Does Bacteremia Follow Upper Gastrointestinal Endoscopy?

To determine the risk of bacteremia, 53 patients had blood collected for culture before and five, ten and 15 minutes following fiberoptic endoscopy of the upper digestive tract. One patient had transient bacteremia with Acinetobacter Sp. Five minutes after endoscopy.
Combining our study with four others, 447 patients have been evaluated of which 6% had bacteremia after upper gastrointestinal endoscopy. Biopsy or other endoscopic operation does not increase the likelihood of bacteremia. We recommend careful attention to instrument and accessory cleaning and prophylactic antibiotics (probably penicillin or oxacillin alone suffices) only for patients with prosthetic heart valves.     

Massive Cerebral Edema Associated with Fulminant Hepatic Failure in Acetaminophen Overdose

Cerebral edema may complicate the course of fulminant hepatic failure. Response to conventional therapy has been disappointing. We present a patient with fatal acetaminophen-induced fulminant hepatic failure, with signs and symptoms of cerebral edema, unresponsive to conventional medical therapy. Cranial decompression was carried out. A justification of the need for further evaluation of cranial decompression in such patients is presented.     

SERUM FREE 1,25-DIHYDROXYVITAMIN D AND THE FREE 1,25-DIHYDROXYVITAMIN D INDEX DURING A LONGITUDINAL STUDY OF HUMAN PREGNANCY AND LACTATION

The changes in three different indices of 1,25-dihydroxyvitamin D (1,25(OH)2D) biological activity were studied longitudinally in 35 women during late pregnancy and lactation and in 26 control women. Measurements were made of maternal serum total 1,25(OH)2D and free 1,25(OH)2D concentration (by centrifugal ultrafiltration) and the free 1,25(OH)2D index (the molar ratio of total 1,25(OH)2D and vitamin D binding protein (DBP]. During late pregnancy total 1,25(OH)2D concentrations were significantly elevated when compared to controls, as were free 1,25(OH)2D and DBP concentrations and the free 1,25(OH)2D index. Serum total 1,25(OH)2D, free 1,25(OH)2D and DBP concentrations all fell dramatically during the first 2 weeks of lactation with total 1,25(OH)2D and free 1,25(OH)2D concentrations falling to levels below those of controls. During the course of lactation both total 1,25(OH)2D and free 1,25(OH)2D levels rose significantly although they were not different from controls at 18 weeks of lactation. In contrast, the free 1,25(OH)2D index fell during the first 2 weeks of lactation, but remained at this level, significantly lower than controls. Neither urinary calcium excretion nor dietary calcium intake correlated with total or free 1,25(OH)2D, DBP, or the free 1,25(OH)2D index. The disagreement in the results of free 1,25(OH)2D concentration and free 1,25(OH)2D index demonstrates that these two approaches to measuring biologically active 1,25(OH)2D are not equivalent. In attempting to account for the increased calcium requirements of human reproduction we conclude that in pregnancy any of the 1,25(OH)2D measurements may be appropriate. In lactation, however, either 1,25(OH)2D is not a major factor or 1,25(OH)2D biological activity is inadequately represented by any of the currently available methods.     

Oral tobacco: prevalence, health risks, dependence potential and public policy

This paper discusses public health policy with regard to oral tobacco use. It notes that in the UK, oral tobacco use is extremely rare. Concern that it might become prevalent among schoolchildren has proved unfounded. Smokeless tobacco almost certainly carries health risks but these risks are probably less than from smoking. What little evidence exists suggests that smokeless tobacco may be less dependence-inducing than cigarettes. In the light of this, the UK Government's decision to ban oral tobacco products is hard to reconcile with their continuing to permit the sale and advertising of cigarettes. A cynic would view the Government's ban as a‘no cost’ measure to placate the public health lobby and ease the pressure for more restrictions on cigarette promotion. The inconsistency in the Government's approach to Skoal Bandits and cigarettes may be used as a focus for pressure to change in the laws governing promotion of cigarettes.     

