An unusual case of obstructive uropathy

Although inguinal bladder hernia associated with obstructive uropathy is an extremely rare entity, it should be suspected in elderly patients with bladder outlet obstruction presented with inguinal hernia and lower urinary tract symptoms.

Mystery of the lost gallstone-Part 2

If gallbladder perforation occurs during cholecystectomy, every spilled gallstone should be retrieved to minimize possible late gallstone-related complications.

Aorto-cutaneous fistula from an infected ascending aorta graft resulting in massive hemorrhage after a Valsalva maneuver for a heavy weight lift

In the setting of an infected prosthetic ascending thoracic aorta, prompt and definitive surgical treatment is mandatory to avoid catastrophic bleeding complications.

Mystery of the lost gallstone-Part 1

If gallbladder perforation occurs during laparoscopic cholecystectomy, every spilled gallstone should be retrieved to minimize possible late gallstone-related septic complications.

A case of massive primary tumor growth in the immediate postoperative period

Major surgical trauma along with discontinuation of antiangiogenic treatment can exacerbate primary tumor growth even in the immediate postoperative period.

Unexplained isolated acute severe thrombocytopenia after surgery for a recurrent malignant retroperitoneal tumor presenting with colon perforation: A case study of a disastrous complication

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Thrombocytopenia in cancer patients is correlated with poor prognosis.

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Drugs, sepsis, HIT, DIC, ITP are the most common causes of postoperative thrombocytopenia.

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Prompt diagnosis is essential as management varies considerably depending on etiology.

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Secondary ITP has not previously been associated with a retroperitoneal tumor.

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Kasabach-Merritt syndrome has not previously been associated with a retroperitoneal tumor.

Introduction

Tumor- or treatment- induced thrombocytopenia in solid cancer patients is common. In the postoperative setting, diagnosis of thrombocytopenia become more complex as infection, sepsis, drugs and transfusion come also into the equation.

Presentation of case

Herein, the case an otherwise-healthy 71-year-old male patient with a sizable recurrent malignant retroperitoneal tumor under pazopanib admitted with colon perforation and submitted to emergency left colectomy with end transverse colostomy is presented. Immediate postoperative period characterized by massive primary tumor growth and isolated acute severe thrombocytopenia. The patient treated with combined prednisone, IVIg and platelets transfusion along with medication discontinuation with no response.

Discussion

Sepsis-, drug- and heparin-induced thrombocytopenia, disseminated intravascular coagulopathy and secondary (sepsis-, drug-, transfusion- or tumor-induced) immune thrombocytopenia (ITP) were included in the differential diagnosis. Based on exclusion, secondary drug- or tumor-induced ITP was the most prominent diagnosis. Concomitant presentation of thrombocytopenia along with massive primary tumor growth made Kasabach-Merritt syndrome also a probable diagnosis. However, neither secondary ITP nor Kasabach-Merritt syndrome has previously been associated with a retroperitoneal tumor in the literature.

Conclusion

Although management of thrombocytopenia depends on etiology, in our patient’s case the diagnosis of secondary ITP and directed management did not result in a successful outcome.

Preoperative endoscopic tattooing for colonic polyp localization: From blue to black

When surgical polypectomy and not segmental resection is planned, preoperative endoscopic tattooing with high-volume undiluted methylene blue should be avoided as it can result in colon perforation.

A misdiagnosed cause of early postoperative bowel obstruction

In the setting of altered anatomy, diagnosis of superior mesenteric artery syndrome requires high clinical and imaging suspicion as the defined imaging criteria cannot be applied.

Extensive colonic pneumatosis in a patient on adjuvant chemotherapy after right colectomy for primary terminal ileum lymphoma: A decision-making process between surgical and non-surgical management

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Pneumatosis intestinalis can be benign or life-threatening.

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Life-threatening causes are bowel obstruction, perforation, ischemia and severe colitis.

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Differential diagnosis between life-threatening and benign pneumatosis intestinalis is difficult.

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Early severity recognition is critical as it would dictate surgical or conservative management.

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Surgery is needed when worrisome clinical, laboratory and imaging findings are present.

Introduction

Pneumatosis intestinalis is a rare condition that may be idiopathic or a sign of numerous underlying gastrointestinal, pulmonary and systemic diseases.

