Remifentanil/midazolam versus tramadol/midazolam use for colonoscopy

One of the most commonly performed outpatient procedure is colonoscopy. The pain and anxiety is frequently associated with colonoscopy. The aim of this study was to compare the effectiveness of remifentanil/midazolam, and tramadol/midazolam for iv sedation and analgesia during colonoscopy. Twentysix patients (age range 18-65 years) scheduled for ambulatory colonoscopy were included to study. All patients received midazolam 1 mg intravenous. After two minutes in Group R (remifentanil/midazolam, n=18) remifentanil bolus (10 microg) and infusion 0.03 microg kg(-1) min(-1) were administered until adequate sedation level was achieved. In Group T (tramadol/midazolam, n=18) iv tramadol 50 mg was given concurrently. During procedure 2 L/min oxygen was supplemented via face mask to all patients. Haemodynamic variables, respiratory depression, level of sedation, postoperative recovery, patient and gastroenterologist satisfaction were surveyed. Patients were asked to verbally rate their level of pain, on an 10-point numerical rating scale (1=no pain, 10=severe pain). Chi-square, student t test, and mann whitney U test were used for statistical analysis. Colonoscopy was carried out successfully in all patients. There were no episodes of desaturation or airway compromise. Haemodynamic parameters were similar in both groups. Sistolic arterial and diastolic arterial pressures were increased at 10 and 15 minutes in all patients (P<0.05). There were no significant changes in heart rate in both groups. The level of sedation in group R was higher than group T during colonoscopy. The patients in group T had higher pain scores. Gastroenterologist satisfaction and patient satisfaction were similar in both groups. Our results suggests that, sedoanalgesia with midazolam/remifentanil may be an alternative to sedoanalgesia with midazolam/tramadol for colonoscopy.     

Prognostic factors in critically ill cancer patients admitted to the intensive care unit

Objective

The objective of this study is to identify factors predicting intensive care unit (ICU) mortality in cancer patients admitted to a medical ICU.

Patients and methods

We conducted a retrospective study in 162 consecutive cancer patients admitted to the medical ICU of a 1000-bed university hospital between January 2009 and June 2012. Medical history, physical and laboratory findings on admission, and therapeutic interventions during ICU stay were recorded. The study end point was ICU mortality. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

Results

The study cohort consisted of 104 (64.2%) patients with solid tumors and 58 patients (35.8%) with hematological malignancies. The major causes of ICU admission were sepsis/septic shock (66.7%) and respiratory failure (63.6%), respectively. Overall ICU mortality rate was 55 % (n = 89). The ICU mortality rates were similar in patients with hematological malignancies and solid tumors (57% vs 53.8%; P = .744). Four variables were independent predictors for ICU mortality in cancer patients: the remission status of the underlying cancer on ICU admission (odds ratio [OR], 0.113; 95% confidence interval [CI], 0.027-0.48; P = .003), Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.032-1.215; P = .007), sepsis/septic shock during ICU stay (OR, 8.94; 95% CI, 2.28-35; P = .002), and vasopressor requirement (OR 16.84; 95% CI, 3.98-71.24; P = .0001). Although Acute Physiology and Chronic Health Evaluation II score (OR, 1.30; 95% CI, 1.054-1.61; P = .014), admission through emergency service (OR, 0.005; 95% CI, 0.00-0.69; P = .035), and vasopressor requirement during ICU stay (OR, 140.64; 95% CI, 3.59-5505.5; P = .008) were independent predictors for ICU mortality in patients with hematological malignancies, Sequential Organ Failure Assessment score (OR, 1.83; 95% CI, 1.29-2.6; P = .001), lactate dehydrogenase level on admission (OR, 1.002; 95% CI, 1-1.005; P = .028), sepsis/septic shock during ICU stay (OR, 138.4; 95% CI, 12.54-1528.4; P = .0001), and complete or partial remission of the underlying cancer (OR, 0.026; 95% CI, 0.002-0.3; P = .004) were the independent risk factors in patients with solid tumors.

Conclusion

Intensive care unit mortality rate was 55% in our cancer patients, which suggests that patients with cancer can benefit from ICU admission. We also found that ICU mortality rates of patients with hematological malignancies and solid tumors were similar.     

Juvenile idiopathic arthritis profile in Turkish children

Background: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of disorders. Publications from different countries point to differences in the disease manifestation of JIA among different populations. The aim of the present paper was to evaluate the clinical and laboratory features of JIA in Turkish children. Methods: A total of 196 JIA patients who fulfilled International League of Associations for Rheumatology (ILAR) diagnostic criteria were included in this retrospective study. The data collected were age, gender, age at disease onset and at diagnosis, and follow‐up duration. Antinuclear antibody (ANA), rheumatoid factor (RF), and human leukocyte antigen B‐27 were evaluated for each patient. Results: There were 102 boys and 94 girls with a mean duration of disease of 4.1 years. The mean age at the first visit was 8.8 years, and the mean age at onset of disease was 6.8 years (range, 8 months–15 years). Polyarticular JIA was the most frequent onset type (37.2%). Other subtypes included oligoarthritis (34.2%), systemic arthritis (15.3%), psoriatic arthritis (1%), enthesitis‐related arthritis (9.7%), and other arthritis (2.2%). ANA was positive in 28 patients (14.2%). Chronic uveitis occurred in two patients with oligoarthritis; and two patients with enthesitis‐related arthritis had acute uveitis. Three patients (1.4%) developed amyloidosis. Conclusion: Compared to reports from Western countries, remarkably different features of JIA were found in Turkish children, which included higher frequency of polyarticular JIA, higher prevalence among boys, lower rate of ANA positivity and uveitis. Further studies are required to understand how genetic and environmental differences affect JIA expression.     

