Selective deep spinal hypothermia with vacuum-assisted cerebral spinal fluid drainage for thoracoabdominal aortic surgery

Recent experiences from several centers indicate that the overall risk of spinal cord ischemia during thoracoabdominal aortic aneurysm repair has decreased to 5-8%. The results from these centers are rather consistent, despite the use of a variety of spinal protection strategies. An alternative to the various distal aortic perfusion techniques is selective spinal cooling by cold saline lavage. The principle advantage of selective hypothermia is the avoidance systemic heparinization and extracorporeal by-passes, while affording comparable spinal protection. The primary method of spinal cooling was pioneered by Cambria et al. at Massachusetts General Hospital. In their experience, paraplegia or paresis occurred in 6.9% of patients (5-year period, 170 cases). An alternative to the Cambria method utilizes readily available perfusion supplies and offers the potential advantages of lower cerebral spinal fluid-systemic blood pressure differences, more expedient cooling, and deeper spinal hypothermia. This report describes this method and the clinical course of a patient treated with it.     

The effects of pyridostigmine bromide on progressive ratio performance in male and female rats

Small doses of pyridostigmine bromide (PB) affect the acquisition and maintenance of food-maintained behavior in laboratory animals. The present experiment was designed to investigate the effects of this drug on food motivation. Male and female rats were trained to respond on a progressive-ratio schedule of reinforcement and treated with different doses of PB. PB dose-dependently decreased breaking points and response rates in male and female rats. Gender differences were not observed. The results indicate that decreased food motivation may be a factor that contributes to the behavioral effects of PB administration.     

A survey of spinal and epidural techniques in adult cardiac surgery

OBJECTIVE: To determine if a significant number of anesthesiologists are performing spinal and epidural techniques in adults undergoing cardiac surgery and if any neurologic injuries have been associated with these techniques. DESIGN: Anonymous survey of clinical practice. SETTING: Data collected via mail from members of the Society of Cardiovascular Anesthesiologists. PARTICIPANTS: Attending anesthesiologists. INTERVENTIONS: Anesthesiologists completed an anonymous survey of their use of spinal and epidural techniques in adult patients undergoing cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Of 3974 anesthesiologists, 974 (24%) responded to the questionnaire; 892 are at institutions that perform cardiac surgery. Of the 892 responders, 68 (7.6%) reported they use spinal techniques, whereas 62 (7%) reported they use epidural techniques. Nine (1%) anesthesiologists reported they use both techniques. There were no reports of neurologic complications related to the use of spinal or epidural techniques performed by the anesthesiologists responding to the survey. CONCLUSIONS: A significant number of anesthesiologists are performing spinal and epidural techniques in adult patients undergoing cardiac surgery. Prospective, controlled trials should be performed to evaluate the benefits and risks of spinal and epidural techniques in this population.     

The breast cancer patient with multiple sentinel nodes: when to stop?

BACKGROUND:

During sentinel lymph node (SLN) biopsy for breast cancer, most authors report identifying a mean of 1 to 3 SLNs, but a range of 1 to 8 (or more) SLNs per patient. A significant minority of patients have 4 or more SLNs. Here we seek to determine the significance for the breast cancer patient of finding multiple SLNs, and whether there is an optimal threshold number of SLNs that should be removed.

STUDY DESIGN:

1,561 patients who underwent successful SLN biopsy using blue dye and radioisotope in combination. Each SLN site was categorized prospectively by the operating surgeon as a dye success, an isotope success, or both. All SLNs containing counts at least four times greater than the postexcision axillary background were considered to be isotope successes.

RESULTS:

Fifteen percent of patients (241) had multiple (> 3) SLNs. Ninety-eight percent of node-positive patients (440 of 449) were identified within the first three SLN sites examined. In 2% of all SLN positive patients (9 of 449) or 4% of patients with multiple SLN (9 of 241), a positive SLN was detected at site four or more. In eight patients the first positive SLN was found at sites four or more. Blue dye and isotope were equally effective in identifying metastases in patients with multiple SLNs.

CONCLUSIONS:

Fifteen percent of patients having SLN biopsy for breast cancer have multiple SLNs. Although 98% of positive SLNs were identified within the first three sites sampled, a small number of patients had their first positive SLN at sites 4 to 8. These data suggest that there is no absolute upper threshold for the number of SLNs that should be removed. Sampling a few additional SLNs probably adds little morbidity to the procedure, yet may significantly alter the treatment of some individuals. SLN biopsy should be continued until all blue and hot nodes are removed.