A multifactorial analysis to explain inadequate surgical analgesia after extradural block

A multivariate analysis of inadequate extradural analgesia was carried out prospectively on 1051 patients undergoing lumbar extradural anaesthesia for surgery performed on structures innervated by T10-S5. Ninety-six patients (9%) experienced pain during surgery. Age, extradural fentanyl, diazepam sedation and duration of surgery had no significant influence. We found some weak evidence that the type of surgery affects the risk of feeling pain. The probability of pain increased with increasing weight, except in overweight women, and was significantly greater for both shorter and taller patients, relative to patients of average height. The probability of pain decreased with increasing dose of local anaesthetic, increasing spread of extradural analgesia, addition of adrenaline, and fentanyl or thiopentone sedation. In conclusion, patient-, surgery- and anaesthesia-related factors influence the risk of inadequate extradural analgesia. If such factors are taken into account, an increase in the success rate may be anticipated.

Failure rate of epidural anaesthesia for foot and ankle surgery. A comparison with other surgical procedures

To test whether epidural anaesthesia for foot and ankle surgery is associated with an unacceptably high incidence of inadequate surgical analgesia, we prospectively compared two groups of patients, one undergoing foot or ankle surgery (160 patients) and the other surgical procedures not performed in areas innervated by L5-S1 ( (168 patients). Lumbar epidural anaesthesia was performed in both groups by administering carbonated lignocaine 2% with adrenaline 1:200000. Seven patients in the foot-ankle group (4.4%) and 10 in the group for comparison (5.9%) exhibited inadequate surgical analgesia. This difference is not statistically significant. Within the foot-ankle group, a significantly lower dose of local anaesthetic per spinal segment had been given to patients who displayed inadequate analgesia, compared with those who exhibited satisfactory analgesia (P < 0.05).

An expansible splint for treatment of nostril stenosis

Stenosis of the nostrils is an uncommon deformity frequently caused by a circumferential scar retraction after trauma, infection, or iatrogenic procedures. To avoid recurrence of postoperative stenosis, it is necessary to maintain the corrected contour of the nostril during the period of wound contraction. For this purpose, we describe a new acrylic nostril conformer that is expansible. The splint fits the patient's nostril exactly and by its expansion can even achieve an overcorrection, improving a poor surgical result.

Screening for hepatocellular carcinoma in patients with Child's A cirrhosis: an 8-year prospective study by ultrasound and alphafetoprotein

One hundred and forty-seven patients with Child's A cirrhosis and no evidence of hepatocellular carcinoma were followed up in an 8-year prospective surveillance program with testing by ultrasound and alphafetoprotein every 6 months. Eighteen of 147 patients were HBsAg positive. Anti-hepatitis C virus antibodies were found in 103 out of 133 cases tested. Sixteen patients had a history of heavy drinking. Thirty hepatocellular carcinomas were detected during follow up. At the time of diagnosis, ultrasound detected focal lesions in all the patients whereas alphafetoprotein was below diagnostic levels. The hepatocellular carcinoma was single in 26 patients and multiple in four. The overall 8-year cumulative tumor-free rate was 69% (95% confidence interval = 58-73). The yearly hepatocellular carcinoma incidence from 1985 to 1992 was respectively 2%, 1.5%, 2%, 3%, 5%, 4.8%, 7% and 10%. The initial value of AFP > 50 ng/ml and < 400 ng/ml was significantly related to the development of hepatocellular carcinoma. This series shows that the cumulative incidence of hepatocellular carcinoma in cirrhosis in Italy is higher than previously reported, but lower than that observed in Asiatic areas. A 6-month interval for ultrasound is reasonable to detect treatable tumors. Alphafetoprotein has no value for early diagnosis, although its intermediate values (> 50 and < 400 ng/ml) may indicate the presence of undetectable cancer which will appear during the follow up, and suggests that ultrasound should be employed more frequently in patients with these values.

