The psychosexual aspects of genital herpes

For patients infected with genital herpes simplex virus (HSV) infection, the psychological impact of a diagnosis can be devastating and may result in psychosexual dysfunction. Negative media reports, inadequate treatment and conflicting information from health-care professionals can further compound the impact of this diagnosis. Fortunately for most patients with a first episode of genital herpes, the emotional burden lessens with time, especially if they do not experience frequent recurrences. Adjustment to recurrent HSV is most difficult in patients with poor coping strategies. Suppressive antiviral drugs are effective in preventing HSV recurrences and have a short-term psychological adaptation, with some residual benefit shown after stopping medication. Drug treatment is not, however, a substitute for counselling or psychosexual support. Type-specific HSV serology is currently available as a research tool. Potential uses include the identification of targeted discordant couples for the prevention of neonatal herpes, the screening of immunocompromized patients at risk of reactivated HSV, and the monitoring of the effectiveness of vaccination programmes and health-education interventions. Patients must be assured of a holistic approach if they are to adjust to a diagnosis of genital HSV and maximize their quality of life.     

Thoracic epidural anaesthesia in infants and children

When compared with conventional analgesic techniques, epidural anaesthesia not only provides improved analgesia, but also has several beneficial effects on the postoperative respiratory, cardiovascular, and metabolic status of the patient. Although the efficacy and safety of caudal and lumbar epidural anaesthesia in children has been demonstrated, there is little information concerning the use of thoracic epidural anaesthesia. The purpose of our review was to evaluate the safety of thoracic epidural anaesthesia in infants and children. We retrospectively reviewed our three-year experience with thoracic epidural anaesthesia for postoperative analgesia in children. Epidural catheters were placed at the thoracic level without difficulty in 63 children ranging in age from three months to 18 yr and in weight from 3.2 to 78 kg. Postoperative analgesia was provided by the continuous infusion of a bupivacaine/fentanyl mixture, supplemented with intermittent epidural fentanyl by bolus as needed. Epidural catheters were successfully placed in all patients. No inadvertent dural punctures were noted. No episodes of respiratory depression related to epidural analgesia occurred. Minor adverse effects including pruritus occurred in six patients, three of whom required pharmacological intervention with diphenhydramine. Our review suggests that this is a safe and effective method of postoperative analgesia following thoracic surgery in children.     

Recurrent herpes simplex virus infections in the adult hand

Ten adult patients referred to the Department of Dermatology and Venereology at Akademiska Hospital, Uppsala, from different surgical units due to recurrent herpes simplex virus (HSV) infections in the hand, were investigated. At recurrence, virus isolation and typing revealed genital HSV type 2 virus in nine out of ten patients indicating that recurrent HSV infections located in the hand should be looked upon as a part of a venereal disease.     

Serological assessment of acyclovir treatment of herpes genitalis

Oral acyclovir was given to 60 patients with herpes genitalis--20 experiencing a first attack and 40 with recurrent attacks. All patients were followed up for 1 year. Serial serum samples from the patients as well as from 20 controls were studied to determine the effect of therapy on the immune response to herpes simplex virus (HSV). No toxicity was observed, and very few patients had rather insignificant side effects (e.g., diarrhea). The frequency of recurrence (number of recurrences per year) of genital herpes in acyclovir-treated patients was found significantly lower than in controls. More frequent recurrences were observed in those who had high antibody titer in their early convalescent phase sera than in those without or with a low titer of such antibodies. The antibody titers were reduced in those who received acyclovir as compared with controls. The mean time to seroconversion was longer in the acyclovir-treated group than in controls. Oral acyclovir is thus effective and well tolerated in patients with herpes genitalis. Treatment with acyclovir also diminishes the humoral antibody response to HSV, but it does not prevent recurrence. The effects of acyclovir on the immune response to HSV are discussed.     

Combined spinal epidural anaesthesia for elective caesarean section in a patient with spondylometaphyseal dysplasia

A patient with spondylometaphyseal dysplasia, an extremely rare form of dwarfism, presented for elective caesarean section. We report the successful management under regional anaesthesia, using a combined spinal epidural technique. There seem to be only two previous reports of spinal anaesthesia and there are no previous reports of the use of combined spinal epidural in a pregnant dwarf. Regional anaesthesia is thought to be complex in these dwarfs due to vertebral malformation and unpredictable anatomy of the spinal canal. They may present difficulties with intubation as well. Spondylometaphyseal dysplasia is reviewed and its anaesthetic implications discussed.     

