Pain on injection of propofol: a comparison of methylene blue and lidocaine

Study Objective

To investigate whether methylene blue, given before injection of propofol, was effective in reducing the frequency and severity of pain associated with propofol injection.

Design

Prospective, randomized, double-blinded clinical study.

Setting

Operating room of a university hospital.

Patients

90 adult, ASA physical status 1 and 2 patients undergoing elective surgery.

Interventions

Patients were randomly allocated to one of three groups of 30 patients each. Group I received 50 mg of methylene blue, Group II received 40 mg of lidocaine, and Group III, the control group, was given normal saline. All drugs were given as a 2.0 mL bolus 45 seconds before propofol administration.

Measurements

Injection pain using vocal responses, facial grimacing, arm withdrawal, tears, and questioning of the patient were noted. A 4-point scale was used for documenting pain.

Main Results

Pain frequency was 90% in the saline group, whereas the frequencies were significantly lower in the lidocaine and methylene blue groups (26.7% and 40%, respectively).

Conclusions

Intravenous pretreatment with methylene blue appears to be effective in reducing the pain during propofol injection.     

A brief report on managing infected nonunion of a high tibial osteotomy in two stages: a case series involving seven knees

The management of nonunion following high tibial osteotomy by total knee replacement (TKR) has been reported previously. We have extended the treatment to embrace cases with an infected high tibial osteotomy by performing an initial debridement with a period of antibiotic treatment followed by TKR. We have reviewed the results of seven knees in six patients with a mean follow-up of 40.5 months (20 to 57) after the staged TKR. At the latest follow-up, all the pseudarthroses had healed and there had been no recurrence of infection. The mean Hospital for Special Surgery knee score improved from 51.2 (35 to 73) to a mean of 91.7 (84 to 98) at final review. Management of nonunion following high tibial osteotomy with a TKR can be extended to infected cases when treated in two stages with a debridement and antibiotic therapy prior to TKR.     

Repair of long bone defects with demineralized bone matrix and autogenous bone composite

Background:

Repair of diaphyseal bone defects is a challenging problem for orthopedic surgeons. In large bone defects the quantity of harvested autogenous bone may not be sufficient to fill the gap and then the use of synthetic or allogenic grafts along with autogenous bone becomes mandatory to achieve compact filling. Finding the optimal graft mixture for treatment of large diaphyseal defects is an important goal in contemporary orthopedics and this was the main focus of this study. The aim of this study is to investigate the efficacy of demineralized bone matrix (DBM) and autogenous cancellous bone (ACB) graft composite in a rabbit bilateral ulna segmental defect model.

Materials and Methods:

Twenty-seven adult female rabbits were divided into five groups. A two-centimeter piece of long bone on the midshaft of the ulna was osteotomized and removed from the rabbits’ forearms. In group 1 (n=7) the defects were treated with ACB, in group 2 (n=7) with DBM, and in group 3 (n=7) with ACB and DBM in the ratio of 1:1. Groups 4 and 5, with three rabbits in each group, were the negative and positive controls, respectively. Twelve weeks after implantation the rabbits were sacrificed and union was evaluated with radiograph (Faxitron), dual-energy x-ray absorptiometry (DEXA), and histological methods (decalcified sectioning).

Results:

Union rates and the volume of new bone in the different groups were as follows: group 1 - 92.8% union and 78.6% new bone; group 2 - 72.2% union and 63.6% new bone; and group 3 - 100% union and 100% new bone. DEXA results (bone mineral density [BMD]) were as follows: group 1 - 0.164 g/cm², group 2 - 0.138 g/cm², and group 3 - 0.194 g/cm².

Conclusions:

DBM serves as a graft extender or enhancer for autogenous graft and decreases the need of autogenous bone graft in the treatment of bone defects. In this study, the DBM and ACB composite facilitated the healing process. The union rate was better with the combination than with the use of any one of these grafts alone.     