A multifactorial analysis of the spread of epidural analgesia

The controversies about the factors determining the spread of epidural analgesia are partly due to inappropriate methodology or sample size of previous studies. We performed a multivariate regression analysis on 803 ASA class 1-2 non-atherosclerotic adults, undergoing lumbar epidural anaesthesia according to a predefined standardised procedure. The spread of epidural analgesia is more accurately studied by analysing dose/segment (R2 = 0.671) instead of spread (R2 = 0.271) as dependent variable. The impact of local anaesthetic (2% lidocaine CO2 or 0.5% bupivacaine) and addition of adrenaline is not significant. Spread significantly increases with increasing age, weight, body-mass index, dose of local anaesthetic, addition of fentanyl, higher site of injection, and decreasing body height. The impact of age and dose is higher under the age of 40 and at doses lower than 20 ml. Increasing the total dose increases the dose needed to block one spinal segment. Unknown idiosyncratic factors still determine a certain proportion of the sample variance. The addition of adrenaline to lidocaine and the use of bupivacaine improve the predictability of spread. In conclusion, we found clinically significant correlations between a group of factors and epidural spread. Alternative anaesthetic solutions lead to different degrees of predictability.

[Comparison of carbonated lidocaine and mepivacaine in epidural anesthesia]

OBJECTIVE

To compare carbonated mepivacaine to carbonated lidocaine in epidural anaesthesia.

DESIGN

Nonrandomised control trial.

SETTING

University Hospital.

PATIENTS

Forty patients undergoing epidural anaesthesia for orthopaedic surgery.

METHODS

Epidural anaesthesia at the fourth lumbar interspace, administering either carbonated mepivacaine 20 ml (group M, 20 patients) or carbonated lidocaine 20 ml (group L, 20 patients). Parameters recorded: onset of sensory block (time required to reach L1 and time required to reach the upper level), cranial spread of analgesia (number of dermatomes), duration of block (time between achievement of maximum spread of analgesia and regression of sensory block by two dermatomes) and motor block (Bromage score).

RESULTS

No statistically significant differences have been found between group M and group L in the time required to reach L1 (means and standard deviations 6.3 +/- 3.8 and 6.5 +/- 2.1 minutes, respectively), in the time required to reach the upper level of analgesia (means and standard deviations 14.3 +/- 4.2 and 16.5 +/- 3.5 minutes, respectively), in the cranial spread of analgesia (means and standard deviations 7.1 +/- 3.4 and 7.6 +/- 2.7 dermatomes, respectively) and in the degree of motor block (means and standard deviations 1.5 +/- 0.8 and 1.1 +/- 0.8, respectively). Group M exhibited a much higher duration of sensory block, compared to group L (means and standard deviations 91.6 +/- 20.2 and 58.8 +/- 23.4 minutes, respectively, p < 0.001).

CONCLUSIONS

Carbonated mepivacaine is more indicated than carbonated lidocaine in epidural anaesthesia when a high duration of sensory block is desired.

Smoking habits and recurrence in Crohn's disease

BACKGROUND/AIMS

Smoking may be a risk factor for surgical recurrence of Crohn's disease. However, other variables associated with recurrence could be confounding factors for smoking. The aim of this study was to evaluate the role of smoking as an independent predictor of clinical, surgical, and endoscopic recurrence.

METHODS

In a series of 182 patients who underwent surgery for Crohn's disease, a multivariate analysis was performed that included all of the significant variables associated with recurrence: sex, age at diagnosis, time between onset of symptoms and surgery, site of disease, indication for surgery, extent of disease, extraintestinal manifestation, and smoking habit.

RESULTS

Independent predictors of clinical recurrence by the Cox proportional hazard model were smoking (hazard ratio, 1.46; 95% confidence interval [CI], 1.1-1.8), extraintestinal manifestations (hazard ratio, 1.61; 95% CI, 1.0-2.5), and extent of disease (hazard ratio, 1.57; 95% CI, 1.0-2.4). Smoking was the only significant predictor of surgical recurrence (hazard ratio, 2.0; 95% CI, 1.2-2.3). For endoscopic recurrence, logistic regression showed that smoking (odds ratio, 2.2; 95% CI, 1.2-3.8) and extent of disease (odds ratio, 2.6; 95% CI, 1.0-6.7) were predictive factors of recurrence.

