ELECTRICAL AND MECHANICAL RESPONSES AFTER NEUROMUSCULAR BLOCKADE WITH VECURONIUM, AND SUBSEQUENT ANTAGONISM WITH NEOSTIGMINE OR EDROPHONIUM

Six unpremedicated patients who had given their informed consentwere given vecuronium 0.08 mg kg^–1 before elective surgery.Recovery from neuromuscular blockade was measured electricallyand mechanically. Neuromuscular blockade was antagonized 1 hafter the administration of vecuronium with two doses of neostigmine2.5 mg (three patients) or edrophonium 0.5 mg kg^–1 (threepatients). Although the onset of initial recovery was similar,subsequent recovery was faster when meassured electrically (EMG)than when measured mechanically. Recovery appeared to be fasterin younger patients. Reintroduction of neuromuscular blockadeoccurred after the second dose of neostigmine 2.5 mg, givento antagonize the block. This did not occur after either doseof edrophonium 0.5 mg kg^–1. ^*University College and Middlesex Hospitals, Mortimer Street,London W1 7PN. Department of Anesthesiology, U.C.L.A. Medical School, Los Angeles,U.S.A.     

Is end-stage deceleration of the fetal heart ominous?

Summary. End-stage deceleration (ESD) defined as deep and sustained fetal bradycardia during the second stage of labour was observed in 55 patients. Fetal well-being and neonatal outcome were assessed with fetal-scalp pH, umbilical-vein pH and l-min Apgar score values. Only six infants with pathological fetal heart-rate patterns before ESD had a l-min Apgar score of <7 and an acidotic umbilical-vein pH. The remaining 49 babies were born in excellent condition, although when ESD persisted for more than 15 min umbilical-vein pH decreased.     

RELATIONSHIP AMONG CYSTECTOMY, MICROVESSEL DENSITY AND PROGNOSIS IN STAGE T1 TRANSITIONAL CELL CARCINOMA OF THE BLADDER

Purpose

The selection of therapy for stage T1 bladder cancer is controversial, and reliable biomarkers that identify patients likely to require cystectomy for local disease control have not been established. We evaluated our experience with T1 bladder cancer to determine whether early cystectomy improves prognosis, and whether microvessel density has prognostic value for T1 lesions and could be used for patient selection.

Materials and Methods

We retrospectively reviewed the records of 88 patients with T1 transitional cell carcinoma of the bladder. Patient outcome was correlated with therapeutic intervention. Paraffin embedded tissue from 54 patients was available for factor VIII immunohistochemical staining for microvessel density quantification.

Results

Median followup was 48 months (range 12 to 239). Of the patients 34% had no tumor recurrence. The rates of recurrence only and progression to higher stage disease were 41 and 25%, respectively. The survival of patients in whom disease progressed was diminished (p = 0.0002). Grade did not predict recurrence or progression nor did cystectomy provide a survival advantage. Microvessel density did not correlate with recurrence or progression.

Conclusions

Patients with T1 bladder cancer have a high risk of recurrence and progression. Tumor progression has a significant negative impact on survival. Neither grade nor early tumor recurrence predicted disease progression. Because early cystectomy did not improve patient outcome, we suggest reserving cystectomy for patients with progression or disease refractory to local therapy. Microvessel density is not a prognostic marker for T1 bladder cancer and has no value in selecting patients with T1 disease for cystectomy.     

Facial Lipoatrophy and the Place of Ultrasound

BACKGROUND: Interest in facial lipoatrophy (LA) has recently intensified; this phenomenon is linked to the rise in the number of people adversely affected by the condition as a side effect of antiretroviral treatment for HIV, combined with the growing number of cosmetic products that claim to be able to correct the appearance of LA. Despite growing awareness of the problem, there is at present no standard and accepted technique with which to assess the severity of LA. OBJECTIVE: This review explores facial LA, the use of ultrasound in the evaluation of facial LA, its advantages and disadvantages, and will place the technique in the context of other means of assessing regional skin and fat thickness. METHOD: Review of literature published on PubMed. RESULTS Ultrasound, as with any technique used to assess facial LA, is associated with distinct advantages and disadvantages. CONCLUSIONS: Studies that use a number of different techniques to evaluate changes in dermal thickness provide the greatest insight into both perceived and actual changes in facial LA. Further investigation into the use of these techniques is warranted, along with a formal consensus of facial LA grades.     

Management of tubal pregnancy with methotrexate

Summary. Ten women with tubal ectopic pregnancy were treated by the injection of methotrexate into the gestational sac under direct laparoscopic vision followed by a course of intramuscular therapy including folinic acid rescue. One course of treatment induced resolution of the extrauterine pregnancy in eight women. Complete resolution (β-hCG<10 miu/ml) was achieved within 6–47 days (mean 14·5 days). Serum β-hCG levels started to decline 3–4 days from the beginning of therapy. Length of hospital stay was 5–11 days (mean 6·4 days). Treatment failed in two patients. One woman had a laparoscopic tubal clip sterilization concomitantly with methotrexate treatment. Tubal patency was demonstrated in all the other seven women (100%) tested subsequently. There is a need to establish criteria for patient selection before methotrexate becomes a routine treatment for tubal pregnancy.     

Distribution of recurrent inhibition in the human upper limb

The distribution of homonymous and heteronymous recurrent inhibition among the motor nuclei innervating the main muscles of the human upper limb has been investigated in 25 healthy subjects. Homonymous recurrent inhibition was studied with a specially designed electrophysiological method with paired H-reflexes, previously described by Bussel & Pierrot-Deseilligny (1977), combined with a pharmacological study using a cholinergic agonist, the l -acetylcarnitine (Rossi & Mazzocchio 1991). These methods were used to investigate the Flexor Carpi Radialis (FCR), Extensor Carpi Radialis (ECR), Opponens Pollicis (OP) and Abductor Digiti Minimi (ADM) motor nuclei. In the Deltoid, Triceps, Flexor Carpi Ulnaris (FCU) and Extensor Carpi Ulnaris (ECU) motor nuclei in which it was impossible to evoke clearly distinguishable H-reflexes, homonymous recurrent inhibition was studied with the PSTH technique: homonymous recurrent inhibition was found in Deltoid, Triceps, FCR, FCU, ECR, ECU motor nuclei but not in OP and ADM motor nuclei. Heteronymous recurrent inhibition was studied with the PSTH technique in the Deltoid, Biceps, Triceps, FCR, ECR, FCU, ECU, Flexor Digitorum Communis (FDC), Extensor Digitorum Communis (EDC) motor nuclei as well as those innervating the intrinsic muscles of the hand. The following results were obtained: (1) motor neurones innervating muscles acting at digits do not receive any heteronymous recurrent inhibition; (2) motor neurones innervating muscles acting at the wrist give recurrent inhibition to motor nuclei of proximal muscles but do not receive any recurrent projections from the latter; and (3) motor neurones innervating proximal muscles (acting at shoulder or elbow) are interconnected by recurrent inhibition and receive heteronymous recurrent projections from some wrist muscles but not from intrinsic hand muscles.