Unintentional neuromuscular blocking agent injection during an axillary brachial plexus nerve block

OBJECTIVE: We describe the consequences of an unintentional injection of atracurium instead of ropivacaine during an axillary brachial plexus nerve block. CASE REPORT: A 79-year-old woman was scheduled for wrist fracture repair. An axillary brachial plexus block was performed by use of a nerve stimulator. Twenty milliliters of 0.5% ropivacaine with 1:200,000 epinephrine was injected on the radial and then on the median nerves. Two minutes later, the patient became dyspneic and was unable to elevate her head from the pillow. A check of the syringes revealed that one contained 50 mg of atracurium instead of 0.5% ropivacaine. After IV propofol was administered, the trachea was intubated and controlled ventilation started. At the end of surgery (more than 2 hours later), reversal of residual neuromuscular block was performed. The motor and sensory brachial plexus block completely recovered 12 hours after the initial bolus injection. No clinical neurological deficit was reported afterward by the patient. CONCLUSIONS: Unintentional injection of atracurium mixed with ropivacaine during axillary brachial plexus block leads to complete body paralysis that requires general anesthesia and mechanical ventilation. Recovery was complete without any neurological sequela. An analysis of the chain of events that led to the error suggests some recommendations to improve our daily practice.     

Development of a pilot telemedicine network for paediatric oncology in Brazil

We established a pilot telemedicine network for paediatric oncology in Brazil, linking the School of Medicine at the University of Sao Paulo in Sao Paulo City to the 'Hospital de Base' in Porto Velho, Rondonia, located in the Amazon region, 3,000 km away. The videoconferencing link used ISDN transmission at 384 kbit/s. The network was used for patient screening, follow-up, treatment monitoring and other activities. Between March 2000 and 2002, 69 videoconferences were held for 33 patients, 29 with cancer. During this period, 16 patients required transfer, 18 patients died and 11 achieved cancer remission. The main cause for patient mortality (infection) was not one that could be addressed directly by telemedicine. Using the School of Medicine as a benchmark, the average mortality rate for paediatric cancer patients in the pilot was higher. However, it was lower than previous levels observed at Rondonia (62% versus 80%).     

Confirmation of the diagnosis of natural rubber latex allergy by the Basotest method

BACKGROUND: The flow cytometry CD63-based basophil activation test (Basotest has already been validated for the diagnosis of immediate-type allergy such as venom, house dust mite or cypress pollen allergies. The aim of this study was to evaluate the performance (specificity and sensitivity) of Basotest in the diagnosis of natural rubber latex allergy. METHODS: We included 46 latex allergic patients (clinical symptoms of latex allergy, positive latex skin prick tests and/or latex specific IgE) and 33 control subjects and performed Basotest on all subjects. RESULTS: The sensitivity and specificity of Basotest were 84.8 and 87.9%, respectively, when we considered the theoretic cut-off at 15% of CD63-positive cells. Using ROC curves, the optimal cut-off was evaluated at 22%, for which sensitivity and specificity were 79.3 and 96.7%, respectively. CONCLUSION: The Basotest is a reliable test in addition to clinical history and tests already validated (such as skin prick tests and specific IgE) to confirm the diagnosis of natural rubber latex allergy.     

A double-blind controlled study of a nonhydroquinone bleaching cream in the treatment of melasma

Background Melasma is an acquired hypermelanosis predominantly affecting the face of women. It is often recalcitrant to treatment with hypopigmenting agents. Objective To assess the efficacy of a nonhydroquinone cream (Amelan M^®) vs. another (Mela‐D^®) as treatment for melasma. Methods Twenty‐two French women with bilateral epidermal and/or mixed melasma were enrolled in a split‐faced prospective trial lasting 4 months during summer season weeks. Twelve patients applied once‐daily Amelan M^® to one side of the face with sun‐protective factor 60 UVA sunscreen each morning and Mela‐D^® once‐daily to the other side of the face. Pigmentation was measured objectively using a mexameter and the melasma area and severity index (MASI) were measured subjectively. Results The mean decrease of pigmentation was statistically significant on the MASI with both cream and only with Amelan M with the mexameter. Some adverse side effects were observed. Conclusions Amelan M^® is really more effective than Mela D^® cream on melasma. Even though some side effects were observed patients preferred the Amelan M‐treated side.     