CONCLUSIONS

Smoking is an independent risk factor for clinical, surgical, and endoscopic recurrence in Crohn's disease.

Phase III trial of initial chemotherapy in stage III or IV head and neck cancers: a study by the Gruppo di Studio sui Tumori della Testa e del Collo

BACKGROUND

The standard treatment for advanced (stage III and IV) head and neck squamous cell carcinoma (i.e., surgery with postoperative radiotherapy in operable patients and radiotherapy alone in inoperable patients) has had poor results. A series of randomized trials of induction chemotherapy have up to now failed to demonstrate an improvement in survival.

PURPOSE

This trial was designed to determine whether intensive induction chemotherapy administered before loco-regional treatment would improve survival of patients with advanced disease.

METHODS

Patients had previously untreated, advanced nonmetastatic (stages III and IV) squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and paranasal sinuses. The study design was a randomized, multi-institutional, phase III trial. Eligible patients (n = 237) were randomly assigned to receive either initial chemotherapy (cisplatin and infusional fluorouracil) followed by loco-regional treatment (group A, n = 118) or loco-regional treatment alone (group B, n = 119). For operable patients (group A, n = 34; group B, n = 32), loco-regional treatment included resection followed by adjuvant radiotherapy. For inoperable patients, radical irradiation was performed with a planned dose of 65-70 Gy to involved areas. A dose of 45-50 Gy was also planned to the uninvolved neck or postoperatively. The statistical (log-rank) test was performed no earlier than 2 years after the randomization of the last patient.

RESULTS

Seventy-one patients (60%) in group A and 67 patients (56%) in group B were considered free of disease after they completed the treatment sequence. The analysis of time to distant metastases showed an advantage for group A patients. (Respective 2- and 3-year values for inoperable patients were 15% and 24% for group A versus 36% and 42% for group B, P = .04; only one operable group A patient had distant metastases after 49 months versus 26% [2 years] and 31% [3 years] for operable group B patients, P = .01.) For inoperable patients, the combined treatment was significantly associated with an increase in complete remission rate (group A, 44%) as compared with radiotherapy alone (group B, 30%) (P = .037). Inoperable patients also benefitted from induction chemotherapy in terms of disease-free survival (49% and 34% for group A versus 28% and 26% for group B; P = .06) and of overall survival (30% and 24% for group A versus 19% and 10% for group B; P = .04).

CONCLUSIONS

When all 237 randomly assigned patients were analyzed, there were no significant differences in the two treatment strategies in loco-regional failure or in disease-free or overall survival, although the development of distant metastases was reduced. For operable patients, the only benefit from neoadjuvant chemotherapy was a significant reduction in the incidence of distant metastases. For inoperable patients, neoadjuvant chemotherapy improved local control, decreased the incidence of distant metastases, and improved the complete remission rate and overall survival.

IMPLICATIONS

Confirmatory studies with effective chemotherapy regimens delivered for an adequate number of cycles are required.

[Pilomatrixoma of the parotid region]

Pilomatrixoma, or calcifying epithelioma of Malherbe, is an uncommon, benign, epithelial tumor of the skin that often arises in head and neck regions, in the first 2 decades of life. The report of two cases of pilomatrixoma in the parotid area permits to clarify the clinical features and the problems in the differential diagnosis of these tumors.

Biliary sludge and gallstones in pregnancy: incidence, risk factors, and natural history

OBJECTIVE

To evaluate the incidence and symptoms of and risk factors for biliary sludge and gallstones during pregnancy and to assess the natural history of these conditions in the first year after delivery.

DESIGN

Cohort study.

