[Influence of fat diet in glicidic metabolism in obese women with Pro12Pro genotype in PPARgamma2 gene]

INTRODUCTION

The peroxisome proliferator-activated receptor gamma 2 (PPARgamma2) is an adipogenic transcription factor that influences in insulin resistance (IR) in the presence of agonists such as polyunsaturated fatty acids (PUFA).

OBJECTIVE

Evaluate the influence of dietary fat in glicidic metabolism in morbidly obese women with Pro12Pro genotype in the gene PPARgamma2.

METHODS

Were selected 25 women with genotype Pro12Pro. The fat intake was estimated by food records, being used for the division of groups, GA (until 30% of the total energy expenditure (TEE)) and GB (greater than 30% of the TEE). Biochemical and anthropometric evaluations were conducted in fasting, following the test meal high in n-6 PUFA and postprandial biochemical evaluations. IR and insulin sensitivity (IS) were assessed by HOMA-IR (Homeostasis Model Assessment) and QUICKI (Quantitative Insulin Sensitivity Check Index), respectively.

RESULTS AND DISCUSSION

GA presented normal HOMAIR and QUICKI. GB presented higher body mass index (BMI), HOMA-IR, saturated fatty acids (SFA) and monounsaturated (MUFA) intake higher, compared with GA (p < 0.05). In GA, the MUFA intake was negatively correlated with HOMA-IR, fasting glucose and insulin, and positively with QUICKI. The fat and SFA intake contributed to the increase in body mass and IR. However, MUFA intake may have reduced the impact of high fat diet in glicidic metabolism. It is suggested that obese women with Pro12Pro genotype in the PPARgamma2 gene avoid high fat and SFA diets, prioritizing MUFA for controlling obesity and improving the IS.

Adrenaline through the endotracheal tube as an answer to severe bronchospasms caused by lidocaine

The authors describe the effect of instilling adrenaline through the endotracheal tube in one case of severe bronchospasms due to intubation with an endotracheal tube lubricated with 10% lidocaine spray in a patient with no history of adverse respiratory or allergic reactions.

Risk index for peri-operative atrial fibrillation in patients undergoing open intracranial neurosurgical procedures

The aim of this prospective study was to determine the prevalence of pre-operative atrial fibrillation and the incidence of postoperative atrial fibrillation in patients undergoing elective or emergency intracranial neurosurgical procedures and the relation to survival and neurological outcome at 6-months follow-up compared to patients with sinus rhythm. A total of 2020 patients were enrolled; 1540 patients underwent elective procedures and 480 underwent emergency procedures. Prevalence of pre-operative atrial fibrillation was 3.7% in elective and 7.2% in emergency procedures (p = 0.0012). In patients undergoing elective cerebral procedures with pre-operative atrial fibrillation, compared to patients with sinus rhythm, 6-month neurological outcome and survival rate are similar. In patients undergoing emergency neurosurgical cerebral procedures, the presence of pre-operative atrial fibrillation is related to an increased risk of poor neurological outcome but with similar survival rate.

Sufentanil-propofol vs remifentanil-propofol during total intravenous anesthesia for neurosurgery. A multicentre study

BACKGROUND

In a randomised, prospective multi-centre study, we compared the intraoperative and postoperative effects of two opioids: sufentanil and remifentanil, in combination with propofol in two groups of patients undergoing neurosurgery.

METHODS

After Local Ethics Committee approval and informed consent obtaining, 69 patients undergoing neurosurgery for supratentorial tumours, between 18 and 75 years of age were randomised to receive either sufentanil or remifentanil in combination with propofol. Intraoperative and postoperative haemodynamic variables, recovery times (time to eye opening and to extubation), the incidence of postoperative respiratory depression, pain, nausea and vomiting were also evaluated. The Short Orientation-Memory-Concentration Test was used to evaluate cognitive function at 15, 45 and 180 min after emergence from anesthesia.

