Differential diagnosis of subungual melanoma from a surgical point of view

Subungual lesion referred to a surgical unit over a 17-year period have been reviewed to assess problems of differential diagnosis and management of suspected subungual melanoma. Such lesions are uncommon, even in a unit with interest in melanoma. Only four melanomas were seen for primary treatment, and eight in all, during the period. We describe the clinical features of other subungual lesions seen in surgical patients which might help in their differentiation from melanoma. Differential diagnosis and a management policy to achieve early diagnosis are discussed in the light of data from this series and study of the relevant literature.     

Interaction between mivacurium and succinylcholine from a different point of view

OBJECTIVES: Succinylcholine (SCH) may first be used and continue with mivacurium (MIV). MIV has been suggested as a pretreatment. Conflicting results arises from studies on SCH-MIV interaction. The following trial revisits this interaction. PATIENTS AND METHODS: The patients were intubated after randomized administration of 100 microg x Kg(-1) of mivacurium (group 1) or 1 mg x Kg(-1) of succinylcholine and, after 50% recovery, 100 microg x Kg(-1) of mivacurium (group 2). A third group received the same regimen as group 2, preceded by pretreatment with 10 microg x Kg(-1) of mivacurium. Maximum effect (MAX), onset time, the 10%-25% recovery index, and duration of effect of mivacurium were determined by electromyography. In groups 2 and 3, the corrected MAX was defined as the difference between the actual MAX effect and the residual block after administration of succinylcholine, and speed of action was defined as the ratio between MAX or corrected MAX and onset time. Data were subjected to analysis of variance and Student-Newman-Keuls and t tests for bivariate comparisons. A value of P less than 0.05 was considered significant. RESULTS: Groups 2 and 3 had significantly greater MAX effects (97% and 98%, respectively) in comparison with group 1 (93%), shorter onset times (135 and 158 seconds in groups 2 and 3 vs 279 seconds in group 1), and greater speed of action without changes in duration of effect. MAX was halved when corrected (to 47% and 49% in groups 2 and 3, respectively), and speed of action was significantly reduced (from 1.34 and 1.62 seconds/% in groups 2 and 3 respectively, to 2.69 and 3.36 seconds/%). Mivacurium pretreatment did not produce relevant clinical changes. CONCLUSIONS: When mivacurium is used before the effects of succinylcholine disappear, a residual effect is not usually taken into consideration. This study corrected MAX and calculated speed of action, demonstrating a reduction in net block and speed of action, consistent with an antagonistic action when the 2 blockers are administered sequentially.     

Post-traumatic jaundice--its mechanism from a view point of hepatic mitochondrial function

It has been proposed that post-traumatic jaundice was the result of increased hemolysis, absorption of hematoma, effects of drugs, and so on. We considered that hepatic impairment in the bilirubin metabolism as a result of hepatic hypoperfusion might also be an important factor of the jaundice. Patients who developed jaundice after trauma were divided into two groups according to the maximum total bilirubin level; groups H (greater than 8 mg/dl) and L (less than 5 mg/dl). Severity of shock, levels of serum hepatic enzyme, and blood ketone body ratio were compared between the groups. Minimum systolic pressure, H 58, L 82 mmHg (p = 0.003); duration of shock (less than 80 mmHg), H 225, L 20 min (p less than 0.001); blood transfusion, H 9188, L 2914 ml (p less than 0.001); direct/total bilirubin, H 0.66, L 0.43 (p less than 0.001). Although no significant difference was noted in serum hepatic enzyme levels, blood ketone body ratios were significantly lower in group H throughout the first week. From these facts, it is considered that an impairment in the most energy requiring process of bilirubin metabolism, excretion of conjugated bilirubin from cytosol to capillary bile duct, due to post-traumatic hepatic mitochondrial dysfunction, followed by the reabsorption of conjugated bilirubin into the blood stream, would be one of factors of post-traumatic jaundice.     

Review on chronic pelvic pain from a urological point of view

 Chronic pelvic pain or interstitial cystitis (IC) is an enigmatic and frustrating condition to manage as physician and to cope with as patient. Patients report moderate to excruciating pain in the suprapubic and/or vaginal area, urgency and frequency (up to 50 micturitions per day), and disruption of their social life. Many patients are declared as drug addicted and neurotic. Social status and the number of sexual partners showed no correlation with incidence. Diagnosis of IC is made by exclusion. A number of pathophysiologic mechanisms have been proposed: changes in epithelial permeability, pelvic floor dysfunction, mastocytosis, activation of C-fibers, increase of nerve growth factors, and bradykinin. No single theory can explain IC.