Epidural naloxone reduces intestinal hypomotility but not analgesia of epidural morphine

PURPOSE

Epidural morphine is associated with decreased bowel motility and increased transit time. Low doses of intravenous naloxone reduce morphine-induced pruritus without reversing analgesia, but the effect of epidural naloxone on bowel motility has not been studied. Therefore we evaluated bowel motility and analgesia when naloxone was co-administered with morphine into the epidural space.

METHODS

Forty-three patients having combined thoracic epidural and general anesthesia for subtotal gastrectomy were randomly assigned to one of two study groups. All received a bolus dose of 3 mg epidural morphine at the beginning of surgery, followed by a continuous epidural infusion containing 3 mg morphine in 100 ml bupivacaine 0.125% with either no naloxone (control group, n = 18) or a calculated dose of 0.208 microg x kg(-1) x hr(-1) of naloxone (experimental group, n = 25) for 48 hr. We measured the time to the first postoperative passage of flatus and feces to evaluate the restoration of bowel function, and visual analog scales (VAS) for pain during rest and movement. Scores were assessed at 2, 4, 8, 16, 24, 36 and 48 hr postoperatively.

RESULTS

The experimental group had a shorter time to the first postoperative passage of flatus (5 1.9 +/- 1 6.6 hr vs 87.0 +/- 19.5 hr, P < 0.001 ) and feces (95.3 +/- 25.0 hr vs 132.9 +/- 29.4 hr, P < 0.001). No differences were found in either resting or active VAS between the two groups.

CONCLUSION

Epidural naloxone reduces epidural morphine-induced intestinal hypomotility without reversing its analgesic effects.

The optimal management of pediatric steam burn from electric rice-cooker: STSG or FTSG?

The steam burn caused by an electric rice-cooker is a unique mode of burn injury in Asian countries, especially Korea and Japan. This type of burn injury is characterized by 1) occurring most frequently on the volar aspect of the hand in toddlers younger than 2 years of age (92.8%); 2) the depth of burns are normally deep second-degree to third-degree (98%) and usually need surgery at the time of injury; 3) flexion contractures of multiple finger joints and web space contracture are common sequelae. We hypothesized that primary full-thickness skin graft (FTSG) would give more reliable results and eliminate the late reconstructive procedures. Between January 1997 and September 1999, 36 patients underwent primary FTSG, and the results of this primary FTSG group were compared with 124 patients who were treated with split-thickness skin graft (STSG; 79/124; 63.7%) or by conservative management (45/124; 36.3%), and readmitted for the correction of hand deformities between September 1995 and September 1999. In the primary FTSG group, 11.1% (4/36) of mild web contractures and 5.5% (2/36) of finger joint contractures were documented, and these did not require the reconstructive procedure during a follow-up period of 8.8 +/- 4.8 months. In 124 patients of the primary STSG or conservative group, the mean time interval to reoperation was 8.9 +/- 4.0 months and all patients received FTSG for correction of late hand deformities. In a retrospective study of the primary STSG group, 42 of 53 patients (79.2%) received reconstructive procedure during a 5-year follow-up period. In this report, we introduce the nature of steam burn caused by electric rice-cooker and propose that primary FTSG may be a reliable method for the treatment of this more severe type of acute burn in pediatric patients.

Effect of BL-21 (Wei-Yu) acupoint stimulation on gastric motility following preanesthetic treatment in dogs

In acupuncture practice of animals, preanesthetics sometimes are needed. The purpose of this study was to select the ideal chemical restraint at acupuncture for gastric motility. Nine healthy mixed breed dogs weighed 10-21 kg and aged 1-3 years old were used in this study. Two EMG surface electrodes were placed between the seromuscular and the mucosal layer of pylorus. Twenty minutes after feeding normal gastric motility was recorded for 60 minutes using physiograph (Narco-Biosystem). Then preanesthetic treated-gastric motility was observed for 30 minutes. Preanesthetics used were xylazine, diazepam, and acepromazine. Acupuncture needles were inserted to BL-21 (Wei-Yu) acupoint, and then changes of gastric motility were recorded for 60 minutes. The gastric motility following xylazine administration (1 mg/kg, IV) was markedly decreased. BL-21 (Wei-Yu) acupoints stimulation did not alter xylazine-induced depression of gastric motility. The diazepam (1 mg/kg IV) treated-gastric motility was increased mildly 20 minutes after drug administration. BL-21 (Wei-Yu) acupoint stimulation after diazepam administration enhanced gastric motility significantly. The gastric motility following acepromazine (0.3 mg/kg, IM) administration was not changed compared with normal gastric motility. Application of traditional acupuncture at BL-21 (Wei-Yu) significantly increased the gastric motility. Based on these results, acepromazine and diazepam could be acceptable chemical restraints for acupuncture therapy of gastric motility, but xylazine couldn't be.

