The value of flumazenil in the reversal of midazolam-induced sedation for upper gastrointestinal endoscopy

Fifty patients who underwent diagnostic upper gastrointestinal endoscopy after midazolam sedation were randomized to receive (after completion of the examination) either the benzodiazepine receptor antagonist flumazenil or an identical-looking placebo. The speed of recovery from sedation was assessed by reaction time testing, measurement of critical flicker fusion frequency, and the semi-quantitative SOCA scoring system. Measurements were made up to 6 h post examination in all subjects, and at 12 and 24 h in all in-patients (n = 20). Flumazenil-treated patients were significantly more alert than those who received placebo at 10 min, 30 min, 1 h and 2 h (P less than 0.001 in all instances). Thereafter the two groups were similar. There was no evidence of recurrence of sedation in flumazenil-treated patients, nor did this drug adversely affect the period of anterograde amnesia between the administration of midazolam and flumazenil.     

Anaesthesia for primary repair of cleft lip and cleft palate: a review of 244 procedures

The peri-operative course of 194 patients undergoing 244 procedures for primary repair of cleft lip and palate over an 8-year-period was studied. A marked increase in the extent of intra-operative monitoring was noted during this period. The Pierre Robin syndrome was the most common associated abnormality and was found in 17% of patients in this series. There were no deaths. A total of 101 procedures were undertaken in infants with cleft lip of whom 10% received an intra-operative blood transfusion. Post-operative opiate analgesics were administered following 97% of these procedures and profound respiratory depression was observed in three children. The use of lignocaine and noradrenaline did not significantly reduce the operative blood loss. A post-operative pyrexial illness was significantly associated with the presence of a positive pre-operative nasal and throat swab and this could be significantly reduced by pre-operative antibiotic treatment. A total of 143 children underwent repair of cleft palate and of these 16.8% received an operative blood transfusion. An elective tracheostomy was required in one patient because of unsuccessful attempts at endotracheal intubation. One patient developed a respiratory arrest after two doses of diamorphine peri-operatively. The use of lignocaine and noradrenaline significantly reduced the operative blood loss. The presence of a positive bacteriological nose or throat swab did not influence the development of a post-operative pyrexia which could however be significantly reduced by the use of pre-operative antibiotics.     

Late adolescent outcome of early onset anorexia nervosa

Forty-three young female patients admitted consecutively to hospital with anorexia nervosa (AN) were re-evaluated in late adolescence an average of 4.3 years following initial presentation. Follow-up interviews were conducted individually by a paediatrician and a psychiatrist on 32 of the original 43 patients (mean age 18.3 years) with outcome assessed by multidimensional physical, menstrual, eating behaviour, psychosocial and global outcome criteria. Physical outcome, as assessed by validated indices of body adiposity, was within the normal range (3-97th percentiles) in 94% of the 32 patients seen at follow-up, although only 56% reported regular cyclical menstrual function. Good physical outcome, however, was not necessarily predictive of successful adjustment in other areas. Eating behaviour was unequivocally normal in only 25% of patients, with a majority still dieting, binging or vomiting with meals, Psychosocial adjustment was satisfactory in the majority of cases but varied widely. Univariate and multivariate statistical analysis identified higher premorbid and admission body mass index (BMI) percentiles, a family history of obesity and shorter duration of illness on admission as significant prognostic indicators of favourable physical outcome. Although girls who develop AN in early adolescence are generally thought to have a favourable long-term prognosis, health professionals need to be aware that these patients form a heterogeneous group and may have considerable ongoing physiologic and psychologic disturbance despite normalization of body mass.     

A Predominantly Adrenaline-secreting Phaeochromocytoma

A 61-year-old woman who presented with diabetes, nausea, weightloss and sweating was found to have a phaeochromocytoma secretingadrenaline, with a small amount of N-methyIadrenaline. Therewas no significant increase in noradrenaline secretion. Shewas normotensive, and developed profound hypotension in responseto the -adrenergic antagonist phenoxybenzamine. These featuresare unusual in phaeochromocytoma, but similar features occurredin the very few previous reported cases of pure adrenaline-secretingphaeochromocytoma. We conclude that it is important to identifysuch patients, so that they should not be given -adrenergicantagonist drugs.     

