Midazolam dose for loss of response to verbal stimulation during the unilateral or bilateral spinal anesthesia

Background: We have conducted this study to investigate whether unilateral or bilateral spinal anesthesia with bupivacaine induces different sensitivity to intravenous (i.v.) midazolam for sedation.
Methods: Forty-two patients undergoing various elective unilateral lower extremity surgeries were allocated into two groups: (1) unilateral spinal anesthesia group (Group US, n =21; heavy bupivacaine 5 mg/ml, 9 mg) and (2) bilateral spinal anesthesia group (Group BS, n =21; heavy bupivacaine 5 mg/ml, 9 mg). One milligram of midazolam was injected i.v. at 30-s intervals until the patients did not respond to the hand grasp test beginning 15 min after spinal anesthesia. The concentration of plasma bupivacaine was evaluated every 15 min for the first 75 min after the start of the spinal anesthesia, and the bispectral index was monitored continuously.
Results: The mean venous plasma concentration of bupivacaine was not significantly different between Group US and BS. The dose of midazolam required to abolish responses to verbal commands was significantly lower in Group BS (mean 5.9±1.2 mg) vs. Group US (mean 9.0±1.4 mg).
Conclusions: A higher dosage of midazolam is required for loss of response to verbal stimulation during unilateral spinal anesthesia than during bilateral spinal anesthesia.     

Natural stent in the management of post-intubation tracheal stenosis

Background and objective:   The treatment choice for post-intubation tracheal stenosis (PITS) in patients for whom surgery is not initially feasible is bronchoscopic silicone stenting. A new silicone stent, called the Natural stent (N stent), was investigated for its clinical efficacy and safety in patients with PITS.
Methods:   A retrospective review was conducted of 32 patients with PITS who underwent N stenting between November 2001 and December 2006 and were followed for at least 12 months.
Results:   Airway dilatation with combined modalities such as Nd : YAG laser, ballooning or bougienage was followed by N stent insertion. After intervention, all patients had symptomatic and spirometric improvement without immediate complications. Removal of the stent without re-stenosis was successful in 38% of the patients at a median time of 7 months after insertion. The stent could not be removed or needed reinsertion in 31% of patients, and 16% of patients underwent surgery after initial stabilization by stenting. Late complications were stent migration (34%), mucostasis (31%), granulation tissue formation (38%) and re-stenosis (40%). All patients tolerated the management of complications during a median follow up of 22 months.
Conclusions:   Bronchoscopic N stenting is an effective treatment for patients with PITS in whom surgery is not feasible on initial presentation. Further stent development is necessary to reduce the late complication rate.     

Vitiligo Occurring after Halo Formation around Congenital Melanocytic Nevi

Abstract: We present two cases wherein vitiligo developed after the onset of halo formation involving congenital melanocytic nevi to emphasize the possibility of this finding as a potential albeit unusual presentation of vitiligo.     

Primary immature teratoma of the prostate with angiosarcoma component: Its unusual response to chemotherapy

Here, we present a case of immature teratoma of prostatic origin, which included an angiosarcoma component. This mass proved unresponsive against preoperative chemotherapy for immature teratoma. Angiosarcoma, although quite rare, should be included in the differential diagnosis as a component of prostatic teratoma, especially in cases in which the tumor proves unresponsive to well-known chemotherapeutic protocols. This is, to our knowledge, the first reported case of primary prostatic immature teratoma containing an angiosarcoma component.     

Eosinophilic cystitis causing spontaneous rupture of the urinary bladder in a child

We report a unique case of eosinophilic cystitis causing intraperitoneal bladder perforation in a child diagnosed by chance with no signs or history of trauma. To our knowledge, this is the first case of eosinophilic cystitis complicated by bladder rupture in children. The patient was successfully treated with primary repair. For children with non-traumatic bladder perforation, eosinophilic cystitis must be considered in the differential diagnosis.     

声调对鼻音功能亢进主观听感知的影响

目的了解声调对鼻音功能亢进主观听感知的影响,为编制符合汉语普通话特点的鼻音功能亢进主观听感知评估材料奠定基础。方法分析20 名普通儿童与20 名腭裂儿童朗读声调不同的评估材料时,鼻音功能亢进主观听感知上的等级差异与鼻化率差异。结果不同声调材料之间,鼻音功能亢进等级及鼻化率均无显著性差异(P>0.05)。结论设计汉语普通话鼻音功能亢进主观评估材料时,可以不考虑声调的影响。     

Perioperative Management of Anticoagulation during Device Implantation—The UK Perspective

Background: Increasing numbers of patients taking oral anticoagulation are presenting for device implantation. Cessation of anticoagulation in the perioperative period may expose patients to increased risk of thromboembolic events, while continuing anticoagulation may increase the risk of bleeding. There are few guidelines or randomized controlled trials to guide perioperative management. Methods: We carried out a questionnaire‐based study of all cardiologists implanting devices in the United Kingdom to establish if there was consensus on management of anticoagulation in patients undergoing pacemaker implantation. Results: There is significant variation in management of these patients. Eighty‐nine percent of doctors stop oral anticoagulation a mean 3.7 days prior to pacemaker implantation in patients with a mechanical mitral valve, with 94% using heparin to provide preoperative anticoagulation: 58% unfractionated heparin, 40% low molecular weight heparin. The maximum accepted international normalized ratio for implantation ranged from 1.4 to 3 (median 1.8). Postoperatively, 86% restart heparin after a mean 8.5 hours. Only 11% continue oral anticoagulation throughout the implantation period. There is a hierarchy of perceived embolic risk with doctors using progressively less anticoagulation in patients with prosthetic aortic valve, high‐risk, and low‐risk atrial fibrillation. In contrast, only 7% of implanters stop theinopyridines prior to device implantation in patients with a 2‐month‐old drug eluting stent. Conclusion: Perioperative anticoagulation management of patients undergoing device procedures is currently performed with little consensus. This emphasizes the need for careful national and international audit of periprocedural anticoagulation management and its associated complications with a view to developing international consensus guidelines. (PACE 2010; 389–393)