RESULTS

There were no significant differences between the groups in the duration of surgery and anesthesia, mean arterial pressure, heart rate, time to eye opening or extubation. The incidence of vomiting, respiratory depression and shivering was similar in both groups. Postoperative pain requiring supplemental analgesics was significantly lower in the sufentanil group (P<0.05). Although there were no significant differences between the groups in postoperative behavioural examinations by Rancho Los Amigos Test, patients anesthetised with sufentanil had significantly better Short Orientation-Memory-Concentration Test values at 15 and 180 min postoperatively (P<0.05). CONCLUSION. We conclude that remifentanil and sufentanil are suitable adjunct to propofol for total intravenous anesthesia (TIVA). Patients receiving sufentanil have reduced analgesic requirements and better cognitive function postoperatively than those who received remifentanil.

Molecular mechanisms of diabetes reversibility after bariatric surgery

OBJECTIVE

Insulin resistance is a strong biological marker of both obesity and type 2 diabetes. Abnormal fat deposition within skeletal muscle has been identified as a mechanism of obesity-associated insulin resistance. Biliopancreatic diversion (BPD), inducing a massive lipid malabsorption, leads to a reversion of type 2 diabetes. To elucidate the mechanisms of diabetes reversibility, the expression of genes involved in glucose and free fatty acids (FFAs) metabolism was investigated in skeletal muscle biopsies from obese, type 2 diabetic subjects. Peripheral insulin sensitivity and insulin secretion was also measured.

SUBJECTS

Eight Caucasian obese diabetic patients (BMI 52.1+/-1.85 kg/m(2)) were studied before and 3 years after BPD.

MEASUREMENTS

The mRNA levels were estimated by quantitative real-time reverse transcription polymerase chain reaction (RT-PCR), insulin sensitivity by the euglycemic-hyperinsulinemic clamp and insulin secretion using a model describing the relationship between insulin secretion and glucose concentration.

RESULTS

Whole-body glucose uptake (M), normalized by fat-free mass, significantly increased in post-obese subjects (P<0.0001). Total insulin output decreased (P<0.05) in association with a significant improvement of beta-cells glucose sensitivity (P<0.05). mRNA levels of FABP3 (P<0.05), FACL (P<0.05), ACC2 (P<0.05), HKII (P<0.05) and PDK4 (P<0.05) were significantly decreased, while SREBP1c mRNA increased (P<0.05) after BPD.

CONCLUSION

Reversibility of type 2 diabetes after BPD is dependent on the improvement of skeletal muscle insulin sensitivity, mediated by changes in the expression of genes regulating glucose and fatty acid metabolism in response to nutrient availability.

Early postoperative cognitive recovery after remifentanil–propofol or sufentanil–propofol anaesthesia for supratentorial craniotomy: a randomized trial

BACKGROUND AND OBJECTIVE

This study was designed to evaluate early postoperative cognitive recovery after total intravenous anaesthesia with remifentanil-propofol or sufentanil-propofol in patients undergoing craniotomy for supratentorial expanding lesions.

METHODS

Sixty patients were consecutively enrolled, and randomly assigned to one of two study groups: remifentanil-propofol or sufentanil-propofol anaesthesia. To evaluate cognitive function the Short Orientation Memory Concentration Test (SOMCT) and Rancho Los Amigos Scale (RLAS) were administered to all patients in a double-blind procedure before surgery at 15, 45 min and 3 h after extubation.

RESULTS

Mean extubation time was similar in the two groups (13 +/- 5 min vs. 19 +/- 6 min). A significantly larger number of patients in the remifentanil-propofol group than in the sufentanil-propofol group required antihypertensive medication postoperatively to maintain mean arterial pressure within 20% of baseline (18/30 vs. 4/29; P = 0.0004). Intergroup analysis showed no differences in baseline SOMCT scores (28 +/- 1 vs. 28 +/- 1) whereas mean SOMCT scores at 15, 45 min and 3 h after extubation were significantly higher in the remifentanil-propofol group (30 patients) than in the sufentanil-propofol group (29 patients) (22 +/- 3 vs. 16 +/- 3; P < 0.0001 and 27 +/- 1 vs. 22 +/- 3; P < 0.0001; 28 +/- 1 vs. 26 +/- 2; P = 0.0126).