Presentation of case

Herein, the case an otherwise-healthy 82-year-old female patient with vague abdominal pain due to total colonic pneumatosis 20 days after completion of R-CHOP chemotherapy for a stage IIE primary non-Hodgkin’s lymphoma of the terminal ileum submitted to right hemicolectomy and ileal resection 6 months previously is presented. As no evidence of intramural bowel gas was present on pre-operative CT, pneumatosis coli considered to be secondary. As no worrisome clinical, laboratory and imaging findings were present, pneumatosis coli seemed to be benign. As no other etiologic factors identified, pneumatosis coli considered to be chemotherapy-induced. The patient treated conservatively with cessation of enteral nutrition and broad spectrum antibiotics with uneventfull recovery.

Discussion

Pneumatosis intestinalis can be benign or life-threatening. Bowel obstruction, perforation, ischemia and severe colitis represent the most life-threatening causes. In clinical practice it is often challenging to distinguish between life-threatening and benign pneumatosis intestinalis, a decision which should be based on the presence or absence of worrisome clinical, laboratory and imaging findings.

Conclusion

In analogous cases, the main dilemma for the physicians is to identify whether surgical intervention is required or not. Given the potential severity of pneumatosis intestinalis, early diagnosis and recognition of its severity is critical as it would dictate surgical or non-surgical management.

Meckel's Diverticulum in Adults: Surgical Concerns

Since Meckel's diverticulum (MD) is rarely diagnosed in adults, there is no consensus on what type of procedure to be performed for symptomatic MD and whether to resect or not an accidentally discovered MD. Treatment of symptomatic MD is definitive surgery, including diverticulectomy, wedge, and segmental resection. The type of procedure depends on: (a) the integrity of diverticulum base and adjacent ileum; (b) the presence and location of ectopic tissue within MD. The presence of ectopic tissue cannot be accurately predicted intraoperatively by palpation and macroscopic appearance. When present, its location can be predicted based on height-to-diameter ratio. Long diverticula (height-to-diameter ratio >2) have ectopic tissue located at the body and tip, whereas short diverticula have wide distribution of ectopic tissue including the base. When indication of surgery is simple diverticulitis, diverticulectomy should be performed for long and wedge resection for short MD. When indication of surgery is complicated diverticulitis with perforated base, complicated intestinal obstruction and tumor, wedge, or segmental resection should be performed. When the indication of surgery is bleeding, wedge and segmental resection are the preferred methods for resection. Regarding management of incidentally discovered MD, routine resection is not indicated. The decision making should be based on risk factors for developing future complications, such as: (1) patient age younger than 50 years; (2) male sex; (3) diverticulum length >2 cm; and (4) ectopic or abnormal features within a diverticulum. In this case, diverticulectomy should be performed for long and wedge resection for short MD.

Obstructive jaundice as primary presentation of a stage IIE Non-Hodgkin lymphoma: A decision making process between advanced lymphoma and locally advanced/metastatic pancreatic adenocarcinoma

INTRODUCTION

Secondary pancreatic tumors are uncommon and account for 2-5% of pancreatic cancer. Tumors characterized most commonly with pancreatic involvement are lymphoma, renal cell and lung carcinomas.

PRESENTATION OF CASE

A 76-year-old female patient with obstructive jaundice as the primary symptom and inguinal lymphadenopathy is presented. Imaging revealed a bulky solitary solid pancreatic head mass along with paraaortic and mesenteric lymphadenopathy. The absence of a previous history of malignancy and the presence of a dominant pancreatic mass along with distal lymphadenopathy confined differential diagnosis to advanced secondary pancreatic lymphoma, which is the most common secondary pancreatic tumor, and locally advanced/metastatic pancreatic adenocarcinoma. Pathologic confirmation with excisional biopsy of an enlarged inguinal lymph node and EUS-FNB of the pancreatic head mass confirmed the diagnosis of secondary Non-Hodgkin pancreatic lymphoma allowing initiation of induction chemotherapy.