Palliatively treated cerebral arteriovenous malformations: follow-up results

The purpose of this study was to evaluate the benefits of palliative embolisation of patients with inoperable intracranial AVMs. It involved the analysis of the long-term clinical follow-up results of 27 patients with inoperable intracranial AVMs. Sixteen patients were treated medically and 11 patients received partial embolisation. The mean size of the lesions was 7.2 +/- 2.6 cm, and the mean follow-up period was 99 +/- 44 months (range 52-192 months). There were no significant statistical differences in the sex, age, size, venous drainage pattern, location of the lesions or presented symptoms. The analysis of the long-term clinical follow-up results showed no significant difference in either the risk of haemorrhage or clinical status of the patients in the two treatment groups. Of the 16 patients in the medical treatment group, 8 (50%) showed a clinical improvement, 3 no improvement and 5 (31%) deterioration. Of the 11 patients in the embolisation group, 5 (45.5%) showed clinical improvement, 3 no improvement and 3 (27.3%) deterioration (P = 0.871). Twenty-five percent (4 cases) of patients in the medical group and 45.5% (5 cases) of patients in the embolisation group suffered from haemorrhage during the follow-up period (P = 0.270). Complications related to embolisation occurred in three cases. This comparative study shows that palliative partial embolisation of intracranial AVMs, in all probability does not produce better clinical results than medical treatment.

General pharmacology studies on beta-domain deleted recombinant factor VIII

beta-Domain deleted recombinant factor VIII (GC-rAHF), newly developed by Korea Green Cross Co., is a novel therapeutic for hemophiliacs and is currently under clinical evaluation. The general pharmacological properties of this drug were evaluated using mice, rats, guinea pigs and rabbits. Intravenous doses of 5 to 500 IU/kg were assayed in several tests to analyze their effects in vivo on various systems. The effect of the substance under study was also tested in vitro on isolated guinea pig ileum preparations at final concentrations of 5 to 50 IU/kg. The result of this study showed that GC-rAHF did not affect general behavior in the Irwin test. Similarly the drug was not found to affect neither normal body temperature nor the spontaneous activity in mice. In addition, it was not found to induce pharmacologically significant alterations of the cardiovascular and respiratory parameters in rats. No effects were observed either in the pentobarbital sodium-induced sleep-induction time and duration, in writhing test or in the test of pentetrazole-induced convulsion. Finally, the tested drug did not modify the gastrointestinal motility, acetylcholine or histamine-induced contraction of the isolated guinea pig ileum, nor gastric secretion. The results demonstrated that GC-rAHF has no effects on the central nervous, cardiovascular, respiratory and digestive systems in the doses of 5, 50 and 500 IU/kg in vivo and 5, 10, 50 and 100 IU/kg in vitro.

Fluoroscopy-aided thoracoscopic resection of pulmonary nodule localized with contrast media

BACKGROUND

The pulmonary nodules have become the major indication of video-assisted thoracic surgery (VATS). Recently, several preoperative or intraoperative techniques for identifying small or deeply seated pulmonary nodules have facilitated thoracoscopic resection. We describe the new technique for detecting difficult lesions.

METHODS

Preoperatively, we marked the visceral pleura near the pulmonary nodules with dye, simultaneously injected contrast media (1 water-soluble Optiray [Mallinckrodt Medical Inc, Quebec, Canada], 18 barium sulfate, 11 Lipiodol [Laboratoire Guerbet, Aulnay-sous-Bois, France]) into or around the nodule under computed tomography (CT) guidance. During VATS, we were able to easily and accurately detect and resect all the nodules localized with contrast media, of which the radiopacity was visualized on the portable fluoroscopic monitor.

