A comparison of patient-controlled epidural analgesia following gynaecological surgery with and without a background infusion

We conducted a randomised, controlled study to investigate the effect of adding a background infusion to patient-controlled epidural analgesia for postoperative pain relief. Forty-two patients scheduled for elective lower abdominal gynaecological surgery received patient-controlled epidural analgesia postoperatively using a mixture of 0.2% ropivacaine and 2.0 microg x ml-1 fentanyl. Patients in group B (n = 20) were given a background infusion of 5 ml x h-1, whereas those in group N (n = 21) were not. There was no difference in pain scores or patient satisfaction scores between the two groups. Patients in group B had a higher total drug consumption (156.8 +/- 34.8 ml vs. 89.5 +/- 41.0 ml; p < 0.0001) and incidence of side-effects (71.4% vs. 30.0%; p = 0.007). Motor blockade during the 24-h study period was also greater in group B (median [range] area under the curve 7.5 [0.0-39.0] h vs. 3.0 [0.0-36.0] h; p = 0.035). We conclude that the addition of a background infusion to patient-controlled epidural anaesthesia is not recommended as it confers no additional benefits.     

Technical refinement in adult-to-adult living donor liver transplantation using right lobe graft

OBJECTIVE: To report the authors' experience with living donor liver transplantation in adults using right lobe liver grafts, performed by a modified technique. SUMMARY BACKGROUND DATA: The initial results of seven living donor liver transplants in adults using extended right lobe grafts were satisfactory, but serious complications occurred in two donors, and six recipients required repeat laparotomy. Another 11 similar operations were performed. Further evaluation was made with the aim of improving the postoperative outcome. METHODS: From December 1996 to August 1998, 11 patients underwent living donor liver transplantation using right lobe grafts. The first four patients underwent surgery using methods previously designed and the next seven underwent a modification designed to minimize devitalized tissues on the liver transection surface, improve hepatic venous drainage, and reduce the number of hepatic duct orifices. RESULTS: There were no donor deaths. Donor complications included cholestasis (n = 1) and minor wound infection (n = 1). All the first four recipients required a repeat laparotomy for infected necrotic liver transection surface (n = 1), acute pancreatitis (n = 1), hepatic vein thrombosis (n = 1), and leakage from one of the two bilioenteric anastomoses (n = 1). The patient with hepatic vein thrombosis died. In the last seven recipients, all of whom survived the operation, one required a repeat laparotomy with the discovery of a methicillin-resistant Staphylococcus aureus culture of fibrinous exudate at the left subphrenic peritoneum, and another had right hepatic duct stump necrosis. The latter was likely related to hypovolemic shock secondary to bleeding from the right saphenous vein on removal of a hemofiltration catheter. Comparison of the incidence of repeat laparotomy between the first four and the remaining seven recipients showed a significant trend of improvement. Combining the result of the seven patients reported previously, the improvement in terms of relaparotomy rate is significant. CONCLUSION: With modification of surgical technique, living donor liver transplantation in adults using right lobe liver grafts can become a relatively safe procedure.     

Genetic polymorphism of NAD(P)H:quinone oxidoreductase is associated with an increased risk of infant acute lymphoblastic leukemia without MLL gene rearrangements.

NAD(P)H:quinone oxidoreductase 1 (NQO1) is a detoxification enzyme that protects cells against oxidative stress and toxic quinones. A polymorphism (C609T) in the gene produces in the heterozygous individuals (C/T) a reduction and in those homozygous for the variant allele (T/T) the abolishment of NQO1 protein activity. To assess whether NQO1 inactivating polymorphism (CT/TT) was a possible risk factor for infant acute lymphoblastic leukemia (iALL), we investigated the distribution of NQO1 genotype in 50 iALL patients, 32 with MLL gene rearrangements (MLL+) and 18 without (MLL-). As controls, 106 cases of pediatric ALL (pALL), and 147 healthy subjects were also studied. Compared to normal controls, the frequency of the low/null activity NQO1 genotypes was significantly higher in the iALL MLL- (72 vs 38%, P=0.006; odds ratio (OR) 4.22, 95% confidence interval (CI) 1.43-12.49), while no differences were observed in iALL MLL+ (44 vs 38%, P=0.553; OR 1.26, 95% CI 0.58-2.74). Similar results were observed when pALL were used as control. Our results indicate that only the iALL patients without MLL rearrangements had a significantly higher frequency of NQO1 genotypes associated with low/null activity enzyme, suggesting a possible role for NQO1 gene as an MLL-independent risk factor, in the leukemogenic process of this subtype of iALL.     

Long-term results of a randomized trial on extended use of high dose L-asparaginase for standard risk childhood acute lymphoblastic leukemia.

