for Group I (destabilized, nonfused, noninstrumented dogs) was more than twice that of the other three groups, which were all equivalent (p less than 0.05). Clinical relevance: Stress shielding, or more correctly, device-related osteoporosis, probably can occur within vertebrae in response to rigid spinal instrumentation. However, the overall mechanical properties of vertebrae underlying spinal instrumentation are probably not at increased risk of fracture because the increase in cross-sectional area of the vertebra and incorporated fusion mass more than compensate for the loss of volumetric bone density.     

Effects of pentazocine in experimental head injury

In previous studies we demonstrated the adverse effects of ethyl alcohol in murine head injury. Using this model in this study, effects of prior administration of pentazocine (Talwin) on the survival of mice are reported. Swiss Webster mice were randomly divided into one of three groups. Group I (n = 20) received pentazocine and Group II (n = 20, controls) received saline. Groups I and II were then injured under ether anaesthesia by allowing a weight to fall from a height of 15 cm on the cranium. Ten animals received pentazocine and were anaesthetized but had no head trauma (Group III). In Group II, 85% survived 24 h, and in Group I, 35% survived; all mice in Group III survived 24 h (significance: chi 2, p less than 0.005; Group I versus Groups II and III). Pentazocine increases the lethality of murine head injury.     

Postoperative evaluation of left ventricular peak filling rate and peak ejection rate by radionuclide ventriculography for aortic regurgitation]

Postoperative left ventricular (LV) time-activity curve and the first derivative in radionuclide method were evaluated in 28 patients with aortic regurgitation to clarify the postoperative cardiac function and to determine the adequate timing of operation. Twenty-eight patients were divided into two groups by preoperative echocardiogram. In Group I cases, echo-finding showed LV contractile dysfunction associated with both enlarged LV end-systolic dimension (LVDs) over 5 cm and depressed fractional shortening (%FS) below 25%. In Group II cases, the finding showed compensated cardiac function with relatively small LVDs below 5 cm or not so depressed %FS over 25%. Preoperative diastolic parameter of LV peak filling rate (PFR) in Groups II of 22 cases was depressed in comparison of normal control, although systolic parameters of peak ejection rate (PER) or ejection fraction were mildly depressed. Postoperatively, those parameters of PFR and PER were improved to normal control level (1. PFR: pre op = 206 +/- 73----post op = 311 +/- 79, p less than 0.001 2. PER: pre op = 309 +/- 65----post op = 389 +/- 103 %EDV/sec. p less than 0.001). In contrast, the preoperative parameters of PFR and PER in Group I of 6 cases were strikingly impaired, and post-operative those parameters were not improved to normal level (1. PFR: op = 154 +/- 39----post op = 190 +/- 88 2. PER: pre op = 223 +/- 74----post op = 244 +/- 78 %EDV/sec, NS). No postoperative complications occurred in Group II cases, in contrast, 2 cases in Group I were complicated with low output syndrome or ventricular fibrillation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Beating heart ischemic mitral valve repair and coronary revascularization in patients with impaired left ventricular function