DISCUSSION

Secondary pancreatic lymphoma can be seen up to 30% of patients with advanced lymphoma; although the head of the pancreas is the most common location, obstructive jaundice is not the predominant symptom as obstruction of the common bile duct is usually absent. In the setting of a solitary nodular type pancreatic mass, key imaging findings highly suggestive of secondary pancreatic lymphoma and not of adenocarcinoma are the absence of vascular invasion, bile and pancreatic duct obstruction, and the presence of lymphadenopathy below the level of the left renal vein.

CONCLUSION

When a secondary pancreatic tumor is highly suspected pathologic confirmation is always needed before initiation of induction or palliative chemotherapy.

Current practice in obstetric anesthesia: a 2012 European survey

BACKGROUND

New scientific findings are gradually implemented into daily clinical routine. The present questionnaire survey investigated the current practice in obstetric anesthesia in Europe.

METHODS

A 19-point questionnaire on obstetric anesthesia practices, regarding the techniques, drugs, fluids, vasopressors and safety measures, was uploaded on the site of the European Society of Anaesthesiology (21/12/2011 to 21/12/2012).

RESULTS

Three hundred and forty-one (341) completed questionnaires were analyzed. Single-shot subarachnoid anesthesia is preferred by 225 (66%) respondents in uncomplicated Cesarean deliveries and by 190 (55.7%) in preeclampsia. Most anaesthesiologists (N.=133, 39%) perform neuraxial techniques if platelet count exceeds 80000/mm3. In anticipated hemorrhage, general anesthesia is administered by 165 (48.4%) respondents. Anesthesia is induced with thiopental/succinylcholine by 193 (56.6%) survey participants, usually under cricoid pressure (N.=201, 58.8%). For prevention of the hypotension associated with regional anesthesia, coloading with 1L of crystalloid represents the most popular measure undertaken by 80 (40.2%) respondents, while vasopressors are not favored (N.=260, 76.2%). For hypotension treatment, ephedrine is preferred over phenylephrine by 124 (36.4%) versus 79 (23.2%) anesthesiologists. Supplemental oxygen is routinely administered to parturients receiving regional anesthesia by 176 (51.6%) respondents. The standard dose of oxytocin is 5IU, according to most answers (N.=160, 46.9%).

CONCLUSION

Subarachnoid anesthesia is mostly favored among European anesthesiologists, while general anesthesia is reserved only for cases with anticipated hemorrhage. Fluid coloading and phenylephrine have gained popularity, in line with current knowledge. Conversely, cricoid pressure, standard supplemental oxygen and high oxytocin doses ‑ though strongly questioned ‑ are still advocated by most anaesthesiologists.

The effects of intrathecal and systemic adjuvants on subarachnoid block

Various intrathecal and systemic adjuvants to local anaesthetics have been found to improve the quality and extend the duration of spinal block. Intrathecal opioids are the most frequently used; the lipophilic fentanyl and sufentanil enhance and moderately prolong the sensory block, whereas the hydrophilic morphine significantly prolongs spinal analgesia. Nausea/vomiting, pruritus, urinary retention and respiratory depression are possible side effects. Adrenergic agonists, such as adrenaline and phenylephrine may prolong the block due to vasoconstriction, while clonidine and dexmedetomidine accelerate the onset and prolong the duration of block and analgesia. Hypotension, sedation and respiratory depression have been reported with clonidine. Other intrathecal adjuvants, such as midazolam, ketamine and neostigmine may also improve the quality of block and prolong analgesia, but are not popular because of their adverse effects. Intrathecal magnesium sulphate mainly potentiates the analgesic action of intrathecal opioids, without significant side effects. A positive impact on spinal analgesia has also been suggested ‑ from animal studies ‑ for intrathecal calcium channel blockers, while the analgesic efficacy of intrathecal nonsteroidal anti-inflammatory drugs remains questionable. Several drugs may also affect the spinal block characteristics after systemic administration. Opioids enhance, alpha-2 agonists and ketamine prolong the block, magnesium sulphate reduces postoperative analgesic consumption and nimodipine may delay the regression of sensory block. Nitrous oxide inhalation has also been found to enhance the level of sensory spinal block. Even though opioids are the most popular adjuvants to spinal local anaesthetics, a variety of drugs given intrathecally or systemically, can accelerate, improve and extend the spinal block.

