Remifentanil for use during conscious sedation in outpatient oral surgery.

PURPOSE: Remifentanil is a new, short-acting opioid that is similar pharmacodynamically to currently available opioids but differs in its pharmacokinetics. In the present study, we compared the use of remifentanil with the use of meperidine during intravenous conscious sedation for third molar surgery. PATIENTS AND METHODS: Forty patients who were scheduled for the removal of impacted third molars were randomly assigned to undergo 1 of 2 intravenous conscious sedation techniques. For both groups, 50:50 nitrous oxide oxygen were administered via nasal hood, and midazolam was titrated to Verril's sign. Twenty patients each then received either remifentanil 0.05 microgram/kg/min or meperidine 50 mg. Both patients and surgeons were blinded to the narcotic that was used. Blood pressure, heart rate, and oxygen saturation were determined before sedation and every 5 minutes during surgery. Recovery was measured using serial Trieger tests every 5 minutes after surgery. Patient and surgeon satisfaction of the quality of sedation was measured with a visual analog scale. RESULTS: Peak heart rate (91 beats/min for remifentanil vs 107 beats/min for meperidine, P <.01) and peak systolic blood pressure (131 mm Hg for remifentanil vs. 142 mm Hg for meperidine, P <.05) were significantly lower for the remifentanil group. Although there was a trend toward increased surgeon satisfaction with remifentanil (86 of 100 with remifentanil vs. 73 of 100 with meperidine), it was not found to be statistically significant. Likewise, other physiologic parameters were not found to be statistically significant. CONCLUSIONS: The lower peak heart rate and systolic blood pressure levels indicate that remifentanil may allow for less fluctuation in cardiovascular parameters. This could prove beneficial in patients with cardiovascular compromise.     

Cyclosporin A-induced remission of primary membranous glomerulonephritis in a child

Sir, A 4-year-old boy presented with oedema and weight gain of 5kg. There had been no preceding infections, vaccinations ormedication. The family history includes the mothers mesangioproliferativeglomerulonephritis. Laboratory results showed decreased albumin (13 g/l) concentration.Calculated glomerular filtration rate was 125 ml/min/1.73 m²and the     

Identification of two calcium currents in acutely dissociated neurons from the rat lateral geniculate nucleus

1. Intracellular recording in the in vitro slice preparation and whole-cell, patch-clamp recording of acutely dissociated neurons from the rat lateral geniculate nucleus (LGN) were combined to study the Ca currents underlying their electrical responses. In slices from young animals (postnatal days 13-16), we found that dorsal LGN neurons have responses similar to those of adult preparations, including the presence of a low-threshold Ca spike (LTS). After enzymatic isolation of LGN neurons from the same animals, the firing properties appeared well preserved, as indicated by whole-cell, current-clamp recordings from dissociated multipolar cells (presumably geniculocortical relay neurons). 2. Two types of Ca currents were identified in voltage-clamped, isolated LGN neurons on the basis of their voltage dependency, pharmacology, and selectivity properties. These two currents resemble the low-voltage-activated (LVA) and high-voltage-activated (HVA) Ca channels found in rat sensory neurons (9). 3. The LVA current component required negative potentials (less than -80 mV) to deinactivate completely, started to activate around -60 mV and reached a plateau level around -25 mV. It peaked within 30-6 ms and decayed with a single time constant of approximately 24 ms at -20 mV. Its inactivation curve ranged from -100 to -40 mV, with a half-inactivation near -60 mV. The HVA current component could be isolated by holding the membrane potential positive to -60 mV, activated at potentials positive to -30 mV and peaked around +5 mV. The time-to-peak ranged from 30 to 6 ms in the voltage range from -30 to +35 mV and decayed very slowly with sustained depolarizing pulses (time constant ranged between 1,600 and 40 ms over the same voltage range). 4. The inactivation of LVA Ca current during depolarizing voltage steps was consistent with a voltage-dependent process. The recovery from inactivation after short (100 ms), inactivating prepulses displayed two exponential phases. The slower phase was predominant under conditions that induce large current flow through the membrane, suggesting a Ca-mediated mechanism. 5. The LVA current was preferentially blocked by 50 microM Ni2+, leaving the HVA currents almost unaltered. Fifty micromolars Cd2+, in contrast, seemed more effective in blocking the HVA component of the Ca current.(ABSTRACT TRUNCATED AT 400 WORDS)     

Auditing paediatric diabetes care and the impact of a specialist nurse trained in paediatric diabetes

AIMS: To define outcome measures for auditing the clinical care of children and adolescents with insulin dependent diabetes mellitus (IDDM) and to assess the benefit of appointing a dedicated paediatric trained diabetes specialist nurse (PDSN). METHODS: Retrospective analysis of medical notes and hospital records. Glycaemic control, growth, weight gain, microvascular complications, school absence, and the proportion of children undergoing an annual clinical review and diabetes education session were assessed. The effect of the appointment of a PDSN on the frequency of hospital admission, length of inpatient stay, and outpatient attendance was evaluated. RESULTS: Children with IDDM were of normal height and grew well for three years after diagnosis, but grew suboptimally thereafter. Weight gain was above average every year after diagnosis. Glycaemic control was poor at all ages with only 16% of children having an acceptable glycated haemoglobin. Eighty five per cent of patients underwent a formal annual clinical review, of whom 16% had background retinopathy and 20% microalbuminuria in one or more samples. After appointing the PDSN the median length of hospital stay for newly diagnosed patients decreased from five days to one day, with 10 of 24 children not admitted. None of the latter was admitted during the next year. There was no evidence of the PDSN affecting the frequency of readmission or length of stay of children with established IDDM. Non-attendance at the outpatient clinic was reduced from a median of 19 to 10%. CONCLUSIONS: Outcome measures for evaluating the care of children with IDDM can be defined and evaluated. Specialist nursing support markedly reduces the length of hospital stay of newly diagnosed patients without sacrificing the quality of care.