PATIENTS

A total of 272 pregnant women recruited in the first trimester.

MEASUREMENTS

Biliary sludge and gallstones were diagnosed using ultrasonography, both during pregnancy and after delivery. Predictors of the presence or disappearance of sludge and stones were examined.

MAIN RESULTS

Overall, from the first trimester of pregnancy until the immediate postpartum period, 67 women were newly diagnosed with biliary sludge, and 6 women were newly diagnosed with gallstones. The respective incidence rates were 31% (95% Cl, 25% to 37%) and 2% (95% Cl, 0.2% to 4%). During pregnancy, 28% of women experienced biliary pain, which was associated only with presence of stones. After delivery, 92 women had sludge and 23 had stones. Sludge disappeared in 61% of these women (Cl, 50% to 73%) after a mean follow-up of 5 months, and stones disappeared in 28% of women (Cl, 10% to 46%) after 9.7 months of follow-up.

CONCLUSIONS

Biliary sludge occurred frequently during pregnancy but was generally asymptomatic and often disappeared spontaneously after delivery. Gallstones were much less frequent and were more likely to be associated with biliary pain.

[Scleronodular retrosternal Hodgkin's disease with cervical protrusion]

The case of a retrosternal localization of Hodgkin disease is a very infrequent one, and its presentation as an inflammatory tumor is exceptional indeed. This case report of a young woman affected by a cervical tumour projecting in front of the sternal bone, both with fever and tenderness, gave a mistaken address toward a diagnosis of suppurative thyroiditis. But the rare evenience of this thyroidal affection made the diagnosis very improbable and the patient was treated by partial exeresis of the cervical mass and drainage of its apparently suppurative content. At the pathologic study the mass revealed its true nature, also if very unusual: the appearance of the specimen, studied also with immuno-chemical methods, revealed its true nature of scleronodular Hodgkin disease probably born on a thymic cyst remnant. Also the possibility of a suppurative evolution from a pyriform laryngeal sinus is discussed, but simply on a differential diagnostic basis for the original hypothesis of an inflammatory mass. The correct diagnosis instead offered the patient the possibility of the correct chemo-radio-therapeutic treatment and of final cure.

Serum levels of 2',5 oligoadenylate synthetase during interferon therapy in patients with B-cell chronic lymphocytic leukemia

We assayed 2',5 oligoadenylate synthetase (2'5-AS) activity in the serum of eight patients with B-cell chronic lymphocytic leukemia (B-CLL) who were undergoing therapy with alpha interferon (IFN). Mean pretreatment levels of 2'5-AS were normal, but upon treatment the levels rose to higher than normal values. Moreover, the degree of enzyme induction in serum was significantly higher in CLL responders (P < 0.003) whereas no difference was found in non-responders. The lack of serum 2'5-AS induction in non-responder patients might be related to unresponsiveness to treatment with IFN. These results seem to show that the measurement of serum levels of 2'5-AS activity may be a useful tool in monitoring IFN treatment.

Intracellular and serum levels of aldolase activity in B chronic lymphocytic leukemia

Intracellular and serum activities of aldolase (ALS) were biochemically determined in lymphocyte subpopulations from normal subjects and patients with B-chronic lymphocytic leukemia (B-CLL). Aldolase activity was significantly lower in T cells of CLL than in normal T cells (2.9 +/- 1.5 vs. 4.7 +/- 2.1 Sigma Units (SU)/6 x 10(6) cells, p < 0.05). The aldolase activity also was significantly (p < 0.001) lower (3.1 +/- 1.9 SU/6 x 10(6) cells) in CLL B lymphocytes than in normal B lymphocytes (18.1 +/- 6.5 SU/6 x 10(6) cells). Moreover, the serum levels of ALS in all patients with B-CLL were higher than that in normal subjects (8.1 +/- 5.8 vs. 2.2 +/- 0.8 SU/ml, p < 0.02). Our findings demonstrate that T lymphocytes from patients with B-CLL display enzyme activity different from that of normal T cells. This may reflect the abnormal maturity of the residual T cell population in B-CLL.