Needling of the Extra 1 Point Decreases BIS Values and Preoperative Anxiety

Acupuncture has anxiolytic effects. We investigated the effect of acupuncture on the Bispectral Index (BIS) values and anxiety. Fifty patients were randomly assigned to group A to receive acupuncture for 15 minutes on the extra 1 point (yintang) or to group C, where they received the same treatment on a control point located 2 cm lateral to the end of the right eyebrow. BIS values were recorded before acupuncture; during acupuncture every 30 seconds for 15 minutes and every 30 seconds for 90 seconds when the acupuncture treatment was accomplished. Anxiety level was assessed before and after acupuncture by a verbal score scale (VSS) (0=no anxiety, 10=worst anxiety). BIS values were significantly decreased during acupuncture when applied on the extra 1 point (p=0.0001) but not on the control point.

Acupuncture application significantly decreased the VSS values within the A group (p=0.027) and in the C group (p=0.0001), when compared to the baseline (pre-acupuncture) VSS values. However, no differences were found between the two groups regarding BIS or VSS values. In conclusion, needling the extra 1 point preoperatively significantly decreases the BIS values and the VSS for anxiety but needling of a control point decrease only VSS values.

How readers perceive the quality of six anesthesia journals, their editors and reviewers: a European survey

The aim of the present study was to evaluate six anesthesia journals and academic criteria, required for the editors and reviewers, as perceived by European anesthesiologists submitted to a questionnaire. The six journals were: Acta Anaesthesiologica Scandinavica (AAS), Anesthesia and Analgesia (AN/AN), Anesthesiology (ANESTH), British Journal of Anaesthesia (BJA), Canadian Journal of Anesthesia (CJA) and European Journal of Anaesthesiology (EJA). Anesthesiologists were questioned on number of articles read per issue, preferred category of article and type of subject addressed, usefulness of supplemental issues as well as to score each journal for quality, format and color. The academic background they would require for editors and reviewers was scored as the sum of the number of their published articles, citations and manuscripts they reviewed. AN/AN, ANESTH, BJA and EJA have higher number of articles read versus the AAS and the CJA. Article quality was estimated higher for AN/AN than for AAS, CJA and EJA, higher for ANESTH than AN/AN, AAS, CJA and EJA ( p < 0.0001 for all comparisons), and higher for BJA than for AAS, CJA and EJA. ANESTH received higher scores for format than EJA, and BJA than CJA. Finally AN/AN received higher scores for format than AAS, CJA and EJA and for color when compared to AAS, CJA, and EJA. Supplemental issues were considered useful by 77.3% of the respondents. General and original articles were preferred by the respondents. The overall scores of the estimated required academic background did not differ between editors and reviewers or between the different criteria. In conclusion, the six anesthesia journals demonstrated differences in all the variables included in the questionnaire addressed to their readers. In contrast the academic background criteria for editors and reviewers as scored by the readers did not show any differences.

Melatonin premedication does not enhance induction of anaesthesia with sevoflurane as assessed by bispectral index monitoring

INTRODUCTION

Exogenous melatonin has sedating and hypnotic actions. The present prospective double-blind randomised study investigated the effect of melatonin premedication on the induction of anaesthesia with sevoflurane.

METHODS

71 women of reproductive age, scheduled for a hysteroscopy, were randomised into the melatonin or the control group. 30 minutes before the induction of anaesthesia, patients in the melatonin and control groups sublingually received 9 mg of melatonin or placebo, respectively. In the operating room, patients were attached to a standard monitor and bispectral index (BIS) monitor. Anaesthesia was induced with 8 percent sevoflurane in oxygen via an anaesthetic system primed with 8 percent sevoflurane. BIS values were recorded every 30 seconds, during the first 300 seconds of sevoflurane administration. Inspired and expired sevoflurane concentrations, heart rate and oxygen saturation were also recorded at the same time intervals. Noninvasive blood pressure was recorded before and after the completion of measurements.