CONCLUSIONS

In conclusion, propofol-remifentanil and propofol-sufentanil are both suitable for fast-track neuroanaesthesia and provide similar intraoperative haemodynamics, awakening and extubation times. Despite a higher risk of treatable postoperative hypertension propofol-remifentanil allows earlier cognitive recovery.

Fistula in ano: anatomoclinical aspects, surgical therapy and results in 844 patients

BACKGROUND

Several new therapies, including advancement flaps and fibrin glue, have been proposed for fistula in ano, with conflicting results. Most colorectal surgeons continue to use classic methods, e.g. fistulotomy, fistulectomy, a combined method, loose or cutting seton, and rubber loop. The aim of the present study is to report the outcome of our patients, operated on by such methods.

METHODS

We retrospectively reviewed the clinical records of 844 patients treated for anal fistula over a 30-year period, and assessed fistula morphology, surgical procedure and healing period. For patients treated 2 or more years prior to this study, we evaluated rates of persistent fistula and relapse, as well as prevalence of incontinence and patient satisfaction.

RESULTS

The majority of patients had trans-sphincteric fistulae (58.3%). We observed 274 secondary extensions (32.5%); these were common in all fistula types except for intrasphincteric fistulae. Most patients were treated by fistulotomy alone (594 patients, 70.4%) or by the combined fistulectomy-fistulotomy method (237 patients, 28.1%), with or without loose seton. All patients with trans-, supra- and extrasphincteric fistulae were re-examined in the operations theatre. Follow-up data were available for 652 (87%) of 751 patients at least two years after surgery. The anal fistula persisted in 3.2% and recurred in 2.1% of cases. A second procedure lowered the initial rate of unsuccessful operations from 5.3% to 2.5%. Continence disorders were reported in 6.9% of patients: 4.0% complained of incontinence to gas, 2.6% to liquid and 0.3% to solid feces.

CONCLUSIONS

Fistulotomy and fistulectomy with loose seton supported by preoperative anal manometry and postoperative evaluation under anaesthesia are followed by good clinical and functional results.

Hospital-acquired infection surveillance in a neurosurgical intensive care unit

A prospective study on hospital-acquired infection (HAI) was undertaken in the eight-bed neurosurgical intensive care unit (NSICU) of a teaching hospital in Rome, Italy. All patients admitted for >48 h between January 2002 and December 2004 were included. The infection control team collected the following data from all patients: demographic characteristics, patient origin, diagnosis, severity score, underlying diseases, invasive procedures, HAI, isolated micro-organisms and antibiotic susceptibilities. Overall, 323 patients were included in the study. Mean age was 55.5 years (range 17-91), and mean American Society of Anesthesiologists' score was 2.88. Seventy (21.7%) patients developed 132 NSICU HAIs: 43 pneumonias, 40 bloodstream infections (BSIs), 30 urinary tract infections (UTIs), 10 cases of meningitis associated with an external ventricular drain (EVD) and nine surgical site infections (SSIs). The SSI rate was high (5.6%), but a reduction was achieved during the three-year period. There were 7.2 bloodstream infection episodes per 1000 days of device exposure; 11.00 pneumonias per 1000 days of mechanical ventilation and 4.5 UTIs per 1,000 days of urinary catheterisation. Among patients with an EVD, the SSI relative risk was 11.3 [95% confidence intervals (CI) 4.2-30.6; P<0.01]. Sixty-one (18.9%) patients died. Logistic regression analysis showed that mortality was significantly associated with infection [odds ratio (OR)=2.28; 95%CI 1.11-4.71; P=0.02] and age (OR=1.04; 95%CI 1.01-1.06; P=0.002). Candida spp. were the leading cause of UTIs (40.0%) and the third most common cause of BSIs (12.7%). Antibiotic-resistant pathogens included meticillin-resistant staphylococci (77.5%), carbapenem-resistant Pseudomonas aeruginosa (36.4%), and extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (75.0%). Although the overall incidence of infection (21.7%) was within the range of published data, the associated mortality, the increasing severity of illness of patients, and the emergence of multi-drug-resistant organisms shows the need to improve infection control measures.

Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20-year experience

BACKGROUND

Submucosal reconstructive hemorrhoidectomy has never been a popular operation due to its difficulty and duration, the amount of blood loss, and the risk of incontinence. The main indication for hemorrhoidectomy according to Parks is fourth-degree hemorrhoids with prolapse of the dentate line outside the anus and with simultaneous presence of external hemorrhoids. We report our experience in the treatment of hemorrhoids using submucosal reconstructive hemorrhoidectomy according to Parks.

METHODS

A total of 640 patients (381 men and 259 women) of median age 42 years (range, 18-81) were treated between 1983 and 2002; 80% of patients had fourth-degree, 19% third-degree and 1% second- degree hemorrhoids. All patients underwent rectosigmoidoscopic examination before surgery; patients over 35 years of age or with a suspected inflammatory or neoplastic disease underwent colonoscopy or barium enema. All patients underwent anorectal manometry before operation, to measure anal resting pressure, maximal squeeze and sphincter length, with the purpose of determining if an internal sphincterotomy was also necessary (in case of high anal resting tone). One-third of the patients also had an internal sphincterotomy to correct anal hypertonia.

RESULTS

Postoperative bleeding occurred in 19 patients (2.9%), 0.9% requiring a reintervention. Severe pain was reported by 9 patients (1.4%); fecal impaction occurred in 3 cases (0.5%) and suture disruption in 2 patients (0.3%). In 74 patients (11.6%), bladder catheterization was needed due to urinary retention. Of 550 patients who had a minimum follow-up of 3 years and were sent a postal questionnaire, 374 patients responded, with a median 7.3-year follow- up; 176 patients (32%) were lost to follow-up. Eleven patients (2.9% of 374 cases) reported pain during defecation, 6 (1.6%) developed skin tags or recurrence, 3 (0.8%) reported gas incontinence, 2 (0.5%) developed anal fistula and 1 (0.3%) had anal stricture.

CONCLUSIONS

Submucosal reconstructive hemorrhoidectomy according to Parks still represents a good choice for the treatment of high-degree hemorrhoids with prolapse of the dentate line outside the anus and external circumferential hemorrhoids.

No difference in emergence time and early cognitive function between sevoflurane-fentanyl and propofol-remifentanil in patients undergoing craniotomy for supratentorial intracranial surgery