Refractory hypotension during combined general and epidural anaesthesia in a patient on tricyclic antidepressants

We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.     

Pneumomediastinum in labour -- probably not caused by a lumbar epidural anaesthesia

We describe a case of pneumomediastinum and subcutaneous emphysema during labour. The patient had previously received an epidural anaesthesia to alleviate labour pain. We found several reports of subcutaneous emphysema and pneumomediastinum (or pneumothorax) possibly caused by or related to epidural anaesthesia use, but conclude that the epidural anaesthesia was probably not a cause in our case.     

Abcès péridural compliquant une rachianesthésie chez un patient diabétique

Infectious complications of spinal or epidural anaesthesia are rare, particularly after spinal anaesthesia. Most of them consist of a meningitis. We report a case of epidural abscess due to s following spinal ana following spinal anaesthesia in a 62-year-old diabetic patient, diagnosed 45 days afterthe puncture with bacterial samples and magnetic resonance imaging. The pejorative neurological outcome required a laminectomy in spite of an efficient anti-staphylococcal treatment.     

Failed spinal analgesia after a combined spinal epidural anaesthesia for Caesarean section

A case of failed spinal analgesia with a combined spinal epidural anaesthesia (CSE) for Caesarean section is described. The lack of desired effect following an inconspicuous spinal, epidural or combined regional anaesthesia by an experienced anaesthetist is a rare and unexpected event. Especially when repeatedly observed in one patient,one should consider modified anatomical conditions of the affected spinal regions. We discuss the differential diagnosis which consists of inherent and acquired modification of tissue, neoplasia and vascular or infectious diseases. This case also confirms that not every adverse event after spinal or extradural anaesthesia is necessarily caused by the puncture.     

Post-operative paraplegia following spinal cord infarction

Thoracic epidural analgesia is a frequently utilised technique. Neurological complications are uncommon, but of grave consequence with significant morbidity. Spinal cord infarction following epidural anaesthesia is rare. We present a case where a hypertensive patient underwent an elective sigmoid colectomy under combined general/epidural anaesthesia for a suspected malignant abdominal mass. An epidural infusion was used for intra-operative and post-operative analgesia. During surgery, the blood pressure was labile and she was hypotensive. Postoperatively, the patient became confused, pyrexial and tachycardic and developed systemic inflammatory response syndrome requiring intensive care management. She developed a flaccid paralysis at L3 level with areflexia, analgesia and impaired sensation. A spinal cord infarct in the region of the conus extending into the thoracic cord was diagnosed. Complications of epidural anaesthesia are easily recognised when they develop immediately; their relationship to the anaesthesia and the post-operative period may be misjudged or underestimated when they appear after a delay, if neurological signs are masked by lack of patient cooperation and drowsiness or if the epidural anaesthesia is prolonged by long-acting drugs. New neurological deficits should be evaluated promptly to document the evolving neurological status and further testing or intervention should be arranged if appropriate. The association with epidural anaesthesia as a cause of paraplegia is reviewed. The aetiological factors that may have contributed to this tragic neurological complication are discussed.     

Use of thoracic epidural anaesthesia for thoracic surgery and its effect on pulmonary function

Pulmonary complications following thoracic surgery significantly contribute to peri-operative morbidity and mortality. This chapter discusses some pathophysiological aspects of thoracic surgery, the effects of epidural anaesthesia on pulmonary function and its implications for use of thoracic epidural anaesthesia after thoracic surgery. A favourable effect of epidural anaesthesia on incidence of pulmonary morbidity was recently demonstrated in a meta-analysis involving a broad spectrum of surgical procedures. There is less evidence that the use of thoracic epidural anaesthesia techniques is associated with fewer respiratory complications in patients undergoing thoracotomy. However, thoracic epidural anaesthesia provides excellent analgesia after thoracotomy, particularly if local anaesthetics are combined with opioids. In addition, decreased length of stay on an intensive care unit and reduced hospital stay could be demonstrated if thoracic epidural anaesthesia was used in cardiac or thoracic surgical patients.     