RESULTS

BIS values (p-value is 0.725, F is 0.125, degrees of freedom [df] 1), inspired (p-value is 0.468, F is 0.535, df 1) and expired (p-value is 0.388, F is 0.756, df 1) sevoflurane concentrations, heart rate (p-values is 0.516, F is 0.427, df 1) and oxygen saturation (p-value is 0.401, F is 0.717, df 1), did not differ between the two groups, at any time point of measurement. Systolic blood pressure before (p-value is 0.131, t 1.530, df 67) and after measurement (p-value is 0.8288, t 0.218, df 54) as well as diastolic blood pressure before (p-value is 0.370, t 0.902, df 67) and after measurement (p-value is 0.764, t 0.302, df 54) did not differ between the two groups.

CONCLUSION

Melatonin premedication under the present study design failed to enhance the induction of anaesthesia with sevoflurane.

Sevoflurane as a single anesthetic and physostigmine failure to enhance arousal

AIM

Sevoflurane is recommended for inhalational induction of anesthesia. Physostigmine may antagonize general anesthetics. The study investigates sevoflurane as a single anesthetic and its possible antagonism by physostigmine.

METHODS

In 60 women scheduled for breast lump excision, anesthesia was induced with 8% sevoflurane. After 3 min of sevoflurane inhalation, a laryngeal mask airway (LMA) was inserted. Anesthesia was maintained with spontaneous ventilation at end tidal sevoflurane 3%. Systolic and diastolic blood pressure, heart rate and end tidal CO(2) were recorded intraoperatively. After skin closure and at end tidal sevoflurane 0.9%, physostigmine 2 mg or normal saline was given. After 2 min systolic, diastolic blood pressure, heart rate and end tidal CO(2) were recorded and sevoflurane was discontinued. Time to eyes opening, LMA removal and verbal response was recorded. Patients were also assessed for orientation, sedation, sitting ability and the ''picking up matches'' test at 0, 15 and 30 min after LMA removal.

RESULTS

Systolic, diastolic blood pressure and heart rate increased after laryngeal mask placement (P=0.0001, P=0.0001 and P=0.0001, respectively). Orientation, sitting ability and ''picking up'' matches were similar in the 2 groups. Sedation at 15 min was less in the control group (P=0.004).

CONCLUSIONS

Sevoflurane can be used as a single anesthetic but its recovery is not enhanced by physostigmine.

Gabapentin attenuates the pressor response to direct laryngoscopy and tracheal intubation

BACKGROUND

Laryngoscopy and tracheal intubation increase blood pressure and heart rate (HR). The aim of the present study was to investigate the effect of gabapentin when given before operation on the haemodynamic responses to laryngoscopy and intubation.

METHODS

Forty-six patients undergoing abdominal hysterectomy for benign disease were randomly allocated to receive gabapentin 1,600 mg or placebo capsules at 6 hourly intervals starting the day (noon) before surgery. Anaesthesia was induced with propofol and cis-atracurium. Systolic, diastolic arterial blood pressures (SAP, DAP) and heart rate (HR) were recorded before and after the anaesthetic and 0, 1, 3, 5 and 10 min after tracheal intubation.

RESULTS

SAP was significantly lower in the gabapentin vs the control group 0, 1, 3, 5 and 10 min after intubation [128 (27) vs 165 (41), P=0.001, 121 (14) vs 148 (29), P=0.0001, 115 (13) vs 134 (24), P=0.002, 111 (12) vs 126 (19), P=0.004 and 108 (12) vs 124 (17), P=0.001 respectively]. DAP also was lower in the gabapentin group 0, 1, 3, and 10 min after intubation [81 (18) vs 104 (19), P=0.0001, 77 (9) vs 91 (16), P=0.001, 71 (10) vs 84 (13), P=0.001 and 67 (10) vs 79 (12), P=0.004]. HR did not differ between the two groups at any time [82 (11) vs 83 (15), 79 (10) vs 80 (12), 86 (17) vs 92 (10), 82 (11) vs 88 (10), 81 (12) vs 81 (11), 77 (13) vs 79 (13), and 75 (15) vs 78 (12)].

CONCLUSION

Gabapentin, under the present study design attenuates the pressor response but not the tachycardia associated with laryngoscopy and tracheal intubation.

Transdermal clonidine: does it affect pain after abdominal hysterectomy?

