Naloxone for shock

BACKGROUND

There is pre-clinical evidence, involving several animal species, suggesting that opioid peptides play a role in the physiopathology of shock (endotoxic, hypovolemic, cardiogenic, spinal, anaphylactic). Many case reports have suggested that naloxone (an opiate antagonist) might be an effective treatment for shock in humans, but others have not supported such a point of view. This controversy led us to undertake a meta-analysis of the available evidence on the efficacy of naloxone as a treatment measure of shock in humans.

OBJECTIVES

To evaluate the effectiveness and safety of naloxone in human shock and to estimate the methodological quality of the clinical trials.

SEARCH STRATEGY

Computerized bibliographic search up to December 2002, review of references of all papers found on the subject and contact with primary investigators of eligible studies.

SELECTION CRITERIA

Randomized controlled trials evaluating naloxone in human shock, regardless of the patient's age (adult, child or neonate).

DATA COLLECTION AND ANALYSIS

Three independent reviewers extracted data on study design, intervention, outcome and methodological quality.

MAIN RESULTS

Three independent readers reviewed 80 human publications and selected six clinical trials. Overall agreement on study selection was perfect (concordance: 100%). This meta-analysis includes six studies involving 126 patients with septic, cardiogenic, hemorrhagic or spinal shock. Naloxone therapy was associated with statistically significant hemodynamic improvement (odds ratio 0.24; 95% confidence interval [95%CI] 0.09-0.68). The mean arterial pressure was significantly higher in the naloxone groups than in the placebo groups (weighted mean difference: +9.33 mmHg; 95%CI 7.07-11.59). No heterogeneity was found for this outcome. The death rate was lower in the naloxone group (odds ratio 0.59; 95%CI 0.21-1.67) but this was consistent with the play of chance. A significant heterogeneity for the latter outcome was detected (p<0.05).

REVIEWER'S CONCLUSIONS

Naloxone improves blood pressure, especially mean arterial blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined, and additional randomized controlled trials are needed to assess its usefulness.

Anterior and posterior middle ear congenital cholesteatomas in children

Congenital cholesteatomas arise from embryonic epithelial cell rests in the middle ear cleft. We report our series of 19 cases observed in 18 children between 1985 and 1990. Clinical data and surgical observations are analyzed. In regard to the location of the lesions, our findings are consistent with most of what has been reported in the literature. Sixty-eight percent of the lesions originated from the anterosuperior part of the mesotympanum. Only 10% were posterosuperiorly located. Pathogenic mechanisms are discussed with respect to the lesion's primary site.