OBJECTIVE: The aim of this study is to evaluate in a cohort of patients with impaired left ventricular (LV) function and ischemic mitral valve regurgitation (MVR), the effects of on-pump/beating heart versus conventional surgery in terms of postoperative mortality and morbidity and LV function improvement. MATERIALS AND METHODS: Between January 1993 and February 2001, 91 patients with LVEF between 17% and 35% and chronic ischemic MVR (grade III-IV), underwent MV repair in concomitance with coronary artery bypass grafting (CABG) Sixty-one patients (Group I) underwent cardiac surgery with cardioplegic arrest, and 30 patients (Group II) underwent beating heart combined surgery. Aortic valve insufficiency was considered a contraindication for the on-pump/beating heart procedure. Mean age in Group I was 64.4 +/- 7 years and in Group II, 65 +/- 6 years (p = 0.69). RESULTS: The in-hospital mortality in Group I was 8 (13%) patients versus 2 (7%) patients in Group II (p > 0.1). The cardiopulmonary bypass (CPB) time was significantly higher in Group I (p < 0.001). In Groups I and II, respectively (p > 0.1), 2.5 +/- 1 and 2.7 +/- 0.8 grafts per patient were employed. Perioperative complications were identified in 37 (60.7%) patients in Group I versus 10 (33%) patients in Group II (p = 0.025). Prolonged inotropic support of greater than 24 hours was needed in 48 (78.7%) patients (Group I) versus 15 (50%) patients (Group II) (p = 0.008). Postoperative IABP and low cardiac output incidence were significantly higher in Group I, p = 0.03 and p = 0.027, respectively. Postoperative bleeding greater than 1000 mL was identified in 24 patients (39.4%) in Group I versus 5 (16.7%) in Group II (p = 0.033). Renal dysfunction incidence was 65.6% (40 patients) in Group I versus 36.7% (11 patients) in Group II (p = 0.013). The echocardiographic examination within six postoperative months revealed a significant improvement of MV regurgitation fraction, LV function, and reduced dimensions in both groups. The postoperative RF was significantly lower in Group II patients 12 +/- 6 (%) versus 16 +/- 5.6 (%) in Group I (p = 0.001). The 1, 2, and 3 years actuarial survival including all deaths was 91.3%, 84.2%, and 70% in Group I and 93.3%, 87.1%, and 75% in Group II (p = ns). NYHA FC improved significantly in all patients from both groups. CONCLUSION: We conclude that patients with impaired LV function and ischemic MVR may undergo combined surgery with acceptable mortality and morbidity. The on/pump beating heart MV repair simultaneous to CABG offers an acceptable postoperative outcome in selected patients.     

Is the reduction of forced expiratory lung volumes proportional to the lung parenchyma resection, 6 months after pneumonectomy?

OBJECTIVES: To preoperatively estimate the degree of first-second forced expired volume (FEV1) and forced vital capacity (FVC) reduction 6 months after pneumonectomy, according to the preoperative performed spirometry and bronchoscopy, and to estimate if the expected postoperative values of FEV1 and FVC are in accordance with the actual values. METHODS: Thirty-five patients, who underwent pneumonectomy for non-small cell lung cancer between 1996 and 1999, were included in the perspective study. All patients had total or near total bronchial obstruction at preoperative bronchoscopy. Patients were divided into three groups according to the preoperative bronchoscopy findings: Group I, obstruction of the main bronchus (six patients); Group II, obstruction of a lobar bronchus (19 patients); and Group III, obstruction of a segmental bronchus (10 patients). The estimation of the percent reduction of FEV1 and FVC has been made according to the formula: percent reduction=(no. of bronchopulmonary segments to be resected-no. of obstructed segments) x 5.26%. RESULTS: The mean overall actual percent reduction of FEV1 and FVC differed significantly from the expected mean overall percent reduction of FEV1 and FVC (P=0.000 and P=0.001, respectively). The actual values were lower than the predicted values using the given formula. In group and subgroup analysis, the mean actual percent reduction of FEV1 and FVC differed significantly from the mean expected percent reduction of FEV1 and FVC in Groups I and II of patients (P<0.01), but no significant differences were observed in Group III of patients (P>0.05). No significant differences between expected and actual mean percent reduction of FEV1 and FVC was also observed in patients of Groups I and II, when lung or lobar atelectasis, respectively, was noted at preoperative chest X-ray (P>0.05). CONCLUSIONS: Only when a segmental bronchus was obstructed at the preoperative bronchoscopy or when lobar or lung atelectasis was the result of the main or lobar bronchus obstruction, the estimated, using the proposed formula, expected percent reduction of FEV1 and FVC values were close to the actual postoperative percent reduction of FEV1 and FVC.     

Manipulation of the anabolic and catabolic responses with BMP-2 and zoledronic acid in a rat femoral fracture model