Clonidine has analgesic properties. We evaluated the analgesic effect of clonidine perioperatively. Forty patients undergoing abdominal hysterectomy received randomly the evening before surgery transdermal clonidine covered with overlay (CLO group) or the overlay alone (CTL group). Ten min before induction they received i.v. clonidine 1 microgram.kg-1 (CLO) or normal saline (CTL). Induction was accomplished with fentanyl 5 micrograms.kg-1, thiopentone 5 mg.kg-1, cis-atracurium 0.15 mg.kg-1 and maintenance with sevoflurane 2% in 70% N2O. Hemodynamic parameters were recorded intraoperatively. Pain was assessed by VAS at rest and movement 2, 4, 6, 8, 24, 48, 72 h and 30 days, postoperatively. During the first 8 h postoperatively all patients received controlled analgesia with fentanyl followed by morphine i.m. 0.15 mg.kg-1 and paracetamol. From 24-72 h postoperatively, patients received 75 mg propoxyphene and 600 mg paracetamol i.m., on demand. Arterial blood pressure was lower in the CLO group 0, 3, 10 min after intubation. There was no difference in pain or fentanyl consumption 8 h postoperatively. The CLO group required less analgesics 24 h postoperatively (p = 0.023). The two groups did not differ in pain or analgesic requirements 72 h and 30 days postoperatively. Clonidine had a weak opioid sparing effect 24 h post-operatively, but did not affect pain in long term.

Impact factor bias and proposed adjustments for its determination

BACKGROUND

The impact factor (IF), a qualitative parameter used to evaluate scientific journals, has several flaws. The aim of the study was to evaluate two of its important constraints, journal self-citation and scientific field, and to investigate the potential for improvement.

METHODS

We studied the five or six highest impact journals from each of seven medical fields: anesthesiology, dermatology, genetics and heredity, immunology, general and internal medicine, ophthalmology and surgery. To correct for journal self-citation, we divided the number of 1998 citations of papers published in 1996 and 1997, minus the self-citations, by the number of papers published in the same period. For inter-field normalization we divided the IF by the mean of the IFs of the upper quartile for the same category of medical field (IF/fcat).

RESULTS

For the 36 journals, there was a negative correlation between IF and self-cited and self-citing rates (rs = -0.765, P < 0.001 and rs = -0.479, P < 0.003, respectively). Self-cited rate is the ratio of a journal's self-citations to the number of times it is cited by all journals including itself. Self-citing rate relates a journal's self-citations to the total references it makes. The IF/fcat for the 36 journals are positively correlated with their conventional IF (rs = 0.91, P < 0.001).

CONCLUSION

Correcting the IF of the 36 journals for self-citation did not significantly change journal rankings. The adjusted IF/fcat to normalize for the scientific field was positively correlated with the conventional IF.

Hypnotic and cardiovascular effects of proprietary and generic propofol formulations do not differ

PURPOSE

The aim of the study was to compare the potency of two different propofol formulations: proprietary and generic propofol using the bispectral index (BIS) monitoring.

METHODS

Forty female patients undergoing breast surgery received propofol 3 mg x kg(-1) followed by propofol infusion adjusted to maintain a 40% BIS value, supplemented by 50% nitrous oxide. Proprietary or generic propofol was administered in a randomized double-blind manner.

RESULTS

The propofol mg/BIS% ratio obtained after the bolus dose, the cumulative infused propofol mg/BIS% ratio at the end of each five-minute interval and the total dose of propofol administered as bolus + infusion were similar between the two groups. The two groups did not differ with regard to systolic and diastolic blood pressure, heart rate, end-tidal carbon dioxide and arterial oxygen saturation.

CONCLUSION

The two propofol formulations are equipotent when hypnotic effect is assessed by BIS monitoring.