RESULTS

Between February 1996 and December 1998, we thoracoscopically resected 30 nodules in 28 patients (13 were women; age, 53 +/- 14 years). The resected nodules were 17 +/- 7.6 mm (range; 4 to 32 mm) in size, and 8.9 +/- 8 mm (range, 2 to 34 mm) in depth. The pathologic diagnosis of the nodules was benign in 20 and malignant in 10 (six primary cancers of lung and four metastatic cancers). There were only minor complications related CT localization.

CONCLUSIONS

This new technique can help the surgeons detect and resect the difficult lesions with safety and rapidity by VATS without thoracotomy.

Clinical characteristics of vertebrobasilar artery dissection

Sixteen patients with the diagnosis of vertebral or basilar artery dissection who were admitted at the Seoul National University Hospital from 1972 to 1996 are described. During the same period, we encountered 76 patients with posterior circulation aneurysms, so the vertebrobasilar artery dissection was 21% of posterior circulation aneurysms. The mean age was 44 years, and male predominated. Nine patients presented with subarachnoid hemorrhage (SAH) and seven with ischemic symptoms. The characteristic angiographic finding of patients with SAH was aneurysmal dilatation (pseudoaneurysm) in eight of nine cases. In cases of ischemic symptoms, only one case had aneurysmal dilatation. Some other angiographic findings were demonstrated such as string sign, tapered narrowing, complete occlusion, or double lumen. Clinical course of SAH group was much different from that of ischemic group. Rebleeding occurred in three patients of SAH group; immediately after the rebleeding all patients became comatose, but after extraventricular drainage, all patients with rebleeding recovered rapidly. In SAH group, four of nine cases died but there was no mortality in the ischemic group. These four patients showed signs of stem failure, when computed tomography (CT) demonstrated no evidence of additional bleeding and follow-up CT showed the infarction at a part of stem and/or cerebellum. Vasospasm or sudden extensive extension of dissection could be the cause of death. Surgical management was performed in three patients, endovascular intervention in four, and conservative management in two. The patients with incomplete embolization or conservative management had poor outcome. In ischemic group, all underwent conservative management including anticoagulation and/or antiplatelet therapy. On follow-up, most of the patients with ischemic symptoms made complete or very good recoveries.

Object matching algorithms using robust Hausdorff distance measures

A Hausdorff distance (HD) is one of commonly used measures for object matching. This work analyzes the conventional HD measures and proposes two robust HD measures based on m-estimation and least trimmed square (LTS) which are more efficient than the conventional HD measures. By computer simulation, the matching performance of the conventional and proposed HD measures is compared with synthetic and real images.

Primary intramedullary spinal cord primitive neuroectodermal tumor with intracranial seeding in an infant

Primary spinal cord primitive neuroectodermal tumor (PNET) is a rare entity. In all 13 cases have been reported in the literature, including 3 with intracranial seeding. A 3-month-old girl with involvement of the spinal cord below the mid-thoracic level is described. The brain MRI revealed findings indicative of seeding along the intracranial subarachnoid space. Biopsy, duraplasty and removal of laminotomy flap were done. In spite of a good response to the first cycle of postoperative "8-drugs-in-a-day' chemotherapy, further treatment was refused. She died 21 days after the onset of leg weakness, which reveals the rapid progression of untreated cases. To our knowledge, this is the first case of spinal cord PNET with parenchymal involvement that has been described in an infant.

[The effect of surfactant therapy associated with high frequency jet ventilation on oxygenation in canine lavaged lungs]

The effects of exogenous surfactant (SF) replacement therapy associated with high frequency jet ventilation (HFJV) on blood gas changes, pulmonary and hemodynamic variables were studied in canine lavaged lungs. The lungs were lavaged repeatedly with physiological saline until PaO2 decreased to 100 mmHg under intravenous pentobarbital anesthesia with 100% oxygen. SF (50 mg.kg-1) in the experimental group (n = 12) and saline in the control group (n = 8) were administered to the trachea using HFJV with a duration of 10 min. HFJV was further continued for 1 hour to make surfactant distribute evenly. Then respiration was controlled by the conventional mechanical ventilator for 3 hrs. During the administration of SF (10 min). PaCO2 was not altered. In the surfactant group, PaO2 improved significantly (200 mmHg) at the end of HFJV and was maintained for the next 3 hrs at this level, but it did not improve in the saline group. Therefore, we suggest that HFJV can be used safely for the treatment of acute respiratory failure and is an effective method for the administration of the pulmonary surfactant into the alveoli.