The flagellar beat of rat sperm is organized by the interaction of two functionally distinct populations of dynein bridges with a stable central axonemal partition

Two distinct patterns of microtubular sliding were observed in rat sperm flagellar axonemes. The particular pattern of sliding was determined by the extraction conditions used to prepare the sperm for axoneme disintegration. Sperm prepared by incubating concentrated suspensions of Triton X-100-extracted sperm at pH 9.0 disintegrated by extruding the doublets and outer dense fibers numbered 4 through 7 in response to Mg-ATP. Sperm prepared by incubating motile Triton X-100-extracted models at 37 degrees C for 1 to 3 hours extruded doublets and outer dense fibers 9, 1 and 2. Axonemes disintegrated by both regimens tended to have doublets 3 and 8 (with their corresponding outer dense fibers), as well as the central pair, in place. In numerous instances, the 3-central-8 complex with outer dense fibers 3 and 8 could be found isolated in midpiece sections prepared from both methods. The 3-central-8 partition was also sometimes seen in isolation in cross-sections of the principal piece where it remained attached to the fibrous sheath. The flagellar remnant produced by extrusion of fibers 4 through 7 under high pH conditions was generally straight or randomly curved. In contrast, the flagellar remnant produced by extrusion of the 9–1-2 bundle of fibers was most often curved into a hook in the midpiece region. While the hook-like configuration was not Ca(2+)-dependent, it may be based on a related mechanism. The sliding of the 9–1-2 group of fibers is a consequence of dynein-tubulin sliding between the 2 and 3 doublets. This sliding pattern appears to be preferentially activated in the motile sperm models in EGTA, but seldom if ever produced sliding in the high-pH-extracted models. We conclude that the 3-central pair-8 complex and associated outer dense fibers form an I-beam-like partition that does not participate in sliding, but acts as a structural foundation for organizing a planar beat. In addition, it is clear that preferential activation of certain dynein arms can be evoked, depending on the treatment regimen employed. This shows definitively that the types of microtubule sliding in the two bend directions are not identical.

E rosette formation in B cell chronic lymphocytic leukemia

We describe a patient with B cell chronic lymphocytic leukemia whose B lymphocytes showed the capacity to form rosettes with sheep red blood cells during prolymphocytoid transformation of the disease. In this case, rosette formation was found to be related to the presence of the classic E rosette receptor since the leukemic cells were recognized by the OKT11 monoclonal antibody. This feature was not shown at diagnosis. Evaluation of this phenomenon is discussed.

[Propofol and alfentanil in total intravenous anesthesia]

We studied 22 patients undergoing total intravenous anaesthesia for both abdominal and superficial surgery. Anaesthesia has been induced and maintained with propofol (1 mg/kg in 20 seconds; 10 mg/kg/h for 10 minutes; 8 mg/kg/h for 10 minutes; 6 mg/kg/h until the end of the operation) and alfentanil (15 mg/kg before the induction and boli of 10-30 mg/kg in the presence of insufficient surgical analgesia). All the patients have been intubated after the administration of vecuronium 0.1 mg/kg, and artificially ventilated with air and oxygen (FiO2 0.4). We observed: 1) haemodynamic stability after the intubation and during surgery; 2) easy control of surgical analgesia; 3) early postoperative recovery, with no correlation with the doses of propofol and alfentanil; 4) absence of postoperative respiratory depression; 5) intraoperative amnesia; 6) low incidence of postoperative side effects. We conclude that, by virtue of the pharmacokinetic characteristics of propofol and alfentanil, most limitations of total intravenous anaesthesia have been overcome.