Bone repair involves a complex set of regulated signaling pathways that control the formation of new bone matrix and the resorption of damaged bone matrix at the fracture site. It has been reported that the optimal time point for single-dose zoledronic acid (ZA) administration systemically increased the strength of bone morphogenetic protein (BMP)-7-mediated callus. However, its repair mechanism during bone fracture healing remains unknown. We aimed to investigate the synergic effect of recombinant human (rh) BMP-2 and ZA in a rat femoral fracture model. Fifty-eight rats were divided into 4 groups. Group I (n = 14) animals were implanted with a carrier alone. Group II (n = 15) animals were implanted with a carrier containing 1-μg rhBMP-2. Group III (n = 14) animals were implanted with a carrier and a subcutaneous systemic ZA injection 2 weeks after surgery. Group IV (n = 15) animals were implanted with a carrier containing 1-μg rhBMP-2 and ZA subcutaneous injection 2 weeks after surgery. The rats were euthanized after 6 weeks and their fractured femurs were explanted and assessed by manual palpation, radiographs, and high-resolution micro-computerized tomography (micro-CT) and were subjected to biomechanical and histological analysis. The fusion rates in Group IV (93.3%) were considerably higher than those in Groups I (28.6%), II (53.3%), and III (57.1%). Additionally, the radiographic scores of Group IV were higher than those in Groups I, II, and III. In micro-CT analysis, the tissue volume (TV) of the callus was higher in Group IV than in Groups I and II (p < 0.05). New bone volume (BV) and trabecular spacing (Tb.Sp) also showed essentially the same trend as that of TV. The ratio of BV to TV (BV/TV), the trabecular number (Tb.N), and the trabecular thickness (Tb.Th) was higher in Groups III and IV than in Groups I and II (p < 0.05). In biomechanical analysis, the ultimate loads at failure and stiffness in Groups III and IV were on average higher than those in Groups I and II (p < 0.05), while the energy absorption of Group IV was higher than those of Groups I and II (p < 0.05). The synergic effect of rhBMP-2 and ZA given systemically as a single dose at the optimal time was efficacious for fracture repair and significantly enhanced bone fusion. Our results suggest that this combination facilitates bone healing and has potential clinical application.     

Hyperbaric bupivacaine affects the doses of midazolam required for sedation after spinal anaesthesia

BACKGROUND AND OBJECTIVE: Patients having spinal anaesthesia with hyperbaric bupivacaine may become sensitive to sedative drugs but no data exists about any dose-related effect of the local anaesthetic on the sedative requirement. We aimed to investigate whether hyperbaric bupivacaine dose in spinal anaesthesia has any effect on midazolam requirements. METHODS: Sixty unpremedicated patients were allocated to three equal groups. Patients in Groups I and II received hyperbaric bupivacaine 0.5% 10 and 17.5 mg respectively for spinal anaesthesia and Group III was a control group without spinal anaesthesia. In Groups I and II, after the evaluation of sensory block, patients received intravenous midazolam 1 mg per 30 s until the Ramsay sedation score reached 3 (drowsy but responsive to command). In Group III, general anaesthesia was induced after sedation score had reached 3 using midazolam. The total dose of midazolam (mg kg(-1)) given to each patient, the level of sensory block and complications were recorded. RESULTS: The level of sensory block was higher in Group II (T7) than Group I (T9) (P < 0.01). The doses of midazolam were 0.063 mg kg(-1) in Group I, 0.065 mg kg(-1) in Group II and 0.101 mg kg(-1) in Group III (P < 0.001). There was no correlation between level of sensory block and dose of midazolam in Group I (r = -0.293, P = 0.21) and Group II (r = 0.204, P = 0.39). CONCLUSIONS: Different doses of hyperbaric bupivacaine for spinal anaesthesia do not affect the midazolam requirements for sedation. However, spinal anaesthesia with hyperbaric bupivacaine with a maximum spread in the middle thoracic dermatomes may be associated with sedative effects and thus a reduced need for further sedation with midazolam.     

Elastic intramedullary nailing combined with methylprednisolone acetate injection for treatment of unicameral bone cysts in children: a retrospective study

PurposeThe aetiology of unicameral bone cysts (UBCs) is unclear. This study aims to evaluate the feasibility of elastic intramedullary nailing (EIN) combined with injections of methylprednisolone acetate (MPA) for the treatment of UBCs in children.MethodsWe retrospectively analyzed 53 children with UBCs in our hospital between January 2010 and April 2016. A total of 24 patients (Group A) were treated by EIN and MPA, whilst 29 patients (Group B) were treated by curettage, bone grafts and EIN fixation. The radiographs of the UBCs were evaluated following the Capanna criteria. All patients were followed-up on the third, sixth, 12th, 24th and 36th months. Fixation time, hospitalization time and complications were evaluated.ResultsIn Group A, the mean number of MPA injections was 1.8 (1 to 3). Based on radiographic evaluation, eight patients were healed (Capanna grade I), 14 were healed with residual cysts (Capanna grade II), one showed recurrence (Capanna grade III) and one showed no response to the treatment (Capanna grade IV). In Group B, 11 patients were evaluated as Capanna grade I, 12 as Capanna grade II, three as Capanna grade III and three as Capanna grade IV. There was significant difference in the early postoperative function activity (p < 0.001), hospitalization time (p = 0.028), blood loss during surgery (p < 0.001) and surgery time (p < 0.001).ConclusionThe combination of EIN and MPA for the treatment of UBCs in children is feasible, has little operative trauma, short surgery time, short hospitalization time, less blood loss and a low risk of incision infection.Level of evidence:III     