Epidural morphine injection after combined spinal and epidural anaesthesia

BACKGROUND AND OBJECTIVE: Although combined spinal and epidural anaesthesia is efficient and easy to perform, the technique can be a double-edged sword having the potential risk that an increased flux of drugs across the meninges through the hole made in it may lead to severe adverse effects. The aim was to compare the incidence of adverse events when an epidural injection of morphine was given after combined spinal and epidural anaesthesia or after epidural anaesthesia. METHODS: Fifteen patients had an epidural catheter inserted at the L2-3 interspace, and then a spinal block administered via the L3-4 interspace. Another 15 patients only had an epidural catheter inserted. After the onset of spinal or epidural anaesthesia had been confirmed, morphine 2 mg was injected into the epidural space, and a continuous epidural infusion of morphine was started. At the end of the operation and at 4, 8 and 12 h after the administration of epidural morphine and on the next day, the following variables were examined: blood pressure, heart rate, respiratory rate, arterial blood-gas analysis, visual analogue scale pain scores, nausea/vomiting scores, and pruritus scores. RESULTS: In the study population, the epidural injection of morphine was not associated with a significantly higher incidence of adverse events when given after spinal anaesthesia than after epidural anaesthesia. CONCLUSIONS: The adverse effects associated with epidural morphine given after spinal anaesthesia did not increase significantly when a 27-G Whitacre needle was used. Thus, the morphine flux through the meningeal hole into the cerebrospinal fluid was trivial.     

Combination of balanced and regional anaesthesia for minimally invasive surgery in a patient with myasthenia gravis

A 45-year-old man with cryptorchism, who was known to suffer from generalized myasthenia gravis, was admitted to hospital for surgical treatment using laparoscopy. Such minimally invasive surgery requires good muscle relaxation. However, the use of neuromuscular blocking agents in patients with myasthenia gravis may lead to prolonged apnoea after operation, thus necessitating mechanical ventilation of the lungs. We used a combination of general anaesthesia (with desflurane), and epidural anaesthesia (with the amide local anaesthetic ropivacaine) to obtain excellent abdominal relaxation during surgery. Tracheal extubation was possible immediately after the operation and no adverse effects were observed. The patient was discharged from hospital on the second day after operation. The combination of regional and general anaesthesia for minimally invasive surgery in this patient permitted safe anaesthetic management.     

A double-blind comparison of epidural bupivacaine and bupivacaine-fentanyl for caesarean section

The effect of adding fentanyl 100 mcg to bupivacaine 0.5% plain to establish epidural anaesthesia for elective caesarean section was investigated in a randomised, double-blind study of sixty healthy women. The quality of intraoperative analgesia as assessed by both patients and anaesthetists was significantly improved with fentanyl. The onset and duration of sensory anaesthesia, degree and duration of motor block, and other characteristics of epidural anaesthesia were unaltered. No adverse maternal side-effects (except mild pruritus) were noted and neonatal outcome was unaffected. The pharmacokinetics of epidural fentanyl administration were investigated by plasma fentanyl assays from maternal and cord blood taken at delivery. Epidural bupivacaine-fentanyl combination is a valuable therapeutic approach to the conduct of epidural anaesthesia for caesarean section in healthy women and foetuses. Further neonatal evaluation of the premature or compromised foetus is suggested before the universal application of this technique.     

Obstetrical epidural anaesthesia in a Canadian outpost hospital

The number of parturients receiving epidural anaesthesia in university medical centres is increasing. This trend is not paralleled in rural hospitals. Obstetrical epidural anaesthesia as provided in a 40-bed, remote hospital is reviewed for the ten-year period from January 1974 to December 1983. Charts were reviewed retrospectively for 116 patients undergoing epidural blockade. The indications, complication rates, as well as infant outcomes were noted. Seven per cent of all parturients received epidural anaesthetics. Ninety per cent of this group received systemic sedation or narcotics prior to epidural catheter insertion. Nineteen patients (16.3 per cent) experienced a major complication, including four dural punctures (3.4 per cent), ten episodes of significant hypotension (8.6 per cent), blood vessel puncture during catheter insertion in four patients (3.4 per cent), and transient paresthesia in one patient (0.8 per cent). Considerations for the provision of epidural anaesthesia in a remote hospital are discussed.     

Epidural anaesthesia for caesarean section in an achondroplastic dwarf

This report describes the anaesthetic management of an 18-yr-old achondroplastic dwarf who presented for elective Caesarean section. Epidural anaesthesia was performed without technical difficulty using 8 ml carbonated lidocaine 2% with epinephrine 1:200,000. Although the skeletal abnormalities of achondroplasia have been cited as contraindications to the use of epidural anaesthesia, clinical experience does not support this contention. Previous reports have described technical difficulties in these patients, such as dural puncture and inability to advance the catheter into the epidural space, but no serious complications resulted and epidural anaesthesia was successful on subsequent attempts. The existing literature on the anaesthetic management of achondroplasia for Caesarean section is reviewed and considerations are presented concerning the choice of local anaesthetic, the epidural test dose, and dose titration.     

