The Importance of Initial Epidurography Prior to Any Drug Administration in Three-Day Adhesiolysis Procedure

Percutaneous epidural adhesiolysis (PEA) is a minimal invasive procedure to relieve sciatalgia caused by post lumbar surgery syndrome (PLSS). Fluoroscopic-guided contrast-epidurography is essential to ensure a safe procedure. We present a case of a 28-year-old male patient who underwent a PEA which was complicated by a dural puncture. We highlight the dangers of such complications and discuss associated risk factors.

[About an unusual case of lipoid pneumonia]

Lipoid pneumonia, although uncommon, should be considered when patients had a chronic pneumonia. We report a case of a 40-year-old female who presented with a chronic pneumonia. The CT-scan analysis, then the bronchoalveolar lavage, revealed a lipoid pneumonia. This lipoid pneumonia was caused by chronic inhalation of niaoulis vapors. This etiology has not been described in the literature. Alveolar condensation disappeared one month after bronchoalveolar lavage. This suggests that bronchoalveolar lavage may contribute to opacity regression besides exogenous lipid eviction.

Recommendations in the event of a suspected transfusion-related acute lung injury (TRALI)

The following recommendations, which aim at improving the clinical diagnosis ofTRALI and the laboratory investigations that can support it, were drawn up by a working group of the Superior Health Council. TRALI is a complication of blood transfusion that is both serious and underreported. Systematic reporting may help to develop preventive actions. Therefore, the Superior Health Council recommends that there should be a more stringent surveillance of patients who receive a blood component transfusion. The clinician should pay very close attention to any change in the patient's respiratory status (cf. dyspnoea and arterial desaturation), which should be notified systematically to the haemovigilance contact person in the hospital.

Oral clonidine vs midazolam in the prevention of sevoflurane-induced agitation in children. A prospective, randomized, controlled trial †

BACKGROUND

This randomized, double-blind study tested the hypothesis that, in comparison with midazolam, premedication with oral clonidine reduces the incidence of emergence agitation in preschool children anaesthetized with sevoflurane.

METHODS

Sixty-eight ASA I-II children undergoing circumcision were randomized into three groups to receive different oral premedication given 30 min before anaesthesia: midazolam 0.5 mg kg-1, clonidine 2 microg kg-1, and clonidine 4 microg kg-1. Sevoflurane anaesthesia was administered via a facemask (O2/N2O: 40/60). Analgesia was with penile block (bupivacaine 0.5% 0.3 ml kg-1) and rectal paracetamol (30 mg kg-1). During the first postoperative hour, children were evaluated using a modified 'objective pain scale'.

RESULTS

Only the 4 microg kg-1 dose of clonidine was associated with a significant reduction in emergence agitation. Fewer children in the clonidine 4 microg kg-1 group displayed agitation (25%) than in the midazolam group (60%) (P=0.025). Incidence of hypotension and bradycardia, time to first micturition and first drink did not differ among groups.

CONCLUSIONS

In comparison with midazolam, clonidine 4 microg kg-1 reduced sevoflurane-induced emergence agitation without increasing postoperative side-effects.

Blood conservation strategies in cardiac surgery

Despite the continuous efforts to increase the safety of blood components, red blood cell transfusions remain associated with some risks and side effects. Therefore, numerous techniques have been developed to decrease blood use, but they also carry risks and bear costs. Most of them are frequently used in cardiac surgery, which still consumes a large part of the available blood supply. Among western countries the use of alternative techniques, but also transfusion practice, has been shown to vary markedly. 'Blood conservation' is a global concept engulfing all possible strategies aimed at reducing patients' exposure to allogeneic blood components. The development of the 'best strategy' consists of the selection of those techniques that are most appropriate to the local specific situation. It implies the establishment of a reliable system, collecting data both at the surgical team and at the medical level.

Fast separations on monolithic silica columns: method transfer, robustness and column ageing for some case studies

Six separation methods, developed on conventional silica high performance liquid chromatography (HPLC) columns were transferred to monolithic silica columns of 5 and 10 cm length. The transferred methods include the separation of an alkylbenzene mixture, the separations of drugs from their impurities (nimesulide, tetracycline, phenoxymethylpenicillin and erythromycin) and the separation of a green tea extract. The transfer of the first three methods was successful while for the latter three it was not. Increasing the flow rate up to 9 ml/min (where possible) inversely decreased the analysis time of the successfully transferred methods to 48 s (alkylbenzene mixture) 1.8 min (nimesulide mixture) and 3 min (tetracycline mixture) while still reasonable well separated peaks were obtained. The robustness and repeatability of the transferred and accelerated separations was found to be acceptable. Despite the use of flow rates up to 9 ml/min and frequent mobile phase changes with pH values varying from 3.5 to 7, the column performance was found to be rather constant and the column ageing to be minimal.

