IDEAL PAIN RELIEF FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY

In a previous report the effectiveness of intraperitoneal bupivacaine in reducing pain following laparoscopic cholecystectomy was demonstrated. Other methods of pain relief are commonly used but none has been compared following laparoscopic cholecystectomy. In two further studies we have compared the analgesic effect of intraperitoneal bupivacaine against wound infiltration with bupivacaine, and against intraperitoneal bupivacaine with the addition of a non-steroidal anti-inflammatory drug (NSAID) in patients undergoing laparoscopic cholecystectomy. Two consecutive studies were performed. In the first, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine injected into the trocar wounds. In the second study, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity and a diclofenac suppository (100 mg) one hour before surgery. Postoperative pain was assessed with a visual analogue pain scale. There was no difference in pain scores in the two groups in either study. Intraperitoneal bupivacaine is as effective as wound infiltration. The addition of an NSAID makes no difference in the reduction of postoperative pain following laparoscopic cholecystectomy.     

Effects of L-5HTP with and without carbidopa on plasma ß-endorphin and pain perception

L-Tryptophan (L-TP) has been used in migraine and other pain conditions. The mechanism underlying the analgesic effect is still partly undefined. In this study the effects of subchronic administration of L-5-hydroxy-tryptophan (L-5HTP) (with and without carbidopa) on plasma beta-endorphin (beta-EP) levels and subjective pain threshold and tolerance were investigated in seven healthy volunteers. To measure also an objective indicator for pain, the nociceptive flexion reflex threshold was studied. L-5HTP treatment with and without carbidopa administration increased beta-EP levels significantly (p less than 0.05). L-5HTP plus carbidopa induced an increase in beta-EP significantly (p less than 0.05) higher than that after L-5HTP alone. Neither subjective pain threshold and tolerance nor RIII threshold was modified by either treatment. Our data seem to point to the existence of a complex linkage between plasma opioid levels and pain perception.     

Duodenal ulceration into the cystic artery

We report two cases of massive gastrointestinal bleeding due to anterior duodenal ulceration into the cystic artery, with gallbladder infarction as a complication. These cases indicate the potential dangers of laser therapy or embolization in bleeding anterior duodenal ulcers penetrating the cystic artery, as such therapy will arrest blood flow through the cystic artery and may precipitate gallbladder infarction.     

Peptic ulcer and gastric carcinoma: diagnosis with biphasic radiography compared with fiberoptic endoscopy

The diagnostic value of biphasic radiographic examination of the stomach and duodenum was compared with that of fiberoptic endoscopy in a prospective, blinded study of 385 patients with dyspepsia. This investigation was directed at gastric malignancies and peptic ulcers. Methodologically there is no absolute standard for a study of this kind because histologic examination is useful for detection of cancer but inadequate for ulcers. As an alternative, kappa indexes and the sensitivity and specificity, as derived by Hui and Walter, were calculated and compared. For the detection of gastric carcinoma, radiographic and endoscopic findings had almost perfect agreement beyond chance. For gastric ulcers, radiography and endoscopy had substantial agreement, which became perfect if small ulcers (less than 5 mm) were excluded. For duodenal ulcers, radiography had a lower sensitivity than endoscopy; this disagreement disappeared if small ulcers were excluded. Both methods have equal merit; choice of the initial diagnostic procedure will therefore depend on cost, discomfort to the patient, and risk of complications.     

National survey of the prevalence and risk factors of glaucoma in St. Lucia, West Indies. Part I. Prevalence findings

Although blacks appear to be at higher risk for blindness from glaucoma, there is little information available on the epidemiology of this disease in this population. Using a cluster sampling technique with systematic allocation of clusters, the authors conducted a national survey of black individuals 30 years of age and older, in St. Lucia. A total of 1679 individuals underwent a screening examination that included visual acuity, intraocular pressure (IOP) measurement, and cup/disc (C/D) evaluation. Every third person had a screening field on the Humphrey field analyzer. Individuals with either elevated IOP, abnormal C/D ratio, or an abnormal screening visual field were referred for a definitive examination and threshold visual fields. A total of 520 people were referred. Identified by stringent criteria for the diagnosis of glaucoma, which required reliable threshold visual fields abnormal by the mirror image method, 147 individuals had glaucoma for a prevalence of 8.8% in the 30 years of age and older population.     

Ectopic ureter and ureterocele: their varied sonographic manifestations

The sonographic examinations of four patients with simple ectopic ureters and 11 with ectopic ureteroceles were reviewed to determine distinguishing characteristics. Ectopic ureters, in cases of extreme dilatation and tortuosity, sometimes mimic multiseptated, cystic abdominal masses. However, the proximal portions of some severely dilated ureters are surprisingly small. Ectopic ureters sometimes indent the lower vesical wall, simulating a ureterocele. Ectopic ureteroceles are dynamic structures, changing in shape and size according to intravesical pressure. The lower pole of a duplex kidney may be difficult to detect because of displacement by the dilated upper renal pelvis and ureter. The renal parenchyma associated with an ectopic ureter may be equally difficult or impossible to find because of diminutive dysplasia or, less commonly, acquired atrophy. Dysplasia is characterized sonographically by highly echogenic parenchyma, lack of corticomedullary differentiation, and occasionally massive enlargement by cysts. Ectopic ureters and ureteroceles can be identified by fetal sonography.     

Vaccination status of children aged 12-23 months in the Mosvold health ward of KwaZulu

Using the random cluster sampling technique of the EPI, 210 children of 12-23 months were selected and their vaccination records were examined. Fifty-one (24%) had no vaccination record and 32 of them (15%) were never vaccinated. Using a 'worst' and 'best' estimate analysis it was found that 74-83% had had BCG, 47-56% had had 3 doses of DPT, 48-57% had had 3 doses of polio and 47-56% had had 1 dose of measles vaccine. Between 28-31% of those who received a first dose of DPT or polio vaccine did not receive a third dose. This 'drop-out' effect increased with increasing distance between children's homes and the nearest clinic, as did vaccination coverage in general. As a result of this study, several measures will be undertaken to improve health care delivery in this area. These include the organisation of a mass immunisation campaign later this year, the initiation of more mobile clinics and the training of community health workers.