L’analgésie péridurale thoracique et rachidienne ont des effets comparables sur la douleur et la fonction respiratoire après chirurgie thoracique

PURPOSE: To compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy. PATIENTS AND METHODS: 55 patients undergoing an elective postero-lateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 microg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 microg.mL(-1) via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 microg.mL(-1) with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO(2), PaCO(2), respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough. RESULTS: No significant difference was noted between both groups concerning VAS, HR, MAP, SpO(2), PaCO(2) and RR. Variations of the respiratory function tests were identical in both groups. CONCLUSION: This study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.     

Comparison of the Effect of Etomidate and Desflurane on Brain Tissue Gases and pH during Prolonged Middle Cerebral Artery Occlusion

Background: The authors compared the effects of etomidate and desflurane on brain tissue oxygen pressure (PO2), carbon dioxide pressure (PCO2), and pH in patients who had middle cerebral artery occlusion for > 15 min.

Methods: After a craniotomy, a probe that measures PO2, P (CO)2, and pH was inserted into cortical tissue at risk for ischemia during middle cerebral artery occlusion. A burst suppression pattern of the electroencephalogram was induced with etomidate (n = 6) or 9% end-tidal desflurane (n = 6) started before middle cerebral artery occlusion. Mean blood pressure was supported with phenylephrine to 90-95 mmHg.

Results: During baseline conditions, tissue PO2, PCO (2), and pH were similar between the two groups (PO2 = 15 mmHg, PCO2 = 60 mmHg, pH = 7.1). During administration of etomidate before middle cerebral artery occlusion, tissue PO2 decreased in five of six patients without a change in PCO2 or pH. During administration of 9% desflurane, tissue PO2 and pH increased before middle cerebral artery clipping. Middle cerebral artery occlusion for an average of 33 min with etomidate and 37 min with desflurane produced a decrease in pH with etomidate (7.09 to 6.63, P <0.05) but not with desflurane (7.12 to 7.15).     

Gallstones in childhood-special problems in diagnosis (author's transl)]

Several pediatric textbooks mention hemolytic anemia as the most frequent cause of cholelithiasis. However cholesterol containing concrements seem to be more frequent. In lack of jaundice the diagnosis of gallstones is difficult, especially, when appearing as uncharacteristic abdominal pain. In a case of a ten year old girl the basic diagnosis of cholelithiasis lasted two years. Wrong diagnoses (appendicitis, duodenal ulcer) associated diseases (carditis, complete heart block) and minor troubles (menarche, oxyuriasis, constipation) were responsible for this long period. Oral cholecystography brought on definitive diagnosis. Liberal indication of this investigation is recommended, especially in corpulent girls.     

Prognostic importance of automated ST-segment monitoring after coronary artery bypass graft surgery

Background : Automated ST-segment monitors are widely used in cardiac surgery units. The purpose of this study was to determine if cardiac morbidity and mortality, after CABG surgery, are predicted by ECG ST-segment changes on automated monitors.
Method : One hundred patients, who underwent CABG, were included in this prospective study. ST-segment deviations were recorded by an automated ST monitor, in the ICU, for 24 h after surgery. A reversible ST depression of more than 0.1 mV or a ST elevation of more than 0.2 mV and for at least 1 min were considered as significant episodes. Adverse cardiac outcomes were defined as: myocardial infarction (MI), severe left ventricular failure, ventricular fibrillation (VF) and cardiac-related death.
Results : Sixty patients (group 1) presented significant episodes of ST deviation (6δ5 episodes per patient). Forty patients (group 2) were free from ST changes. Eight patients from group 1 had postoperative adverse cardiac outcomes: 5 MI, 2 VF and 1 cardiac-related death. Patients from group 2 were all free from adverse cardiac outcomes. Automated ST-segment analysis during the first 24 h had a positive predictive value of 13% and a negative predictive value of 100%.
Conclusion : Automated ST analysis is a non-invasive, sensitive and very easy-to-use monitoring system to screen patients who may develop myocardial ischemia and cardiac complications after CABG surgery.     

Recurrent spontaneous bacterial peritonitis in a patient with polycythemia vera

Spontaneous bacterial peritonitis (SBP) is an infectious process that usually occurs in patients with cirrhosis. There are few reports of SBP in patients with other pathologies such as nephrotic syndrome, acute and chronic hepatitis, cardiac ascites, and ascites secondary to neoplastic disease. We report a patient with polycythemia vera in whom recurrent episodes of SBP occurred 8 months following a portacaval shunt operation for Budd-Chiari syndrome. Conceivably, the polycythemia vera (PV) complicated by hepatic vein thrombosis and portacaval shunt resulted in significant loss of hepatic reticuloendothelial system function and predisposed the patient to bacterial peritonitis.     

Nicotinamide is a potent inducer of endocrine differentiation in cultured human fetal pancreatic cells.

The effects of nicotinamide (NIC) on human fetal and adult endocrine pancreatic cells were studied in tissue culture. Treatment of the fetal cells with 10 mM NIC resulted in a twofold increase in DNA content and a threefold increase in insulin content. This was associated with the development of beta cell outgrowths from undifferentiated epithelial cell clusters and an increase in the expression of the insulin, glucagon, and somatostatin genes. DNA synthesis was stimulated only in the undifferentiated cells. Half-maximal doses for the insulinotropic and mitogenic effects of NIC were 5-10 and 1-2 mM, respectively. Islet-like cell clusters cultured with NIC responded to glucose stimulation with a biphasic increase in insulin release (fourfold peak), whereas control cells were unresponsive to glucose. Both control and NIC-treated cells developed into functional islet tissue after transplantation into athymic nude mice. As compared with adult islets, the insulinotropic action of NIC could only be demonstrated in the fetal cells. Our results indicate that NIC induces differentiation and maturation of human fetal pancreatic islet cells. This model should be useful for the study of molecular mechanisms involved in beta cell development.     

Ultrastructural study of enteric ganglia in three patients with Rett syndrome

In order to verify whether a pseudo-obstruction syndrome was associated with morphological changes in enteric ganglia, we performed an ultrastructural study on rectal biopsy specimens in three patients with Rett syndrome. Features of enteric neurons, detected to a different extent in all three biopsy specimens, included an abnormal dilatation of endoplasmic reticulum with a disorganization of cisternae of the Golgi apparatus, and masses of unidentified electron-dense granulo-filamentous material, probably of lipidic origin, observed in the perikaryon. Large electron-lucent membrane-bound vacuoles were found mostly within satellite glial cells. Sometimes, the axon terminals were swollen and showed intraxonal vacuolization. We conclude that the reported findings do not represent a specific sign of degeneration and do not constitute a significant morphological marker of disease.     

An evaluation of the Modified R/B Enteric Differential System for the identification of the Enterobacteriaceae.

Two hundred and twenty-two organisms were identified by conventional methods and by the Modified R/B Enteric Differential System. Two hundred and eighteeen (98-2%) of these organisms were correctly identified by the R/B system. The results of individual tests were also compared. The convenience and general ease of handling of the R/B system are discussed.     

Metabolic acidosis in the newborn period

In this chapter we have described the metabolic diseases which are known to have caused acidosis during the newborn period. We have also provided some diagnostic and treatment guidelines. The occurrence of acidosis in a newborn baby should initiate several actions, aimed simultaneously at treatment and diagnosis. An initial blood gas determination, accompanied by the results of serum electrolytes and glucose, will, in most instances, separate respiratory from metabolic causes. Finding of an increased anion gap and/or presence of hypoglycaemia should direct attention towards errors in intermediary metabolism.