Balanced anesthesia with sevoflurane-fentanyl has been widely accepted as anesthetic management for neurosurgery. Propofol-remifentanil regimen has been successfully used in various surgical settings, but a comprehensive comparison of sevoflurane-fentanyl and propofol-remifentanil anesthesia in patients undergoing craniotomy for supratentorial intracranial surgery has not yet been done. The aim of this prospective, randomized, open-label clinical trial was to compare clinical properties of sevoflurane-fentanyl with propofol-remifentanil anesthesia in patients undergoing supratentorial intracranial surgery. The primary endpoint was to compare early postoperative recovery and cognitive functions within the two groups; we also evaluated hemodynamic events, vomiting, shivering, and pain. One hundred twenty patients (64 males; age 15-75 years) were randomized to either total intravenous anesthesia (group T) or sevoflurane anesthesia (group S). Emergence and extubation times and cognitive function (Short Orientation Memory Concentration Test [SOMCT]) were compared in the two groups. Brain swelling, incidence of hypotensive and hypertensive episodes, postoperative vomiting, shivering, and pain were also analyzed. The mean emergence time (12.2 +/- 4.9 minutes for group S versus 12.3 +/- 6.1 minutes for group T; P = 0.92) and extubation time (18.2 +/- 2.3 minutes for group S versus 18.3 +/- 2.1 minutes for group T; P = 0.80) were similar in the two groups. Average SOMCT scores, both 15 minutes after extubation (25.6 +/- 4.9 in group S versus 23.9 +/- 7.5 in group T; P = 0.14) and 45 minutes after extubation (27.3 +/- 2.2 in group S versus 26.0 +/- 5.1 in group T; P = 0.07) were also comparable. Brain swelling was present in seven and five patients in groups S and T, respectively (P = 0.76). Hypotension was present in 12% (group S) and 28% (group T) of patients (P = 0.02). Hypertension was present in 17% of patients in group S and 40% of patients in group T (P = 0.0046). Shivering was present in 18% and 25% of patients in groups T and S (P = 0.37). Our study demonstrates that there is no patient benefit of using total intravenous anesthesia with an ultra-short-acting opioid over the conventional balanced volatile technique in terms of recovery and cognitive functions.

Calibrated lateral internal sphincterotomy for chronic anal fissure

Lateral internal sphincterotomy is an effective procedure for the treatment of anal fissure, but may affected anal continence. We describe a procedure aimed at tailoring the division of the sphincter according to the degree of the hypertonia and to the sphincter length in order to offer an effective and safe treatment for chronic anal fissure.

METHODS

The internal sphincter was divided on the basis of anal manometry results. The average of maximum values of resting pressure determined by the stationary motility protocol was considered the reference parameter to measure hypertonia. Mild hypertone was considered to be 50-60 mmHg, moderate hypertone 60-80 mmHg, and severe hypertone >80 mmHg. In case of mild hypertone, 20% of the internal sphincter was divided; in case of moderate hypertone; 40% and 60% for severe hypertone. Calibrated lateral internal sphincterotomy is the division of the internal sphincter based on these parameters. Over 5 years, 388 patients underwent this procedure (197 men, 191 women) with a median age of 43 years (range, 18-80).

RESULTS

Postoperative complications consisted of abscess in 4 patients (1.0%), hemorrhage in 2 patients (0.5%), and pain in 6 patients (1.5%). Follow-up data are available for 261 patients (67.3%). Two months after surgery, 9 patients (3.4%) complained of persistent or recurring pain with or without fissure and 1 (0.4%) complained of gas incontinence. At postoperative manometry, 12 patients (4.6%) revealed persistence of anal resting pressure over 40 mmHg, 9 patients (3.4%) were still symptomatic and 97.6% were cured at a median follow-up of 8 months. An anal resting pressure lower than 30 mmHg was found in 10 patients (3.8%), only one of whom was incontinent.

CONCLUSIONS

Calibrated sphincterotomy may represent an effective and safe procedure for the treatment of chronic anal fissure.

Nefopam or clonidine in the pharmacologic prevention of shivering in patients undergoing conscious sedation for interventional neuroradiology

The aim of this randomised, double-blind study was to investigate the usefulness of intravenous nefopam, clonidine or placebo in preventing shivering in patients undergoing conscious sedation for interventional neuroradiological procedures. A total of 101 patients were prospectively enrolled and assigned to one of three groups to receive nefopam, clonidine or placebo. The overall incidence of intra-operative shivering was significantly lower in patients treated with nefopam than in those treated with clonidine or placebo (2/32 (6%) vs. 11/38 (29%), p < 0.02; 2/32 (6%) vs. 24/31 (77%), p < 0.0001, respectively). The number of patients who required ephedrine infusions to maintain a mean arterial pressure of 100 mm Hg was higher in the clonidine group than in the nefopam and placebo groups (18/38 (47%) vs. 5/32 (17%), p < 0.05; 18/38 (47%) vs. 6/31 (19%), p < 0.05, respectively). We found that both nefopam and clonidine significantly lowered the rate and severity of shivering during interventional neuroradiological procedures. Fewer patients in the nefopam group than in the other two groups required vasoactive drugs.