Polyomavirus simian virus 40 infection associated with nephropathy in a lung-transplant recipient

BACKGROUND: Between 1955 and 1963, millions of individuals worldwide received vaccines contaminated with polyomavirus simian virus (SV)40. Recent data suggest that some individuals may develop renal dysfunction related to SV40 infection, including individuals too young to have received contaminated vaccines. CASE REPORT AND RESULTS: Three years after bilateral lung transplantation, a 32-year-old man with cystic fibrosis developed nephrotic syndrome and progressed to end-stage renal failure over 1.5 years. He was shown to have nephropathy caused by SV40. The diagnosis was documented by detecting and confirming sequences of SV40 (but not BK or JC virus) in his kidney biopsy and urine by polymerase chain reaction, Southern blot, and DNA sequencing. Positive immunohistochemistry for SV40 was found in his kidney, and neutralizing antibodies for SV40 were detected in his serum, before and after the onset of renal dysfunction. A source for the virus was not determined. His household contacts did not have serologic or molecular evidence of SV40 infection. No serum or tissue samples were available from his 27-year-old donor. DISCUSSION: This report shows that SV40 is circulating in the community and can cause nephropathy in transplant patients.     

Centrally administered oxytocin elicits exaggerated grooming in oxytocin null mice

Experiments were conducted to determine if the chronic absence of the neurotransmitter oxytocin (OT) in null mice resulted in alterations in the responsiveness and abundance of central OT receptors. Self-grooming elicited by intracerebroventricularly administered OT was studied as an indicator of the activation of central OT receptors and autoradiography was used to map the distribution and density of OT receptors in OT null and wild type mice. The intracerebroventricular administration of OT, but not vehicle, artificial cerebrospinal fluid (aCSF), produced a robust increase in grooming behavior in both OT null and wild type animals, P<.001. However, OT-induced grooming was significantly greater in OT null than wild type mice, P<.005. The enhanced grooming was selective to OT as indicated by the finding that grooming to intracerebroventricular arginine vasopressin (AVP) was of the same magnitude in both OT null and wild type mice. OT-induced grooming appears to be mediated through the activation of OT receptors because pretreatment of animals with an OT antagonist, Atosiban, abolished OT-induced grooming, but not AVP-induced grooming. OT receptor distribution and binding in brains of OT null and wild type mice were examined by autoradiography and were not significantly different. The results indicate that the chronic absence of OT in null mice leads to an increase in OT receptor responsiveness that contributes to the augmented grooming activity elicited by centrally administered OT.     

Fenfluramine-induced hypothermia is associated with cutaneous dilation in conscious rats

The antiobesity agent, fenfluramine, produces hypothermia in rodents by an, as yet, uncharacterized mechanism. The present study was conducted in conscious rats to determine if fenfluramine-induced hypothermia was associated with cutaneous dilation. In animals maintained at 16 degrees C, core body temperature (T(CORE)) was measured telemetrically, and tail surface temperature was monitored with thermocouples fixed to the tail (T(TAIL)). D-Fenfluramine (10 mg/kg ip) produced a rapid increase in T(TAIL) of 7.7+/-0.4 degrees C (P<.001) and a decline in T(CORE) of 4+/-0.3 degrees C (P<.001). Two findings indicate that the increase in T(TAIL) was due to the withdrawal of a sympathetic vasoconstrictor tone. First, pretreatment with the ganglionic blocker, pentolinium, prevented fenfluramine-induced changes in T(TAIL). Second, when sympathetic tone to the tail was physiologically withdrawn by increasing the environmental temperature to 28 degrees C, fenfluramine treatment produced no increase in T(TAIL). Moreover, the effects of fenfluramine on T(TAIL) and T(CORE) depended on the uptake of fenfluramine into serotonergic neurons because these effects were markedly attenuated by pretreatment with the selective serotonin re-uptake inhibitor, fluoxetine. The hypothermic effect of fenfluramine occurred despite the fact that total body oxygen consumption increased by 20%. The results suggest that heat loss due to the dilation of the cutaneous circulation contributes to fenfluramine-induced hypothermia.