Propofol and sevoflurane during epidural/general anesthesia: comparison of early recovery characteristics and pain relief

We investigated the early recovery characteristics and pain relief of adult patients during combined anesthesia with (epidural and general), either with propofol or sevoflurane for maintenance in major abdominal surgery. Twenty-two patients (ASA I-III) were enrolled in this randomized, prospective study. After fluid preloading, 10 ml of bupivacaine 0.5% + 5 ml of prilocaine 0.5% + 1 ml of fentanyl 50 microg mL(-1) were administered via an epidural catheter. General anesthesia was induced with fentanyl and propofol after T6 sensorial blockade. Propofol group (n = 11) received propofol (2-5 mg kg(-1) h(-1)), sevoflurane group (n = 11) received sevoflurane (1-2%) for maintenance. Anesthesia was supplemented with N2O in O2 and intravenous fentanyl. Continuous epidural infusion of 0.125% bupivacaine + 1 microg fentanyl (5-7 mL h(-1)) was started forty-five min after the epidural bolus dose and 5 ml of it was given at the start of the wound closure. All anesthetics were discontinued except epidural infusion during the last suture. After emergence time was determined, the patients were transferred to the PACU. They were observed for orientation times of person and place. The pain scores (verbal analogue scale, 0-10) were assessed with 30 min intervals. When the patient's pain score was >3, rescue analgesic protocol (diclofenac Na 75 mg im followed by meperidine HCI approximately 0.25 mg kg(-1) iv at the latter period) was applied. In the case of inadequate pain relief during the latter assessment periods, meperidine HCI approximately 0.25 mg kg(-1) was administered. Mann-Whitney U test and Fisher's exact test were used for the statistical analysis. A value of p<0.05 was considered significant. Between the groups no statistical differences were observed in the emergence time (5 vs. 6 min, median) and in the orientation time to person (6 vs. 10 min). Recovery of orientation to place was found faster in propofol group (7 vs. 12 min, p = 0.041). Pain scores of the patients between the groups were not statistically different at 0, 30, 60, 90, 120 min postoperatively (3, 2, 3, 2, 2, and 2, 4, 4, 3, 3, respectively). Rescue analgesic protocol and additional meperidine HCI were applied to 63.6% and 45.4% of patients in the propofol group, 54.5% and 36.3% of patients in the sevoflurane group, respectively. There weren't any statistical differences in regard to these, either. Except orientation time to place, the times of emergence and orientation to person, the pain scores and the analgesic requirements of the patients in both groups were similar. Propofol or sevoflurane did not offer any advantages for postoperative pain relief on behalf of either one when combined with epidural anesthesia.     

Conversion and somatization disorders; dissociative symptoms and other characteristics

OBJECTIVE: There is a difference in classification of conversion disorder in ICD-10 and DSM-IV. Conversion disorder is included in dissociative disorders in ICD-10. In view of this, we aimed to clarify this discrepancy in the classification of this diagnosis. METHODS: We assessed 87 patients with conversion disorder and 71 patients with somatization disorder for sociodemographic characteristics, suicide ideation, psychiatric symptoms and dissociative symptoms using the Patient Information Form, the Dissociative Experience Scale (DES), the Symptom Check List (SCL-90-R) and the Suicide Ideation Scale. RESULTS: The number of the high school graduates, singles and students with conversion disorders was higher than the number of patients with the same characteristics who have somatization disorder. In conversion disorder, the SCL-90-R total score and the score in paranoid ideation, psychoticism subgroups were higher than the scores in somatization disorders. There were no statistical differences in suicide ideation and the total score of dissociative symptoms between the two disorders. The number of patients whose total DES score of 30 and above was higher in conversion disorders. DISCUSSION: As a result of this present study, we concluded that to enlighten the concepts of conversion, further somatization and dissociation studies are necessary.     

Clinical Features and Prognosis in Ocular Toxoplasmosis

Purpose To evaluate retrospectively the clinical characteristics, complications, and prognosis in patients with ocular toxoplasmosis.Patients and Methods We reviewed the records of 189 patients (243 eyes) with ocular toxoplasmosis who were examined between 1972 and 1999. Color fundus photography and, in some patients, fluorescein angiography and indocyanine green angiography were performed. There were 98 male (52%) and 91 female (48%) patients with a mean age of 22.8 ± 8.9 years.Results Of the patients, 140 (74%) had congenital and 49 (26%) had acquired toxoplasmosis. At the initial examination, there were active lesions in 65 eyes and inactive lesions in 178 eyes. Active lesions included retinochoroiditis in 59 (91%), papillitis in 2 (3%), and neuroretinitis in 4 (6%) eyes. There was also an inactive scar in 17 eyes with active retinochoroiditis. Localisation of the active retinochoroiditis was the macula in 44 (74%), the macula and peripheral retina in 3 (5%), the peripheral retina in 9 (15%) and the peripapillary retina in 3 (5%) eyes. Optic atrophy, pigment epithelial detachment, choroidal neovascularization, lamellar macular hole, and retinal neovascularization were seen during the follow-up period.Conclusions Ocular toxoplasmosis commonly affects the macula and seriously impairs visual acuity. The prevention of acquired and congenital infections is very important in controlling ocular toxoplasmosis. Patients should be followed to avoid late complications. Jpn J Ophthalmol 2004;48:386–391 © Japanese Ophthalmological Society 2004This study was an oral presentation at the International Symposium on Ocular Inflammation VI, June 18–23, 2000, Istanbul, Turkey.     