Intramyocitic lipid accumulation and SREBP-1c expression are related to insulin resistance and cardiovascular risk in morbid obesity

The aim of this study was to investigate the sterol regulatory element-binding protein 1c (SREBP1c) mRNA muscle expression in morbid obese subjects before and after massive lipid malabsorption due to bariatric surgery (bilio-pancreatic diversion, BPD). We studied 11 obese subjects (BMI 49+/-2 kg/m2) before and 24 months after BPD. Skeletal muscle SREBP1c mRNA expression was determined using RT-competitive PCR. Intramyocytic triglycerides were quantified by HPLC. Insulin sensitivity (M/I) was assessed by euglycemic-hyperinsulinemic clamp. Energy expenditure and respiratory quotient (RQ) were measured over 24 h in a calorimetric chamber. Total cardiovascular risk dropped from 2 before to -2.5 after BPD (P<0.0001). The M/I value was normalized after surgery (0.036+/-0.0148 to 0.095+/-0.0147 micromol kgFFM(-1) min(-1) pmoles(-1) P<0.001). SREBP-1c mRNA levels were decreased (from 4.12+/-2.43 to 2.69+/-1.83% of cyclophilin mRNA, P=0.02) after BPD. In a multiple regression analysis, M/I values (P<0.0001) as well as the intramyocytic triglyceride levels (P=0.039) were the most powerful independent variables for predicting cardiovascular risk. Our results show that the reduction of cardiovascular risk after bariatric massive weight loss is strongly related to the reversion of insulin resistance and to the lowering of intramyocytic triglyceride depots. These two parameters are associated with a significant reduction in SREBP-1c mRNA expression in skeletal muscle, suggesting that this transcription factor might be involved in the accumulation of triglycerides in muscle cells of morbidly obese subjects.

Skeletal muscle triglycerides lowering is associated with net improvement of insulin sensitivity, TNF-alpha reduction and GLUT4 expression enhancement

AIMS/HYPOTHESIS

The aim of the present study was to investigate the relationship between intramyocytic triglycerides levels, muscle TNF-alpha and GLUT4 expression and insulin resistance.

METHODS

Insulin sensitivity was studied in 14 severely obese women (BMI>40 kg/m(2)), before and 6 months after low-dietary intake or bariatric malabsorptive surgery (bilio-pancreatic diversion, BPD), by the euglycaemic hyperinsulinaemic clamp technique, while the amount of intramyocytic triglycerides was chemically measured in needle muscle biopsies. Using reverse transcriptase-polymerase chain reaction analysis, the muscle mRNA expression of TNF-alpha and GLUT4 was also investigated.

RESULTS

The weight loss after surgery was 25.98+/-5.81 kg (P<0.001), while that obtained with the diet was 5.07+/-5.99 kg (P=NS). Marked decrease in TNF-alpha mRNA levels (76.67+/-12.59 to 14.01+/-5.21 AU, P<0.001) were observed in comparison with pre-treatment, whereas GLUT4 was significantly increased (62.25+/-11.77-124.25+/-21.01 AU, P<0.001) only in BPD patients. Increased glucose uptake (M) was accompanied by a significant decrease of TNF-alpha mRNA (76.67+/-12.59-14.01+/-5.21 AU, P<0.01) and an increase of GLUT4. The amounts of TNF-alpha mRNAs in skeletal muscle correlated inversely with GLUT4 mRNAs and directly with intramyocytic triglycerides levels. In a step-down regression analysis (r(2)=0.95) TNFalpha mRNA (P=0.0014), muscular TG levels (P=0.018), and GLUT4 mRNA (P=0.028) resulted to be the most powerful independent variables for predicting M values.