Epidemiology of Crohn's disease in Sicily: a hospital incidence study from 1987 to 1989. "The Sicilian Study Group of Inflammatory Bowel Disease"

An epidemiologic study of Crohn's disease was carried out in the Province of Palermo, Italy, between 1987 and 1989. The incidence of first hospitalization was prospectively evaluated in this period. A total of 103 patients (59 males, 44 females) were diagnosed. The standardized annual incidence was 2.7/100,000. The incidence was quite constant during the 3 years of the study (1987: 2.9/100,000; 1988: 2.4/100,000; 1989: 2.99/100,000). Incidence rates were slightly higher in men than in women. The disease had a bimodal age distribution in female (with peaks at age 20-29 and 60-69) and males (with peaks at age 30-39, 40-49). No cases were observed at age 0-9. The incidence of Crohn's disease in southern Italy is comparable to that reported in northern Europe.

Guillain-Barré polyradiculoneuritis after blood transfusion

We report the case of a 72 year-old woman who developed acute polyradiculoneuritis 7 days after a series of 4 blood transfusion. While blood transfusion is not listed as an antedecent event of Guillain-Barré syndrome (GBS), GBS following surgical procedures is well known. In the present case the close temporal relationship and the absence of all factors which usually precede the onset of the disease including surgery, suggest a possible role of blood transfusion in the onset of the GBS.

Serum levels of CD8 antigen and soluble interleukin 2 receptors in patients with B cell chronic lymphocytic leukemia

We assayed the plasma levels of CD8 antigen (CD8Ag) and soluble interleukin 2 receptor (sIL-2R) in 34 subjects with B cell chronic lymphocytic leukemia (B-CLL) and in 15 controls using an immunoenzymatic method. The results showed higher average levels of soluble CD8 (sCD8) and sIL-2R in the leukemic patients compared to the controls (sCD8 = 860 vs. 306 U/ml; sIL-2R = 4,131 vs. 311 U/ml). The two antigen levels were significantly higher in patients with progressive disease than in those with indolent disease, and they also correlated with Rai's stage. sIL-2R levels correlated with lymphocyte count (p less than 0.001), while there was no correlation between sCD8 levels and total number of lymphocytes. These results seem to show that the measurement of serum levels of CD8Ag and sIL-2R may be a useful tool in the prognostic evaluation of patients with B-CLL.

Prognostic value of serum thymidine kinase and beta 2 microglobulin in subjects affected by multiple myeloma

The authors, using a radio-enzymatic and a radio-immunological method, investigated the serum levels of Thymidine Kinase (TK) and Beta 2 Microglobulin (Beta 2M) in 24 subjects affected by Multiple Myeloma (MM) and in 10 controls. The data obtained confirm the good prognostical significance already reported for TK and Beta 2M in subjects with MM. First of all, the results indicate higher levels of TK compared to the controls (9.31 U/l vs 2.9 U/l - p less than 0.005). Similarly, also the levels of Beta 2M indicate a significant increase compared to the healthy subjects. Both TK and Beta 2M levels increased with the progression of the stage of the disease (6.69 mg/ml vs 1.67 mg/ml - p less than 0.005). After therapy there was a significant decrease of TK and Beta 2M levels in responders. Finally, TK demonstrated to be able to detect during the follow-up a possible relapse of the disease.

[Comparison of a combination of fentanyl and alfentanil with propofol in brief surgery]

We studied 96 patients undergoing short gynecological procedures. Anaesthesia has been induced with fentanyl 1.5 micrograms/kg (45 patients) or alfentanil micrograms /kg (51 patients) and a hypnotic dose of propofol, and maintained with 70% N2O via facial mask. We observed a better and more rapid control of surgical analgesia with alfentanil, and an earlier recovery of postoperative psychophysical functions. Post-induction apnea has been more frequent and prolonged in the alfentanil group, but no difference in the time necessary to recover an adequate ventilation has been observed between the two groups. Alfentanil anaesthesia determined a more marked intraoperative bradycardia. By virtue of the speed of onset and the short duration of action, alfentanil is a suitable anaesthetic agent for short surgical procedures, particularly in day-stay patients.