The effects of gingko biloba extract (EGb 761) on experimental acute pancreatitis

BACKGROUND AND OBJECTIVE: Acute pancreatitis is an important and fatal disease with high mortality and morbidity. Although the pathogenesis of acute pancreatitis is poorly understood, there are many studies that suggest the role for oxygen free radicals (OFRs) in the development of pancreatitis and its complications and show beneficial effects of scavenger treatment. In the present study, we aimed to investigate whether Egb761, the standardized extract of gingko biloba, restrains the generation of OFRs and ameliorates the histopathologic findings of acute pancreatitis. MATERIALS AND METHODS: Sixty male Sprague Dawley rats were randomly assigned to one of the following experimental groups. In early and late pancreatitis and treatment groups, acute pancreatitis was induced by retrograde infusion of 3% sodium taurocholate. In treatment groups, 100 mg/kg Egb 761 was given intraperitoneally (IP) 24 h and immediately before induction of pancreatitis. Sham-operated rats received isotonic saline instead of sodium taurocholate. After observation times of 3.5 and 12 h, the pancreas was removed for light microscopy and determination of malondialdehyde (MDA) levels as a marker for OFRs-induced lipid peroxidation. Serum samples also were obtained for amylase and lipase levels. RESULTS: There was no significant difference in control and sham-operated groups in terms of histopathologic findings and serum enzyme levels. The tissue concentrations of MDA and serum enzyme levels were significantly elevated in early and late treatment groups as compared with the control group. The treatment with Egb 761 caused significant decrease in serum amylase and lipase levels and histopathologic scores as compared with early and late pancreatitis groups. CONCLUSIONS: Prophylactic application of Egb761 exerts highly beneficial influence on the course of acute pancreatitis, and this seems to be related to the oxygen radical scavenger effect of Egb761.     

Ulnar artery aneurysm in a patient with Behçet’s disease

Behçet’s disease is a systemic disease characterized by oral aphthosis, genital ulcers, ocular lesions, gastrointestinal, musculoskeletal, neurological and major vessel involvement. Arterial involvement, aneurysms and arterial thrombosis have been reported in 1.5–3% of patients. In this case report, we present a patient with ulnar arterial aneurysm associated with Behçet’s disease.     

The islet autoantibody titres: their clinical relevance in latent autoimmune diabetes in adults (LADA) and the classification of diabetes mellitus

Latent autoimmune diabetes in the adult (LADA) is a slowly progressive form of autoimmune diabetes, characterized by diabetes‐associated autoantibody positivity. A recent hypothesis proposes that LADA consists of a heterogeneous population, wherein several subgroups can be identified based on their autoimmune status. A systematic review of the literature was carried out to appraise whether the clinical characteristics of LADA patients correlate with the titre and numbers of diabetes‐associated autoantibodies. We found that the simultaneous presence of multiple autoantibodies and/or a high‐titre anti‐glutamic acid decarboxylase (GAD)—compared with single and low‐titre autoantibody—is associated with an early age of onset, low fasting C‐peptide values as a marker of reduced pancreatic B‐cell function, a high predictive value for future insulin requirement, the presence of other autoimmune disorders, a low prevalence of markers of the metabolic syndrome including high body mass index, hypertension and dyslipidaemia, and a high prevalence of the genotype known to increase the risk of Type 1 diabetes. We propose a more continuous classification of diabetes mellitus, based on the finding that the clinical characteristics gradually change from classic Type 1 diabetes to LADA and finally to Type 2 diabetes. Future studies should focus on determining optimal cut‐off points of anti‐GAD for differentiating clinically relevant diabetes mellitus subgroups.     

A substituted tetrahydro-tetrazolo-pyrimidine is a specific and novel inhibitor of hepatitis B virus surface antigen secretion

The high levels of hepatitis B virus (HBV) surface antigen (HBsAg)-bearing subviral particles in the serum of chronically infected individuals are thought to play a role in suppressing the HBV-specific immune response. Current therapeutics are not directed at reducing this viral antigenemia; thus, our group has focused on identifying inhibitors of HBsAg secretion. By using the HBV-expressing cell line HepG2.2.15, high-throughput screening of an 80,288-compound synthetic small-molecule library identified HBF-0259, an aromatically substituted tetrahydro-tetrazolo-(1, 5-a)-pyrimidine. Following resynthesis, HBF-0259 had a 50% effective concentration of approximately 1.5 microM in a secondary, HBV-expressing cell line, with a concentration that exhibited 50% cytotoxicity of >50 microM. The equilibrium concentration of HBF-0259 in aqueous solution at physiological pH was 15 to 16 microM; the selective index was thus >9. As intended by our screening paradigm, HBF-0259 is a selective, potent inhibitor of secretion of both subviral and DNA-containing viral particles, while the secretion of alpha-1-acid glycoprotein and alpha-1-antitrypsin was unaffected. The HBV e antigen, which is not a constituent of HBV particles, was also unaffected, suggesting that the secretion of particles bearing HBV structural glycoproteins is targeted directly. Inhibitory activity was also confirmed by transfection of HBsAg, indicating that the action of the compound is independent of those of other viral proteins. HBF-0259 had no effect on HBV DNA synthesis, demonstrating that inhibition is independent of viral genomic replication. Finally, HBF-0259 had little or no effect on the cell-to-cell spread of two unrelated viruses, suggesting that it is a specific inhibitor of secretion of HBsAg. Possible mechanisms of action and the implications for its development are discussed.