CONCLUSION/INTERPRETATION

These findings suggest that insulin resistance in morbidly obese patients is positively associated to the intramyocytic triglycerides content and to TNF-alpha gene expression and inversely correlated to GLUT4 expression.

Cor triatriatum sinistrum and persistent left superior vena cava: an original association

Cor triatriatum sinistrum is a rare congenital heart disease usually diagnosed in symptomatic children. Symptoms depend on the degree of obstruction to pulmonary venous return with pulmonary hypertension and other associated abnormalities. Persistent left superior vena cava is quite a common congenital heart disease (about 0.5% in healthy populations). It should be suspected every time a dilated coronary sinus is detected at the echo examination. Transthoracic and transoesophageal examinations visualize the site and the size of the fibrous membrane as well as the degree of obstruction, and allow the evaluation of pulmonary pressures that are very important clues for prognosis and therapy. This case report describes the clinical signs and the diagnostic ultrasound findings evaluated in comparison with magnetic resonance imaging, a well-defined gold standard in heart disease of this uncommon congenital association.

Laser induced decohesion of coatings: probing by laser ultrasonics

The aim of the present study is to investigate a conventional laser-ultrasonics technique for the determination of intrinsic properties of oxide coatings and their adhesion strength on a metallic substrate. The good agreement between experiments and computations in an epicenter configuration allows determining the longitudinal wave velocity as well as the Young's modulus of the oxide coatings versus the porosity. For a critical value of the laser energy, a breakdown at the coating-substrate interface is generated by the laser irradiation. The critical tensile stress field developed at the coating/substrate interface, which leads to the interfacial fracture, can be easily calculated. The value of the practical adhesion which is defined is found to be in accordance with those obtained by classic contact techniques (tensile adhesion test, indentation, bending test). Finally, this work demonstrates that this quantitative, contactless test fits well to simultaneously characterise the oxide coatings and evaluate the coating-substrate adhesion.

[Fournier's gangrene in a patient with Hodgkin's disease: a clinical case]

The authors report a case of Fournier's gangrene in a 54-year-old patient subjected 6 days earlier to chemotherapy for mediastinal Hodgkin's disease. The patient had fever and reported the onset of worsening pain and heat sensations in the inguinal, perineal and scrotal areas. Objectively, there was local oedema followed by the onset of crepitation. The patient had a very low white blood cell count (900/cu.mm). The Patient underwent emergency surgery with multiple, communicating incisions in the inguinal, perineal and scrotal areas, with the removal of necrotic tissue and daily washing with physiological solution and 12% H2O2. He also received antibiotic treatment with metronidazole and gentamicin and 5 cycles of high-pressure oxygen therapy, with disappearance of pain and fever and good local tissue repair.

Effects of shivering prevention on haemodynamic and metabolic demands in hypothermic postoperative neurosurgical patients

We evaluated the haemodynamic and metabolic effects of prevention of shivering after prophylactic nefopam administration in neurosurgical patients undergoing craniotomy and mild systemic hypothermia (33-35 degrees C). Forty patients were enrolled in a randomised, double-blind study. Before extubation, patients received intravenously either nefopam 0.12 mg.kg-1 or an equal volume of saline 0.9%. Left ventricular systolic work index, oxygen consumption index and systemic lactate concentration were recorded before, immediately after and every 20 min for 2 h after extubation. Shivering appeared in two patients treated with nefopam and in all control patients (p < 0.001). Both left ventricular systolic work index and oxygen consumption index were similar in the two groups before extubation, increased after extubation, and further increased in control patients showing a statistical difference compared to patients treated with nefopam. Our results suggest that nefopam is effective in preventing postoperative shivering in patients undergoing neurosurgery and mild hypothermia and attenuates the haemodynamic effects of shivering during rewarming.