Herpes Mastitis: Diagnosis and Management

Herpetic lesions most frequently occur on oral and genital areas. However, herpes simplex virus (HSV) can be a rare cause of breast infection. In few published articles, the route of transmission is predominantly from infant to mother. We report two cases about simultaneous mammary and extramammary (oral and genital) herpetic infection in nonlactating women. In both cases, HSV breast lesions were acquired by sexual contacts with partners who were asymptomatic HSV carriers. Through a review of literature, we highlight clinical signs for an early diagnosis. We also emphasize the advantage of the valacyclovir for treating this uncommon pathology.     

喷昔洛韦乳膏治疗生殖器疱疹

目的 :探讨国产喷昔洛韦乳膏治疗生殖器疱疹的疗效和安全性。　方法 :在 9家医院采用多中心开放临床试验 ,对生殖器疱疹局部外涂 1%喷昔洛韦乳膏 ,2次 /d ,疗程 7d。　结果 :65例初发和复发性生殖器疱疹治愈率达 87.7% ( 5 7/ 65 ) ,总有效率为 95 .4 % ( 62 / 65 ) ,5例 ( 9 2 3 % )发生轻度一过性不良反应。　结论 :1%喷昔洛韦乳膏外用治疗生殖器疱疹是一种安全、有效的方法     

Herpes labialis in parturients receiving epidural morphine following cesarean section

A significant association exists between the use of epidural morphine (EM), reactivation of herpes labialis (HL) commonly known as coldsores, and pruritus in the obstetric population. A randomized prospective study was designed to eliminate previously identified confounding variables. Immediately following delivery, parturients having undergone cesarean section with epidural anesthesia with carbonated lidocaine (Xylocaine CO2, Astra, Mississauga, Ontario, Canada) with 1:200,000 epinephrine were sequentially randomized to receive either EM or im opioids for postoperative analgesia. One blood sample was collected for viral serology and two mouthwashes (day 0 and 2) were collected to determine oral viral shedding. The patients were observed daily for 5 days. Coldsores were cultured for herpes simplex virus (HSV). Of 187 patients, 96 received EM and 91 im opioids; herpes labialis occurred in 14 of 96 (14.6%) of the former but in 0 of 91 of the latter (P = 0.0004). All 14 experienced facial pruritus. The two groups were at equal risk for reactivation (seropositivity 64.6% and 62.6%, respectively). Analysis of data for those with positive HSV serology reveals 14 of 62 (22.5%) had EM and herpes labialis compared with 0 of 57 in the im group (P less than 0.0001). The incidence of oral viral shedding was low. Surgical stress, the local anesthetic solution, and epinephrine addition to the local anesthetic were eliminated as confounders. Stepwise logistic regression analysis revealed that EM and a history of herpes labialis in these patients were predictive for reactivating oral HSV.     

Recurrent herpes simplex virus labialis and the use of epidural morphine in obstetric patients

A retrospective study of sequential obstetric patients delivering at University Hospital and receiving epidural anesthesia was conducted to determine if a suggested association exists between the recurrence of oral herpes simplex lesions and the use of epidural morphine. In a retrospective study of 291 patients, 13 of 134 (9.7%) receiving epidural morphine developed recurrent oral herpes lesions in contrast to 1 of 157 (0.6%) not receiving the drug (P less than 0.001). In a prospective hospital-based study of 729 consecutive obstetric patients, 146 patients received epidural opioids (morphine, fentanyl, or both) and 583 did not. Recurrent HSVL lesions occurred in 13 of 140 (9.3%) patients given epidural morphine but in only 6 of 583 (1.0%) not given epidural opioids (P less than 0.001). Three of the 13 patients with HSVL received both epidural morphine and fentanyl and 10 received only epidural morphine. Because of the small numbers of patients receiving only fentanyl, no relation between HSVL reactivation and epidural fentanyl could be established. In patients having caesarean sections, the association of recurrent HSVL and the use of epidural morphine was significant (P = 0.04), suggesting cesarean delivery was not a confounder. A hitherto undescribed triggering agent, epidural morphine, appears to be associated with reactivation of HSVL in obstetric patients in the postpartum period.