Influence of Epidural Anaesthesia on the Course of Labour in Patients with Antepartum Fetal Death

The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for parity and gestational age, who received narcotic pain relief. Both groups had similar preinduction cervical dilatation and the induction was performed by amniotomy and oxytocin infusion. The mean first stage of labour was 5.4 hours in the epidural group, and 8.7 hours in the controls (p = 0.0192). The mean cervical dilatation rate was 3.3 cm/hour and 1.0 cm/hour respectively (p = 0.0142). The second stage was similar in both groups. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus.     

CA-125: A potential prognostic indicator in patients with cervical cancer?

We evaluated 104 patients with newly diagnosed carcinoma of the cervix. Pre- and post-therapy and followup CA-125 levels were measured in 64 patients. Fifty-five patients (86%) had squamous cell carcinoma and 9 (14%) had adenocarcinoma of the cervix. At initial presentation 19 (30%) had CA-125 levels >35 U/ml, 12 (19%) had levels of 16–35 U/ml, and 33 (51%) had levels <16 U/ml. Of the 11 patients who had pre- and post-treatment levels >35 U/ml, 10 are dead of the disease and 1 is alive with persistent or recurrent disease. Of the 20 patients with elevated CA-125 levels at presentation who reverted to normal after therapy, 19 are clinically without evidence of disease at 14–46 months (median 27 months). Of the 33 patients with normal pre- and post-therapy CA-125 levels, 31 are clinically without evidence of disease. Two of these thirty-three patients had increasing CA-125 levels during routine follow-up and both have disease recurrence confirmed. There was no apparent correlation between CA-125 level and tumor type, tumor grade, or stage of disease. Our data suggest that patients with initially elevated CA-125 levels that revert to normal after therapy have a favorable prognosis. Persistent elevation of CA-125 levels during and after therapy in patients with carcinoma of the cervix was associated with a poor prognosis.     

Fluvoxamine augmentation of olanzapine in chronic schizophrenia: pharmacokinetic interactions and clinical effects

Olanzapine is a substrate of the cytochrome P450 enzyme (CYP) 1A2. In this study, pharmacokinetic interactions and clinical effects of adding the CYP1A2 inhibitor fluvoxamine to steady-state olanzapine was examined in patients suffering from schizophrenia. Eight patients had been treated for at least 3 months with 10 to 20 mg/day olanzapine. Fluvoxamine (100 mg/day) was added (week 0) to the olanzapine treatment and continued for 8 weeks. Concentrations of olanzapine and its metabolite N-desmethylolanzapine and of fluvoxamine were analyzed at weeks 0, 1, 4, and 8. Addition of fluvoxamine resulted in a 12% to 112% ( < 0.01) increase of olanzapine from 31 +/- SD 15 ng/mL (week 0) to 56 +/- 31 ng/mL (week 8) in all patients. N-desmethylolanzapine concentrations were not significantly changed ( > 0.05). Fluvoxamine concentrations were 48 +/- 26 ng/mL on week 1 and 83 +/- 47 ng/mL on week 8. It is concluded that fluvoxamine affects olanzapine degradation and thus increases olanzapine concentrations. Although the combination was well tolerated in this sample and the negative symptom response appeared to be favorable in at least five patients, the combination therapy of olanzapine and fluvoxamine should be used cautiously and should be controlled by therapeutic drug monitoring to avoid olanzapine-induced side effects or intoxications.     

Short-term treatment of post-traumatic stress disorder with naltrexone: an open-label preliminary study

Eight patients (6 men and 2 women) with chronic post-traumatic stress disorder (PTSD) were treated with naltrexone 100-200 mg/day. Seven patients completed 2 weeks of treatment. A subtle and clinically insignificant improvement was noted in intrusive and hyperarousal symptoms (p < 0.05 for both), but not in avoidance symptoms. All patients demonstrated side effects which limited the targeted dose. It is suggested that the subtle positive effect of naltrexone and the hypersensitivity of these patients to its side effects do not encourage the use of naltrexone in the treatment of PTSD patients.     

Multiple shifts in the representation of a motor sequence during the acquisition of skilled performance

When do learning-related changes in performance occur? Here we show that the knowledge of a sequence of movements evolves through several distinctive phases that depend on two critical factors: the amount of practice as well as the passage of time. Our results show the following. (i) Within a given session, large performance gains constituted a signature for motor novelty. Such gains occurred only for newly introduced conditions irrespective of the absolute level of performance. (ii) A single training session resulted in both immediate but also time-dependent, latent learning hours after the termination of practice. Time in sleep determined the time of expression of these delayed gains. Moreover, the delayed gains were sequence-specific, indicating a qualitative change in the representation of the task within 24 h posttraining. (iii) Prolonged training resulted in additional between-session gains that, unlike the effects of a single training session, were confined to the trained hand. Thus, the effects of multisession training were qualitatively different than the immediate and time-dependent effects of a single session. Altogether, our results indicate multiple time-dependent shifts in the representation of motor experience during the acquisition of skilled performance.     