PURPOSE: Between September 1991 and May 1997, within the International Berlin-Frankfurt-Muenster Study Group (I-BFM-SG), a randomized study was performed aimed at assessing the efficacy of prolonged use of high-dose l-asparaginase (HD-l-ASP) during continuation therapy in children with standard risk (SR) acute lymphoblastic leukemia (ALL), treated with a reduced BFM-type chemotherapy. PATIENTS AND METHODS: The Italian, Dutch, and Hungarian groups participated in this study denominated IDH-ALL-91, and 494 children were enrolled. Treatment consisted of a BFM-type modified backbone with omission of the IB part in induction and elimination of two doses of anthracyclines during reinduction in both arms at the beginning of continuation therapy. Patients were randomly assigned to receive (YES-ASP) or not (NO-ASP) 20 weekly HD-l-ASP (25,000 IU/m2). RESULTS: The event-free-survival and overall survival probabilities at 10 years for the entire group were 82.5% (1.8) and 90.3% (1.3), respectively. Of the 490 patients eligible for random assignment, 355 (72.4%) were randomly assigned (178 YES-ASP and 177 NO-ASP). After a median follow-up of 9 years, the probability of disease-free survival at 10 years was 87.5% (SE, 2.5) for YES-ASP arm versus 78.7% (SE, 3.3) for NO-ASP arm (P = .03). In multivariate analysis, NO-ASP arm (P = .03), male sex (P = .004), and age older than 10 years (P = .0003) had a significantly adverse impact on outcome. CONCLUSION: In this subset of patients, selected with criteria not including monitoring of minimal residual disease, application of extended HD-l-ASP may improve prognosis, compensating reduced leukemia control that results from adoption of a reduced-intensity BFM-backbone for treatment of children with SR ALL.     

Causes and trend of maternal death in a local obstetric unit in Hong Kong

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Laparoscopic cervical cerclage: a series in women with a history of second trimester miscarriage

We sought to develop a laparoscopic technique for placement of a cervical cerclage in women with a history of failed vaginal cerclage and recurrent miscarriage. This was a case series, design classification III. The study took place at The Recurrent Miscarriage Clinic at National Women's Hospital, Auckland, New Zealand. Ten women with a history of second trimester miscarriage after failed vaginal cerclage, and 1 woman with a history of second trimester miscarriage and findings of a clinically deficient cervix were studied. A laparoscopic cervical cerclage was placed before pregnancy. No intraoperative or postoperative complications were experienced. Ten of 11 women subsequently became pregnant and all delivered live babies by cesarean section in the third trimester. Laparoscopic cervical cerclage is feasible and effective. Outcomes are good in a particularly high-risk group of women with cervical incompetence, who have had failed vaginal cerclage and have a history of recurrent pregnancy loss.     

Primary aortoduodenal fistula caused by tuberculous aortitis presenting as recurrent massive gastrointestinal bleeding

Upper gastrointestinal bleeding from primary aortoduodenal fistula (PADF) is unusual and fatal. The etiology of PADF from tuberculous aortitis is rare. We report a 69-year-old male patient who suffered recurrent hematemesis and hematochezia with hypovolemic shock of unknown origin. Initial endoscopy failed to lead to a diagnosis. A bleeder over the third portion of the duodenum was found after the third endoscopy. Exploratory laparotomy showed a ruptured aortic pseudoaneurysm with an aortoduodenal fistula. Dacron graft repair of the aorta and simple closure of the duodenal fistula were carried out. Pathologic examination revealed tuberculous aortitis. The patient survived and was symptom-free following operation and antituberculous therapy. Review of the literature revealed that the clinical presentations in this disorder are insidious. The endoscopic findings are atypical. We conclude that so-called "herald bleeding", a history of tuberculous infection or aortic aneurysm and a high degree of suspicion are critical for successful diagnosis. Early diagnosis and surgical exploration are needed for timely and successful management.     

Neonatal and 5-year outcomes after birth at 30-34 weeks of gestation

OBJECTIVE: To evaluate the rates of in-hospital death, neonatal complications, and 5-year outcomes of infants born at 30-34 weeks of gestation. METHODS: In nine regions of France, all 2,020 stillbirths and live births at 30, 31, and 32 weeks in 1997 and all 457 births at 33 and 34 weeks in April and October 1997 were recorded. Survivors were evaluated at 5 years of age. RESULTS: Increasing gestational age from 30 to 34 weeks was associated with progressive decreases in in-hospital mortality (from 8.1% to 0.4%) and neonatal complications (respiratory distress syndrome, 43.8% to 2.6%; maternofetal infections, 7.2% to 2.6%; and severe white matter injury, 5.5% to 1.3%). Although infants at 33 and 34 weeks of gestation rarely experienced necrotizing enterocolitis, bronchopulmonary dysplasia, or nosocomial infections, they still required endotracheal ventilation, antibiotics, or parenteral nutrition. At 5 years of age, older gestational age was associated with significant decreases in rates of cerebral palsy (6.3% at 30 weeks and 0.7% at 34 weeks) and mild to severe cognitive impairments (35.3% at 30 weeks and 23.9% at 34 weeks). In singletons, preterm rupture of membranes or preterm labor carried an increased risk of cerebral palsy but not of cognitive impairment. CONCLUSION: Neonates born at 30-34 weeks experienced substantial morbidity and often required admission to neonatal intensive care units. These outcomes suggest that prolonging pregnancies beyond 34 weeks may be desirable whenever possible. Infants born at 30-34 weeks should be carefully monitored to ensure prompt detection and management of neurodevelopmental impairment.     

Amniotic band syndrome with limb amputation after exposure to mifepristone in early pregnancy

To date, the number of cases reported after exposure to mifepristone alone in early pregnancy is limited. In 24 cases, only 1 observation of fetal malformation associated with mifepristone has previously been reported. We report a case of amniotic band syndrome with limb amputation after exposure to mifepristone in early pregnancy. This association raises the question of a possible causal relationship.