Microsurgical management of spinal schwannomas: evaluation of 128 cases

OBJECT: The authors conducted a study to evaluate the clinical characteristics and surgical outcomes in patients with spinal schwannomas and without neurofibromatosis (NF). METHODS: The data obtained in 128 patients who underwent resection of spinal schwannomas were analyzed. All cases with neurofibromas and those with a known diagnosis of NF Type 1 or 2 were excluded. Karnofsky Performance Scale (KPS) scores were used to compare patient outcomes when examining the anatomical location and spinal level of the tumor. The neurological outcome was further assessed using the Medical Research Council (MRC) muscle testing scale. RESULTS: Altogether, 131 schwannomas were treated in 128 patients (76 males and 52 females; mean age 47.7 years). The peak prevalence is seen between the 3rd and 6th decades. Pain was the most common presenting symptom. Gross-total resection was achieved in 127 (97.0%) of the 131 lesions. The nerve root had to be sacrificed in 34 cases and resulted in minor sensory deficits in 16 patients (12.5%) and slight motor weakness (MRC Grade 3/5) in 3 (2.3%). The KPS scores and MRC grades were significantly higher at the time of last follow-up in all patient groups (p = 0.001 and p = 0.005, respectively). CONCLUSIONS: Spinal schwannomas may occur at any level of the spinal axis and are most commonly intradural. The most frequent clinical presentation is pain. Most spinal schwannomas in non-NF cases can be resected totally without or with minor postoperative deficits. Preoperative autonomic dysfunction does not improve significantly after surgical management.     

Third left pulmonary vein with abnormal return associated with arteriovenous fistula

Anomalies of pulmonary veins are uncommon and vary widely in their anatomic spectrum and clinical presentation. A 20-year-old woman with complaints of effort-induced dyspnea and easy fatigability was diagnosed with a third left pulmonary vein with abnormal return and arteriovenous fistula accompanied by a secundum atrial septal defect (ASD). Complete surgical repair was performed by ASD closure with a pericardial patch and triple ligation of the left vertical vein and associated third pulmonary vein. The patient was discharged on the seventh postoperative day in good health. Her last control examination was performed in the second postoperative year, revealing normal echocardiographic findings with an excellent clinical course.     

Outcome of 234 pregnancies in 140 renal transplant recipients from five middle eastern countries

OBJECTIVE: To study the pregnancy and offspring outcomes in postrenal transplant recipients. METHODS: This is a retrospective case-note review study investigating the outcome of 234 pregnancies in 140 renal transplant recipients from five different Middle Eastern countries. RESULTS: Of the overall pregnancies 74.4% were successful albeit with high prevalences of preterm and Caesarean deliveries (40.8% and 53%, respectively). The mean serum creatinine did not rise significantly during pregnancy in the group as a whole but did so in patients who had serum creatinine of or above 150 micromol/L at the beginning of their pregnancies. The mean birth weight was (2,458 g) with 41.3% of the newborns being of low birth weight (<2,500 g). The prevalences of stillbirths were 7.3% and of spontaneous abortion was 19.3%. Preeclampsia and gestational diabetes were observed in 26.1% and 2% of pregnancies, respectively. CONCLUSIONS: In the presence of good allograft function, the majority of pregnancies in renal transplant recipients have a good outcome but with increased incidence of preeclampsia, reduced gestational age, and low birth weights. Patients with baseline serum creatinine of above 150 micromol/L have an increased risk of allograft dysfunction resulting from the pregnancy.     

Severe erosion of lumbar vertebral body because of a chronic ruptured abdominal aortic aneurysm.

BACKGROUND CONTEXT: Erosion of vertebral bodies because of abdominal aortic aneurysm is an extremely rare condition. This vertebral destruction is usually seen after aortic graft surgery; nevertheless, it is not expected in primary aortic aneurysms. PURPOSE: The purpose of this article was to present a patient who suffers from back and hip pain because of a chronic ruptured primary aortic aneurysm. STUDY DESIGN: Case report. METHOD: A 51-year-old patient had complaints of back pain. Physical examination revealed a pulsatile mass in the periumblical region. By using conventional radiographies, vertebral erosion was detected at the anterior part of L3-L4-L5 vertebrae. A chronic ruptured thrombosed aortic aneurysm was identified by magnetic resonance imaging. RESULTS: After resection of the aneurysm, it was possible that the lack of anterior column support could result in future instability. Therefore, an L4-L5 anterior partial corpectomy and reconstruction of the anterior defect with titanium mesh cage with posterior instrumentation and fusion were performed. CONCLUSION: It was concluded that back pain caused by chronic aortic aneurysms is a rare condition and may be one of the possible etiologies in differential diagnosis of low back pain and/or sciatica in some patients.     