[Surgical excision of pulmonary metastasis of cancer of the breast: apropos of 40 patients]

Between 1987 and 1995, 52 breast cancer patients had a surgical resection of lung secondaries. In 40 patients, the diagnosis of metastatic breast cancer could be confirmed following pathological examination. Five-year survival rates of these 40 patients was 54 +/- 8% and 5-year disease free survival was 30 +/- 8%. The median survival (70 months) of these patients was better than that of 57 patients with isolated lung metastases who had been treated conservatively (chemo- or/and hormonotherapy) during the same time interval. Twenty-six patients benefitted from a radical excision and had a longer disease free interval (42 versus 27 months, p = 0.03) than patients who had had a wedge resection. Overall survival was not significantly different (71 versus 41 months, p = 0.07). We feel that isolated lung nodules may best be treated by radical (segment or lobe) excision, in particular since preoperative differential diagnosis with primary lung cancer may be difficult. In the presence of multiple nodules, first line medical treatment by chemo- or hormonotherapy should be advocated, allowing to reduce the tumor load and to optimize survival in association with surgery.

Effects of diluent volume of a single dose of epidural bupivacaine in parturients during the first stage of labor

BACKGROUND AND OBJECTIVES

0.1% bupivacaine for obstetric epidural analgesia is given by infusion, using a loading dose of a higher concentration alone or in combination with opioid analgesics. A single dose of 0.1% without any additive for relief of first-stage labor pain has not yet been documented.

METHODS

Fifty-eight primiparae in active labor and with less than 5 cm cervical dilatation received 20 mg epidural bupivacaine diluted in 4 mL [group 1: 0.5% (I)], 10 mL [group 2: 0.2% (II)], or 20 mL [group 3: 0.1% (III)]. Pain relief, dermatomal spread, and motor block were assessed.

RESULTS

Visual analog pain scale (VAS) was significantly lower in group 2 (0.88 +/- 1.34) and group 3 (0.25 +/- 0.61) than in group 1 (4.37 +/- 2.57). Onset and time to maximum analgesia was significantly shorter in group 2 than in group 3. Mean duration of analgesia was 120 +/- 21 minutes in group 3, 100 +/- 26 in group 2, and 43 +/- 21 in group 1. The mean numbers and upper limits of dermatomes blocked did not differ between groups 2 and 3, but were higher than in group 1. Motor blocks in groups 2 and 3 were more extensive than in group 1 with no difference between groups 2 and 3. Ten mL 0.2% or 20 mL 0.1% epidural bupivacaine results in a similar degree of pain relief, superior to that following 4 mL 0.5%, while duration was longest after 20 mL 0.1%.

CONCLUSIONS

Analgesia lasts significantly longer following 20 mL 0.1% bupivacaine than following 10 mL 0.2% bupivacaine when given for first-stage labor pain. Four milliliters 0.5% bupivacaine results in inadequate pain relief.

Effects of Diluent Volume of a Single Dose of Epidural Bupivacaine in Parturients During the First Stage of Labor

Background and Objectives

0.1% bupivacaine for obstetric epidural analgesia is given by infusion, using a loading dose of a higher concentration alone or in combination with opioid analgesics. A single dose of 0.1% without any additive for relief of first-stage labor pain has not yet been documented.

Methods

Fifty-eight primiparae in active labor and with less than 5 cm cervical dilatation received 20 mg epidural bupivacaine diluted in 4 mL [group 1: 0.5% (I)], 10 mL [group 2: 0.2% (II)], or 20 mL [group 3: 0.1% (III)]. Pain relief, dermatomal spread, and motor block were assessed.

Results

Visual analog pain scale (VAS) was significantly lower in group 2 (0.88 ± 1.34) and group 3 (0.25 ± 0.61) than in group 1 (4.37 ± 2.57). Onset and time to maximum analgesia was significantly shorter in group 2 than in group 3. Mean duration of analgesia was 120 ± 21 minutes in group 3, 100 ± 26 in group 2, and 43 ± 21 in group 1. The mean numbers and upper limits of dermatomes blocked did not differ between groups 2 and 3, but were higher than in group 1. Motor blocks in groups 2 and 3 were more extensive than in group 1 with no difference between groups 2 and 3. Ten mL 0.2% or 20 mL 0.1% epidural bupivacaine results in a similar degree of pain relief, superior to that following 4 mL 0.5%, while duration was longest after 20 mL 0.1%.