Open aneurysm repair in elderly patients not candidates for endovascular repair (EVAR): Comparison with patients undergoing EVAR or preferential open repair

The authors reviewed a 2-year experience with abdominal aortic aneurysm (AAA) repair to determine if patients who were excluded from endovascular aneurysm repair (EVAR) because of anatomic criteria (Group III) represented a higher risk for subsequent open aneurysm repair than either patients undergoing EVAR (Group II) or those patients who preferentially underwent open repair (Group I). Between January 2001 and December 2003, 107 patients underwent AAA repair. Open repair was recommended in patients <70 years of age and without significant comorbidities (Group I). There were 35 patients in Group I; 72 patients were evaluated for EVAR; 29 patients underwent EVAR (Group II), and 43 were excluded and underwent open repair (Group III). Exclusion criteria were those recommended by the graft manufacturers. Patients in Group I were significantly younger than those in Groups II and III (p < 0.0001). Gender, incidence of diabetes, and hypertension were similar in all groups. Patients in Group III had a greater incidence of coronary artery disease (CAD) than those in Groups I and II, trending toward statistical significance (p = 0.06). Aneurysm size in Group II was statistically smaller than in Group I or III. Group III had significantly more complications (25.6% vs 5.7% and 6.9%) than either Group I or II (p < 0.015). Cardiac complications were similar in all groups. Three patients in Group III required prolonged intubation and 3 in Group III developed renal insufficiency. A history of CAD was predictive of complications (21.8% vs 5.8%, p < 0.024), as was inclusion in Group III. There were 2 deaths in this series, both in Group III. Length of stay was significantly less in Group II (4.17 +/-2.36 days) than in Group I (6.57 +/-1.84 days) or Group III (12.30 +/-9.82 days) (p = 0.0001). Open aneurysm repair can be safely performed in younger good-risk patients (Group I) with results equivalent to EVAR (Group II) but with slightly longer length of stay (LOS). In older patients with suitable anatomy EVAR can be performed with minimal morbidity and short LOS. Older patients not suitable for EVAR (Group III) constitute a higher risk group of patients because of increased incidence of CAD and the need for more complex repairs. However, the mortality rate in this group was only 4.6%.     

The effect of intravenous pantoprazole and ranitidine for improving preoperative gastric fluid properties in adults undergoing elective surgery

We studied pantoprazole, a new potent and fast-acting proton pump inhibitor. Its effects on preoperative gastric fluid volume and pH have not yet been determined. In this randomized, controlled trial, we examined the effects of preoperative IV pantoprazole or ranitidine on gastric pH and volume. Ninety patients (ASA status I and II, scheduled for elective surgery) were studied. One hour before surgery, patients in Group I (n = 30) were given IV saline 5 mL, those in Group II (n = 30) were given 40 mg of pantoprazole IV, and those in Group III (n = 30) were given 50 mg of ranitidine IV. A nasogastric tube was inserted immediately after anesthesia induction. Gastric contents were aspirated, and volume and pH were recorded. The pH values determined in Group I were 3.73 +/- 0.82; in Group II, they were 5.30 +/- 1.84; and in Group III, they were 4.80 +/- 1.40. There was no statistical difference between Groups 2 and 3, but there was a significant difference between Group I and Groups 2 and 3 (P < 0.0005). The volume of the gastric contents was 28.67 +/- 10.98 mL in Group I, 15.20 +/- 15.52 mL in Group II, and 7.77 +/- 11.17 mL in Group III. There was no statistical difference between Groups 2 and 3, but there was a statistically significant difference between Group I and Groups 2 and 3 (P < 0.0005). The proportion of patients considered "at risk" of significant lung injury should aspiration occur was 20% of Group I, 10% of Group II, and 3.3% of Group III. When statistically evaluated, there was no difference among groups. We concluded that the administration of IV pantoprazole and ranitidine 1 h before surgery is effective in reducing gastric pH and volume. IMPLICATIONS: This randomized, controlled trial examined the effects of preoperative IV pantoprazole or ranitidine on gastric pH and volume. We concluded that IV pantoprazole and ranitidine, given 1 h before surgery, are effective in reducing gastric pH and volume.     