Effects of Myocardial Ischemia on Triggered Activity in Hamster Atrial Transplants

Effects of Ischemia on Triggered Activity. The effects of acute myocardial ischemia on delayed afterdepolarizations and triggered activity were determined in vascularized hamster atrial cheek pouch transplants. Triggered activity was initiated in eight normally perfused transplants by spontaneous or paced action potentials. During control, bursts of triggered activity lasted 14.4 ± 2.S sec (mean ± SEM), had an average cycle length of 456.6 ± 33.8 msec, and terminated following a subthreshold delayed afterdepolarization having an amplitude of 13.8 ± 0.5 mV. Interruption of blood flow to the transplants initially suppressed induction of triggered activity by spontaneous action potentials, shortened bursts of triggered activity initiated by pacing, and tended to prolong the cycle length during triggered bursts. Complete suppression of triggered activity occurred after 15–70 minutes of ischemia. Despite a reduction of delayed afterdepolarization amplitude during ischemia, the membrane potential at the peak of the afterdepolarization became less negative, secondary to ischemia-induced reductions of resting membrane and takeoff potentials. Thus, suppression of triggered activity during ischemia appeared to be caused by a shift of the voltage threshold to less negative membrane potentials, rather than by a reduction in delayed afterdepolarization amplitude. (J Cardiovasc Electrophysiol, Vol. 1. pp. 139–144, April 1990)     

Evaluation of a New Chemotherapeutic Agent in Patients with "Advanced Refractory" Acute Leukemia. Studies of 6-Azauracil

6-Azauracil was studied in patients with "advanced" acute leukemia, refractory to standard chemotherapy. Under the conditions of the study thiscompound was found to have no significant antileukemic activity. As a result,these data have defined the natural history of this phase of acute leukemia. Asignificant proportion (30 per cent) of these patients showed objective hematologic improvement even in the absence of effective specific therapy, whichmight be ascribed to a prospective new agent. The median survival from theonset of the study of this group of patients was two months, and survivalpatterns for adults and children were similar.

Submitted on December 23, 1959 Accepted on February 20, 1960     

Emergence delirium and postoperative pain in children undergoing adenotonsillectomy: a comparison of propofol vs sevoflurane anesthesia

Background: Emergence delirium (ED) is a frequent postoperative complication in young children undergoing ENT procedures and it may be exacerbated by sevoflurane anesthesia whereas propofol maintenance has been suggested to decrease the incidence of ED. The aim of this randomized, prospective, double‐blind study was to evaluate the effect of sevoflurane vs propofol anesthesia on the quality of recovery after adenotonsillectomy. Methods: Forty‐two patients were randomized to maintenance with either propofol or sevoflurane for adenotonsillectomy. At the conclusion of surgery, patients were extubated awake. ED and pain were assessed using the Pediatric Anesthesia Emergence Delirium (PAED) and the Children’s Hospital of Eastern Ontario Scale (CHEOPS), respectively. Higher PAED scores (0–20) indicate greater severity of ED. Nursing and parental satisfaction, hospital length of stay, postoperative nausea and vomiting (PONV), anesthetic complications, and subsequent emergency room admissions were also assessed. Results: Median PAED score was 14 in the propofol group and 17 in the sevoflurane group (NS). Propofol was associated with less pain medication required during recovery and a lower incidence of PONV (5.3% vs 36.8%, P < 0.05). Nursing and parental satisfaction as well as time spent in recovery room was similar for the two groups. Conclusion: Propofol anesthesia does not influence agitation after adenotonsillectomy, as measured by the PAED score. A PAED score of ≥10 was not useful in identifying patients with ED. However, propofol maintenance is associated with less need for pain medication in the recovery room and a lower incidence of PONV compared to sevoflurane anesthesia.     

MICROSURGICAL REPAIR OF THE ADOLESCENT VARICOCELE

Purpose

Since clinically apparent varicoceles may affect testicular volume and sperm production, early repair has been advocated. However, repair of the pediatric varicocele with conventional nonmagnified techniques may result in persistence of the varicocele after up to 16% of these procedures. Also testicular artery injury and postoperative hydrocele formation can occur after nonmagnified repair. The microsurgical technique has been successfully completed in a large series of adults with a dramatic reduction in complication and recurrence rates. We report our experience with the microsurgical technique in boys.