The analgesic efficacy of intravenous tenoxicam as an adjunct to patient-controlled analgesia in total abdominal hysterectomy

Nonsteroidal antiinflammatory drugs may reduce postoperative opioid consumption. We evaluated the analgesic efficacy of preoperatively administered tenoxicam in patients undergoing total abdominal hysterectomy. Patients were randomly assigned to receive IV either normal saline 4 mL (Group NS), tenoxicam 20 mg (Group T20), or tenoxicam 40 mg (Group T40) before the induction of anesthesia in a double-blinded fashion. Patient-controlled analgesia with fentanyl was used to assess postoperative opioid requirements. Pain was evaluated by visual analog scale at 2, 4, 6, 8, and 24 h postoperatively. Intraoperative bleeding as assessed by the surgeon, incidence of nausea, and gastrointestinal symptoms were recorded. No statistically significant difference was identified between groups in fentanyl consumption or pain scores. The incidence of nausea was similar in all groups. Two patients in Group T20 and two in Group T40 exhibited mild gastrointestinal symptoms. Intraoperative oozing was noted in two patients in Group T40. We conclude that patients undergoing total abdominal hysterectomy and receiving fentanyl via patient-controlled analgesia postoperatively do not benefit from tenoxicam pretreatment. On the contrary, the drug may be associated with an increased incidence of side effects.

IMPLICATIONS

The preoperative administration of 20 or 40 mg IV tenoxicam does not reduce fentanyl consumption via Patient-Controlled Analgesia, compared with placebo, after total abdominal hysterectomy. Additionally, tenoxicam may increase intraoperative bleeding and gastrointestinal side effects.

Self-citations in six anaesthesia journals and their significance in determining the impact factor

Self-citation of a journal may affect its impact factor. We investigated self-citations in the 1995 and 1996 issues of six anaesthesia journals by calculating the self-citing and self-cited rates for each journal. Self-citing rate relates a journal's self-citations to its total number of references. We defined self-cited rate as the ratio of a journal's self-citations to the number of times it is cited by the six anaesthesia journals. We also correlated self-citing rates with the impact factor of the six journals for 1997. Citations among the six journals differed significantly (P < 0.0001). Anesthesiology had the highest self-citing rate (57%). Anaesthesia, Anesthesia and Analgesia, British Journal of Anaesthesia, Canadian Journal of Anaesthesia and the European Journal of Anaesthesiology had self-citing rates of 28%, 28%, 30%, 11% and 4% respectively. The self-cited rates were 31%, 35%, 34%, 27%, 31% and 17% for Anaesthesia, Anesthesiology, Anesthesia and Analgesia, British Journal of Anaesthesia, Canadian Journal of Anaesthesia and the European Journal of Anaesthesiology, respectively. North America journals cited the North America literature. This also occurred, to a lesser extent, in the European anaesthesia journals. A significant correlation between self-citing rates and impact factors was found (r = 0.899, P = 0.015). A high self-citing rate of a journal may positively affect its impact factor.

Ventilatory adequacy and respiratory mechanics with laryngeal mask versus tracheal intubation during positive pressure ventilation

The ventilatory adequacy and respiratory mechanics during positive pressure ventilation (PPV) via the laryngeal mask airway (LMA) are compared with the respiratory mechanics via the tracheal tube (TT). Thirty patients undergoing breast surgery were studied. After induction of anesthesia and muscle relaxation an LMA was inserted. Data were collected every 5 min for a 15 min period and included inspired (VTinsp) and expired (VTexp) tidal volumes, I:E ratio, peak airway pressure (Ppeak), plateau pressure (Pplat), total dynamic compliance (C), and the percentage of VT exhaled passively in the first second of expiration (V1.0%). Then the trachea was intubated and measurements were repeated as previously. Gas leak was calculated as the fraction (VTinsp- VTexp)/Vtinsp. VTinsp and VTexp did not differ significantly between the LMA or TT anesthesia at any time (P = 0.9318, P = 0.7071 for VTinsp and VTexp respectively), neither the Ppeak (P = 0.1382). Significant differences were found for Pplat (P = 0.000) and C (P = 0.0001). Individual comparisons showed a significant difference between the LMA Pplat at 5 min when compared with all the Pplat mean values recorded with the LMA or the TT (P < 0.05-0.01). The C mean value with the LMA at 5 min was significantly lower when compared with all the C mean values via the TT anesthesia (P < 0.05-0.01). Significant differences were found among the V1.0% measurements (P = 0.030) but not between individual comparisons. Leak was similar with the LMA or TT airway management. It is concluded that, in patients with normal airway pressure and compliance, PPV using the LMA is comparatively effective with the use of TT.