Prevalence patterns of gastric cancers in Turkey: model of a developing country with high occurrence of Helicobacter pylori

AIM: In developed countries, there has been a recent increase in the prevalence of adenocarcinoma of the esophagus and cardia, along with a decrease in distal gastric cancers. Little is known regarding the prevalence of these diseases in developing countries. The aim of the present study was to evaluate changes in the prevalence of gastric adenocarcinomas in Turkey as a function of anatomic location. METHODS: Data were retrospectively collected from 16 centers from January 1990 to December 2000. Owing to the exclusion criteria, a total of 4065 cases of tumors of the stomach and distal esophagus were included. Tumors localized to the body, the antrum and pyloric channel were considered distal cancers. Helicobacter pylori (H. pylori) was also detected. RESULTS: Patients' mean age was 60.7 +/- 9 years, with a male : female ratio of 68:32. The ratio of distal/proximal adenocarcinoma was 2:1 for the western part of Turkey and 3:8 for the eastern part of the country (P < 0.0001), and this did not change during the 11 years. H. pylori was detected significantly less in the west compared to the east for distal tumors (65.7 vs 38.7%, respectively, P = 0.02). CONCLUSION: In Turkey, a developing country with a high H. pylori prevalence, contrary to the state of developed countries, the ratio of distal versus proximal gastric adenocarcinomas has not changed. Geographical distribution should be taken into the account in projecting the changing patterns of gastric cancers.     

The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: A prospective, randomized study.

The aim of the present prospective, randomized study was to investigate and compare the safety and efficacy of dexmedetomidine versus midazolam in providing sedation for gastroscopy. A total of 50 adult patients (25 patients receiving dexmedetomidine and 25 patients receiving midazolam), 18 to 60 years of age, and rated I and II on the American Society of Anesthesiologists physical status classification system were included. A brief questionnaire was used to collect demographic data; patients were asked to rate anxiety, satisfaction with care to date and expected discomfort on a visual analogue scale. The following parameters were measured continuously and recorded every minute: heart rate, mean arterial pressure, hemoglobin oxygen saturation and respiratory rate. The two groups were similar with regard to age, body mass index, sex, education, duration of endoscopy, and ethanol or tobacco use. After the procedure, full recovery time, mean arterial pressure, heart rate, respiratory rate and hemoglobin oxygen saturation levels were similar in both groups. Both groups also had low levels of perceived procedural gagging, discomfort and anxiety scores (P > 0.05), and high satisfaction levels (90.1+/-3.0 for dexmedetomidine versus 84.9+/-4.5 for midazolam; P > 0.05). Retching and endoscopist satisfaction were significantly different in patients receiving dexmedetomidine versus those receiving midazolam (88.8+/-6.5 versus 73.5+/-16.4, P < 0.05; and 20.6+/-4.4 versus 45.2+/-6.0; P < 0.001). In the midazolam group, the number of patients who had adverse effects was higher than the dexmedetomidine group (P < 0.05). As a result, dexmedetomidine performed as effectively and safely as midazolam when used as a sedative in upper gastroscopy; it was superior to midazolam with regard to retching, rate of side effects and endoscopist satisfaction. It was concluded that dexmedetomidine may be a good alternative to midazolam to sedate patients for upper endoscopy.     

Systemic toxicity of tacrolimus given by various routes and the response to dose reduction

PURPOSE: To evaluate the long-term systemic toxicity of tacrolimus (FK-506) administered by various routes, and to assess the effect of dose reduction on toxicity. METHODS: The study animals were 120 experimentally naive adult female Wistar rats weighing 200-250 g each. The rats were randomly divided into 10 equal groups (n=12 in each) and treated with tacrolimus administered topically (in drops, 0.3%, q.i.d.), intravitreally (0.5 mg/kg bodyweight/week), intramuscularly (1 mg/kg bodyweight/week), low-dose intravenously (1 mg/kg bodyweight/week) and in high-dose intravenously (2 mg/kg bodyweight/week) for 3 months. The rats in the control groups (one for each different route of administration) were treated with 0.9% NaCl. The blood concentration of tacrolimus, complete blood count and biochemistry parameters were measured each month for the 3-month study period. RESULTS: The rats in the control groups and experimental groups administered topical and intravitreal tacrolimus did not demonstrate any systemic toxic effects. The rats that developed certain toxic effects (hyperglycaemia, hyperkalaemia and nephrotoxicity) in the groups given low-dose or high-dose i.v. tacrolimus responded well to dose reduction. Following dose reduction, blood glucose concentrations decreased from 247.4 +/- 42.3 mg/dL to 189.6 +/- 37.9 mg/dL (P <0.05), and from 237.4 +/- 41.1 mg/dL to 182.3 +/- 22.7 mg/dL (P <0.05) in the low- and high-dose i.v. tacrolimus-treated rats, respectively. The rats that developed impaired hepatic function after high-dose tacrolimus did not respond to dose reduction. Baseline cholesterol concentrations for the intramuscular and low- and high-dose i.v. tacrolimus-treated groups, demonstrated decreases, respectively, from 87.4 +/- 14.0 mg/dL, 86.4 +/- 14.0 mg/dL and 90.4 +/- 14.3 mg/dL to 53.6 +/- 9.8 mg/dL, 52.1 +/- 12.5 mg/dL and 63.5 +/- 11.7 mg/dL by the end of the second month. The differences were found to be statistically significant (P <0.05 for each result). CONCLUSION: Topical or intravitreal administration of tacrolimus seems to be systemically safe whereas parenteral administration can cause some systemic haematological changes such as dose-dependent decreased serum cholesterol concentrations. Dose reduction may prevent such adverse effects.