Multihost, Multiparasite systems: An application of bifurcation theory

Author to whom all correspondence should be addressed (email: j.v.greenman{at}stir.ac.uk). The local analysis of multihost multiparasite models has beenhampered by algebraic intractability. There have been two responsesto this difficulty: extensive numerical investigation, and simplificationto a level where analytical techniques work. In this paper wedescribe another approach, based on bifurcation theory, in whichthe qualitative properties of the model equilibrium structureare realized on an array of maps drawn in parameter space. Thisapproach is described in the context of two models: the basictwo-host shared microparasite S–I model and the single-hosttwo-microparasite S–I (susceptible-infective) model. Theprocedure involved does not require model simplification througha reduction in dimensionality. It can handle intraspecific aswell as parasite-mediated competition and, in the second model,single-host parasite coexistence. The map arrays provide a concisecatalogue of the possible modes of behaviour of a system andan explanation for changes in that behaviour. In particular,the reasons why the conjectures made about the behaviour ofthe first of these models do not hold throughout parameter spaceare immediately clear from the map structure, as are the conditionsfor collusive and competitive behaviour between the two typesof parasite in the second model.     

CHANGES IN THE PITUITARY-TESTICULAR SYSTEM WITH AGE

In order to provide a comprehensive account of pituitary-testicular function in man, 466 subjects, ranging in age from 2 to 101 years, were studied to examine blood levels of the pituitary gonadotrophins (LH and FSH), the sex steroids testosterone and oestradiol, the binding capacity of the sex hormone binding globulin (SHBG), the free testosterone and oestradiol fractions, and the transfer constant for the peripheral conversion of testosterone to oestradiol. The results were compared with clinical indices of testicular size, sexual function and secondary sex hair distribution. Serum LH and FSH were low before puberty, increased in pubertal adolescents to levels somewhat above those of adults and subsequently increased progressively over the age of 40 years. Testosterone levels fell slowly after the age of 40, while there was a slight rise in plasma oestradiol with increasing age. FSH and testosterone showed small seasonal variations in young adult men, the lowest values being seen in winter. SHBG binding capacity was high in two prepubertal boys, fell in adult men, but increased in old age. Free testosterone and oestradiol levels fell in old age. The metabolic clearance rates (MCR) of testosterone and oestradiol also fell in old age, while the conversion of testosterone to oestradiol was increased. Many correlations were observed between various hormonal and clinical measurements. The evidence is consistent with a primary decrease in testicular function over the age of 40 years.     

Treatment of steatorrhoea in cystic fibrosis: a comparison of enteric-coated microspheres of pancreatin versus non-enteric-coated pancreatin and adjuvant cimetidine

Enteric-coated microspheres of pancreatin were compared with non-enteric-coated pancreatin combined with cimetidine taken 40 min before meals in the treatment of patients with cystic fibrosis. Fourteen adults with steatorrhoea due to cystic fibrosis were investigated in an open, randomized crossover study, over two consecutive 28-day treatment periods. Lipase intake was adjusted to each patient's previous requirements and was the same during both months; they were instructed to continue with their normal diet. Patients collected faeces for 72 h at the end of each month and completed diary cards daily throughout. Bowel actions were less frequent on enteric-coated microspheres of pancreatin than on non-enteric-coated pancreatin/cimetidine (1.7 vs. 2.4/day; P less than 0.001) and stool character was improved (P less than 0.001). Mean daily faecal weight was similar on enteric-coated microspheres of pancreatin to that on the combination (254 g vs. 291 g; N.S.), whereas daily faecal fat excretion tended to be less on enteric-coated microspheres of pancreatin (21 g vs. 27 g; N.S.), and percentage fat absorption tended to be greater (81% vs. 73%; N.S.). Mean body weight increased by 0.3 kg on enteric-coated microspheres of pancreatin and fell by 0.1 kg on the combination (N.S.). These data indicate that enteric-coated microspheres of pancreatin are at least as effective as non-enteric-coated pancreatin with cimetidine in the treatment of steatorrhoea in cystic fibrosis.