Serum neuron-specific enolase as a predictor of short-term outcome and its correlation with Glasgow Coma Scale in traumatic brain injury

Elevated serum neuron-specific enolase levels are correlated with brain cell damage. Low scores according to Glasgow Coma Scale are also considered as serious poor prognostic factor. The aims of the study were to investigate whether there is a correlation between the two measurements in patients with traumatic brain injury and whether serum neuron-specific enolase levels have potential as a screening test to predict outcome. A total of 169 consecutive patients with traumatic brain injury admitted to our clinic between 2002 and 2005 are included in this study. Those patients, who had any major health problem before trauma, were excluded from the study. However, patients with isolated head injury were included in the study. Serial serum neuron-specific enolase concentrations taken at the first 2, 24, and 48 h after traumatic brain injury were analyzed. A computed tomography was performed on each patient on admission. Their Glasgow Coma Scale scores were recorded serially. The relationship between Glasgow Coma Scale scores and the serum neuron-specific enolase levels were assessed by statistical methods. There was a significant negative correlation between the serum neuron-specific enolase levels and Glasgow Coma Scale scores. The levels of neuron-specific enolase were significantly higher in the patients who died in 30 days after trauma and whose scores were lower than or equal to 8 points in Glasgow Coma Scale. Although there are several serious limitations of the use of neuron-specific enolase as a biomarker in traumatic brain injury (i.e., hypoperfusion, extracranial trauma, bleeding, liver, or kidney damage also increase the level of neuron-specific enolase), its concentrations may be useful as a practical and helpful screening test to identify neurotrauma patients who are at increased risk and may provide supplementary estimation with radiological and clinical findings.     

Partial external biliary diversion for the treatment of intractable pruritus in children with progressive familial intrahepatic cholestasis: Report of two cases

Progressive familial intrahepatic cholestasis (PFIC) is a cholestatic liver disease of childhood. Pruritus secondary to increased bile salts in the serum may not respond to medical treatment. Partial external biliary diversion (PEBD), which reduces the serum bile salt level in the enterohepatic cycle, is used in the treatment of this symptom. In this study, our experience in performing this technique and the early promising results of PEBD in two children with PFIC are reported along with a review of the current literature. Partial external biliary diversion was performed by interposing a 15-cm jejunum between the gallbladder and abdominal wall. Biliary drainage through a stoma began in the fi rst postoperative day and reached 120-200 ml/day. Pruritus improved and then stopped on the 15th postoperative day, while the serum bile acid concentration also decreased. Partial external biliary diversion by jejunal interposition provides an excellent control of pruritus in children with PFIC with no adverse effects. A cholecystectomy should therefore be avoided in patients with PFIC.     

Characteristics and prognosis of resected T3 non-small cell lung cancer

AIM: The aim this study is to determine the characteristics, survival, and factors affecting the survival of resected T3 non-small cell lung cancer. METHODS: The records of 97 cases were retrospectively reviewed with T3 non-small cell lung cancer patients that were operated between 1996-2001. Complete resection was achieved in 71 (73.2%) patient. The distribution of N status was 47.4%, 28.9%, and 23.7% for N0, N1 and N2 respectively. The evaluated prognostic factors in univariate and multivariate analyses were, histologic type, type of resection, N status, subgroups of pT3, resection margins and effect of adjuvant therapy. RESULTS: Overall 5-year survival rate was 24.3%. Median survival and 5-year survival of the patients whose tumors resected completely was 33 months and 31.5%, whereas 18 months and 7.3% for the patients resected incompletely (P=0.03). Median survival being not significantly different among the three subgroups: 25, 23, and 32 months (P=0.7) in the bronchial pT3, mediastinal pT3, and peripheral pT3 subgroups, respectively. Histology (P=0.57), type of surgical resection (lobectomy versus pneumonectomy) (P=0.25), and use of adjuvant therapy (P=0.054) did not influence the survival significantly. However N status influenced the survival significantly (P=0.01). According to the multivariate analyses, two factors were selected as prognostic indicators: N2 status (P=0.03) and incomplete resection (P=0.03). CONCLUSION: Three pT3 subgroups did not show survival differences. Complete resection and N2 status are the two most influencing factors in survival of the patients. Adjuvant therapy effected the survival and the quality of life reversely.