Dextromethorphan reduces immediate and late postoperative analgesic requirements and improves patients' subjective scorings after epidural lidocaine and general anesthesia

Central N-methyl-D-aspartate receptors modulate postoperative pain. We compared the effects of preincision oral dextromethorphan (DM), an N-methyl-D-aspartate receptor antagonist, on postoperative IV patient-controlled analgesia morphine demand and on subjective variables in 80 patients undergoing lower-body procedures who were randomly assigned to epidural lidocaine (LA; 16 mL, 1.6%) or general anesthesia (GA). The patients were premedicated 90 min before surgery with placebo or DM 90 mg (20 patients per group) in a double-blinded manner. Postoperative IV patient-controlled analgesia morphine administration started when subjective pain intensity was > or =4 of 10 (visual analog scale) and lasted 2 h. Observation continued up to 3 days, during which patients could use diclofenac. LA-DM and GA-DM patients required 45%-50% less morphine and diclofenac compared with their placebo counterparts (P < 0.001). However, GA-DM patients made twice as many attempts to self-administer morphine as LA-DM patients (P = 0.005). Eight LA-DM versus two GA-DM patients (P < 0.01) used no morphine or diclofenac. All DM patients experienced significantly (P < 0.001) less pain, were less sedated, and felt better than their placebo counterparts; however, compared with placebo, DM improved subjective scorings in the GA patients more significantly (P < 0.05) than in the LA patients. We conclude that oral DM 90 mg in patients undergoing surgery under LA or GA reduces morphine and diclofenac use by approximately 50% in the immediate and late postoperative period compared with placebo. Subjectively scored levels of pain, sedation, and well-being were better as well.     

Sleep-wake patterns in children with intrauterine growth retardation

The purpose of this study was to characterize the sleep patterns of children with intrauterine growth retardation, known to be at risk for neurodevelopmental disorders, and seek a possible correlation with behavior, concentration, and attention problems. The sleep patterns of 26 children with intrauterine growth retardation aged 4 to 7 years were compared with those of 47 control children using activity monitors (actigraphs). In addition, data were collected from the parents regarding sleep habits, behavior, concentration, and attention. Children with intrauterine growth retardation aged 4 to 7 years were found to have a tendency toward poorer quality of sleep than their matched controls. This inclination was statistically significant only for one sleep measure, the true sleep time. A tendency toward increased fragmentation of sleep, prolonged waking, and decreased sleep efficiency, although not statistically significant in this study, was demonstrated. Our results showed that 58% of the children with intrauterine growth retardation, compared with 40% of the children in the control group, could be defined as "poor sleepers" (sleep efficiency lower than 90% or three or more waking episodes per night). This disturbed sleep profile is probably an integral part of the neurodevelopmental profile typical of these at-risk children. No significant correlations were found between sleep quality and behavior, concentration, and attention problems.     

Dextromethorphan for the reduction of immediate and late postoperative pain and morphine consumption in orthopedic oncology patients: a randomized,placebo-controlled,double-blind study

BACKGROUND: Postoperative pain is mediated centrally by N-methyl-D-aspartate (NMDA) receptors. The beneficial effects of preincision oral dextromethorphan (DM), which is an NMDA antagonist, on postoperative pain and intravenous patient-controlled analgesia (IV-PCA) morphine (MO) consumption have been examined in patients undergoing surgery. The authors investigated 75 patients who underwent surgery for bone and soft tissue malignancies, in whom postoperative pain is more severe compared with patients who undergo general surgery. METHODS: Patients received placebo, DM 60 mg, or DM 90 mg (25 patients per group) before surgery and on each of the two following days in a randomized, double-blind, placebo-controlled manner. Postoperative IV-PCA MO was started when subjective pain intensity was >/= 4/10 (visual score) and lasted for 72 hours. Rescue drugs on demand were oral paracetamol or dipyrone. RESULTS: The patients in the DM60 and DM90 groups similarly experienced 50-80% less pain (P < 0.01) compared with patients in the placebo group, both immediately and up to 3 days postoperatively, as well as a 50% reduction in the estimated overall maximal pain intensity (P < 0.01). Both DM groups consumed 50-70% less MO than the nonmedicated individuals in the placebo group (P < 0.01), and their demand for rescue drugs on the first postoperative day also was significantly lower (P < 0.01). Patients in the DM groups also were sedated less ( approximately 70%; P < 0.01). There were no differences among the groups in terms of when the patients left their beds, when they were discharged home, or the number of overall side effects. CONCLUSIONS: DM is associated with reduced pain intensity, sedation, and analgesic requirements, even in patients undergoing surgery for bone and soft tissue malignancies. A 3-day DM administration neither increased the incidence of side effects nor accelerated ambulation and discharge home.