Conclusions

Analgesia lasts significantly longer following 20 mL 0.1% bupivacaine than following 10 mL 0.2% bupivacaine when given for first-stage labor pain. Four milliliters 0.5% bupivacaine results in inadequate pain relief.

[A combined radiochemotherapy trial for non-small cell lung cancers: initial results]

PURPOSE

Analysis of the preliminary results of a phase I study investigating the feasibility of concomitant chemotherapy with daily doses of carboplatin (20 to 25 mg/m2/d over 45 or 10 min) and accelerated chest irradiation (60 to 64 Gy over 4 weeks, 2 Gy per fraction, using the concomitant boost technique).

MATERIALS AND METHODS

This combination was given alone or following three cycles of induction chemotherapy (cisplatin, 25 mg/m2 per day from d1 to d5; 5-fluorouracil, 600 mg/m2 per day from d1 to d5 and vinorelbine, 25 mg/m2 per day at d1 and d5 with a 4-week interval) in 15 patients with locally advanced unresectable non-small cell lung cancer. All patients received the planned sequence.

RESULTS

The dose-limiting toxicity was esophagitis (5 out of 15 grade 4). No toxic deaths were observed. The tumor response rate was high: six out of 15 complete responses and 14 out of 15 tumor regressions greater than 50%. The median survival was not reached after a mean follow-up of 14 months (range, 6-28 months).

CONCLUSION

We are now planning a multicenter phase II study using the following combination: 20 mg/m2 of daily carboplatin over 10 min and a 60-Gy irradiation dose over 4 weeks.

Benign and malignant musculoskeletal lesions: dynamic contrast-enhanced MR imaging--parametric "first-pass" images depict tissue vascularization and perfusion

PURPOSE

To assess the diagnostic value of parametric magnetic resonance images that display the first pass (FP) of gadopentetate dimeglumine.

MATERIALS AND METHODS

Dynamic, contrast material-enhanced, fast low-angle shot MR imaging was performed of 100 musculoskeletal lesions in 36 female and 64 male patients (aged 9-81 years [mean, 34 years]). The highest slope value of the time-intensity curve was calculated pixel by pixel and displayed on the FP image, with a gray-scale value equal to the slope value. Tissue vascularization and perfusion were evaluated at pathologic and angiographic examinations in 33 lesions.

RESULTS

A significant difference (P < .001) was found between the FP slope values of benign (mean, 36.2% per second) and malignant (mean, 67.4% per second) lesions. FP images depicted tissue vascularization and perfusion rather than benignity or malignancy, because there is an overlap in the slope values of highly vascular benign lesions and malignant lesions.

CONCLUSION

FP images provide diagnostically useful information by depicting tissue vascularization and perfusion.

First-pass images of musculoskeletal lesions: a new and useful diagnostic application of dynamic contrast-enhanced MRI

The purpose of this study was to evaluate the diagnostic value of parametric images which display the first-pass of Gd-DTPA after intravenous bolus injection. Single slice dynamic contrast-enhanced MRI (Turbo-FLASH) with a temporal resolution of 2.41 s was performed in 40 benign and malignant musculoskeletal lesions. Parametric 'first-pass' images were obtained by using a new postprocessing technique, derived from a home written computer program, which calculated the steepest slope of the time-intensity curve pixel by pixel. First-pass images provided qualitative and quantitative information, which was useful for diagnosis and therapy. Demonstration of the areas with the highest vascularization was very helpful in planning the best biopsy site in 6 patients and to delineate tumor from peritumoral muscle edema in 4 patients. In 10 patients the first-pass images provided additional information, which was not visible on the conventional spin-echo images. The most promising application was the ability to evaluate the response to preoperative chemotherapy in a patient with Ewing's sarcoma. Although a highly statistically significant difference (p < 0.001) was found between the first-pass slope values of benign and malignant lesions, the sensitivity (77%) and specificity (71%) of this method were too low to permit a definite differentiation of highly vascular benign from malignant lesions. Pathologic examination of 17 lesions, performed in the plane of the first-pass image, showed a good correlation between the first-pass slope values and the vascularization of the tissues.(ABSTRACT TRUNCATED AT 250 WORDS)

Elastofibroma dorsi: CT, MR and pathologic study in a new case

As reported before elastofibroma dorsi is a rare benign tumor of elastic connective tissue with typical clinical and suggestive radiological features. We evaluated the CT and MR characteristics of this periscapular lesion in a new case, before and after contrast enhancement, and tried to determine in how far the nature and extent of the tumor can be predicted.