Materials and Methods

A total of 30 boys (average age 15.9 years) underwent 42 microsurgical varicocelectomies (12 bilateral). All patients had a large left varicocele. Indications for repair included testicular atrophy (size difference between testicles of greater than 2 ml.) in 20 boys, pain in 5 and a large varicocele without pain or testicular atrophy in 5. Six boys were referred following failure of conventional nonmicrosurgical techniques. All boys were examined no sooner than 1 month postoperatively (mean followup 12).

Results

Preoperative volume of the affected testis averaged 13.0 ml., and an average size discrepancy between testicles of 2.8 ml. was noted before unilateral varicocelectomy. No cases of persistent or recurrent varicoceles were detected, and 1 postoperative hydrocele resolved spontaneously. After unilateral varicocelectomy the treated testes grew an average of 50.1%, while the contralateral testes grew only 23%. Overall, 89% of patients with testicular atrophy demonstrated reversal of testicular growth retardation after unilateral varicocelectomy. In contrast, both testes showed similar growth rates after bilateral varicocelectomy (45% left testis, 39% right testis).

Conclusions

The meticulous dissection necessary to preserve arterial and lymphatic supply, and to ligate all spermatic veins in the pediatric patient is readily accomplished using a microsurgical approach, and results in low recurrence and complication rates. Rapid catch-up growth of the affected testis after microsurgical varicocelectomy suggests that intervention during adolescence is effective and warranted.     

Preoxygenation before laryngoscopy in children: how long is enough?

The ideal preoxygenation period prior to laryngoscopy in children is unclear. This study was performed to determine an appropriate duration of preoxygenation for infants and children prior to laryngoscopy using endtidal oxygen (Fe ′O₂) criteria. Healthy paediatric patients for elective day surgery procedures were studied. An inflatable mask connected to an oxygen-primed paediatric anaesthesia semiclosed circuit was placed on the face while patients breathed spontaneously during 6.min^?1 oxygen flow. An Fe ′O₂ of 0.9 was considered the endpoint, and if not achieved in two min the protocol was ended. Fifty-eight children were studied. Six patients never achieved an Fe ′O₂ of 0.9 and were not considered in the analysis. The times (in seconds with mean±sd and range) to achieve a minimum endtidal (Fe ′O₂) of 0.9 for under six months were 36±11.4(20–50), 7–12 months were 35.5±13.3(20–60),13–36 months were 42.6±18.7(20–90), 37–60 months were 50.8±18.5(30–90), >60 months were 68.4±24.1(30–100). Logistic regression curves were determined for each age group describing the probability of achieving an Fe ′O₂ of 0.9 against time of preoxygenation. All children with satisfactory mask fit were able to preoxygenate to an Fe ′O₂ of 0.9 within 100 s.     

ELECTROMOTIVE DRUG ADMINISTRATION OF LIDOCAINE TO ANESTHETIZE THE BLADDER BEFORE INTRAVESICAL CAPSAICIN

Purpose

The discomfort caused by intravesical capsaicin during instillation may restrict its use in some patients. We studied the effectiveness of using electromotive drug administration (EMDA) of lidocaine to anesthetize the bladder before capsaicin.

Materials and Methods

EMDA of lidocaine and epinephrine was performed in 8 patients with detrusor hyperreflexia using catheters, electrodes and an electrical current generator (20 mA., 15 minutes) followed immediately by intravesical capsaicin (2 mmol./l.) for 30 minutes under urodynamic monitoring. The patients scored suprapubic pain at 5 minutes and at the end of the capsaicin instillations on a scale of 0 to 10. Of the 8 patients 5 had had previous capsaicin treatments and the scores were compared to previous scores when intravesical lidocaine without EMDA had been used as local anesthesia before capsaicin.

Results

The pain scores during capsaicin instillations after EMDA of lidocaine were much lower than those during capsaicin instillations after lidocaine alone. EMDA virtually eliminated the hyperreflexic contractions of the bladder occurring during capsaicin instillations, thus reducing the risk of urethral leakage, and prevented autonomic dysreflexia that had previously occurred in 1 patient.

Conclusions

EMDA of lidocaine is an effective means of reducing pain during subsequent intravesical capsaicin, which makes the use of capsaicin in the treatment of detrusor hyperreflexia more acceptable.