Preparation of the left ventricle for anatomical correction in patients with simple transposition of the great arteries. Surgical guidelines

Pulmonary artery banding in combination with an aortopulmonary shunt was performed on 16 patients with simple transposition of the great arteries to prepare the left ventricle for anatomical correction. Three groups were identified after operation: Group I (four patients) had increased pulmonary blood flow and tight pulmonary artery banding; Group II (four patients) had increased pulmonary blood flow and moderate pulmonary artery banding; Group III (eight patients) had normal pulmonary blood flow and moderate pulmonary artery banding. Postoperative low cardiac output was present in all patients in Group I, whereas mild heart failure was present in two patients in Group II and in two in Group III. There was one hospital death (6%). The follow-up period was 125 patient-months. Left ventricular systolic pressure rose from 63 +/- 11 torr before the operation to 101 +/- 35 torr after the procedure in Group I (p less than 0.05), from 59 +/- 10 to 93 +/- 33 torr in Group II (p less than 0.05), and from 55 +/- 10 to 84 +/- 16 torr in Group III (p less than 0.005). The increase in left ventricular muscle mass was from 44 +/- 2 gm/m2 preoperatively to 108 +/- 12 gm/m2 after operation in Group I (p less than 0.01), from 43 +/- 3 to 93 +/- 8 gm/m2 in Group II (p less than 0.02), and from 46 +/- 3 to 55 +/- 14 gm/m2 in Group III (p = no statistically significant difference). The postoperative change in left ventricular end-diastolic volume was from 100% +/- 17% to 133% +/- 23% of normal in Groups I and II (p less than 0.05) and from 123% +/- 29% to 107% +/- 36% of normal in Group III (p = no statistically significant difference). In preparing the left ventricle for anatomical correction, avoidance of severe pulmonary artery banding decreases the incidence of postoperative myocardial dysfunction, a moderate degree of volume overload and pulmonary artery banding provides the most effective stimulus for ventricular growth, and a small to moderate atrial septal defect is advantageous because it ensures the volume preload necessary for the development of the left ventricle.     

Robotic‐assisted laparoscopic radical prostatectomy: Learning curve of first 100 cases

Objective: Robotic‐assisted laparoscopic radical prostatectomy (RALP) is gaining popularity for treating localized prostate cancer. We aimed to analyze the learning curve of a single surgeon using RALP in Taiwan. Methods: Medical records of 100 consecutive patients who underwent RALP were retrospectively reviewed. Preoperative, perioperative and postoperative parameters between patients in the first 30 cases (Group I), the second 30 cases (Group II) and cases 61–100 (Group III) undergoing RALP were analyzed. Results: Console time was shorter and blood loss was reduced in Groups II and III compared with Group I. Significant differences were found in vesicourethral anastomosis time (46.38 min for Group I vs 31.0 min for Group II vs 27 min for Group III, P < 0.01). Postoperative stay became statistically significantly shorter, from 7.33 days for Group I to 3.93 days for Group II to 3.0 days for Group III. Positive surgical margin of pT2 was reduced (13.3% for Group I, 7.1% for Group II and 0% for Group III) but not of pT3 (86.7% for Group I, 75% for Group II and 62.9% for Group III). Continence rate at 3 months was higher in Groups II (95%) and III (96.6%) than in Group 1 (76.7%, P < 0.05). Conclusions: For every 30 cases of RALP, vesicourethral anastomosis time and postoperative stay were significantly shorter. However, the incidence of surgical margin in pT3 prostate cancer was not significantly reduced. A learning curve of more than 100 cases is required to decrease the positive surgical margin in pT3 tumors.