The timing of intravenous antibiotics and clinical outcomes of Mycobacterium abscessus complex lung diseases

BACKGROUND: The importance of early intravenous (IV) antibiotic use for Mycobacterium abscessus complex lung diseases (MABC-LD) treatment remains unknown. METHODS: A retrospective multi-centre observational study was conducted in Taiwan. Patients who were diagnosed with and received treatment for MABC-LD from January 2007 to April 2021 were included. Treatment outcome was defined as modified microbiological cure of MABC-LD.RESULTS: Of the 89 enrolled patients, 34 (38.2%) received IV antibiotics as part of the treatment regimen. The median time to IV initiation was 1 day (IQR 1???49); 24 (70.6%) of these patients received IV agents within 4 weeks, defined as early-use. Forty-two (47.2%) patients achieved modified microbiological cure. In the multivariable logistic analysis, early IV antibiotic use was an independent factor associated with modified microbiological cure (aOR 5.32, 95% CI 1.66???17.00), whereas high radiological score (aOR 0.86, 95% CI 0.73???1.00) demonstrated negative association.CONCLUSIONS: In the present study, early use of effective IV antibiotic was prescribed in a low percentage (27%) for MABC-LD. By contrast, early IV antibiotic use was correlated with higher microbiological cure than were late or non-use. Future larger and prospective studies are needed to validate the association.

Impact of comorbidities on survival following major injury across different types of road users

BACKGROUND

While comorbidities and types of road users are known to influence survival in people hospitalised with injury, few studies have examined the association between comorbidities and survival in people injured in road traffic crashes. Further, few studies have examined outcomes across different types of road users with different types of pre-existing comorbidities. This study aims to examine differences in survival within 30 days of admission among different road user types with and without different pre-existing comorbidities.

METHOD

Retrospective cohort study using data for all major road trauma cases were extracted from the NSW Trauma Registry Minimum Dataset (1 January 2013 - 31 July 2019) and linked to the NSW Admitted Patient Data Collection, and the NSW Registry of Births, Deaths and Marriages - death dataset. Pre-existing comorbidities and road user types were identified by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and Charlson Comorbidity Index in the Trauma Registry, hospital admission, and death datasets. Logistic regression was used to assess the associations between six types of road users (pedestrian, pedal cycle, two- and three-wheel motorcycle, car and pick-up truck, heavy vehicle and bus, and other types of vehicle) and death within 30 days of hospital admission while controlling for comorbidities. All models used 'car and pick-up truck driver/passenger' as the road user reference group and adjusted for demographic variables, injury severity, and level of impaired consciousness.

RESULTS

Within 6253 traffic injury person-records (all aged ≥15 years old, ISS>12), and in final models, injured road users with major trauma who had a history of cardiovascular diseases (including stroke), diabetes mellitus, and higher Charlson Comorbidity Index score, were more likely to die, than those without pre-existing comorbidities. Furthermore, in final models, pedestrians were more likely to die than car occupants (OR: 1.68 - 1.77, 95CI%: 1.26 - 2.29 depending on comorbidity type).

CONCLUSIONS

This study highlights the need to prioritize enhanced management of trauma patients with comorbidities, given the increasing prevalence of chronic medical conditions globally, together with actions to prevent pedestrian crashes in strategies to reach Vision Zero.

Progression of chronic kidney disease and the risk of tuberculosis: an observational cohort study

<sec id="st1"> <title>BACKGROUND</title> Little is known about tuberculosis (TB) risk in the earlier stages of chronic kidney disease (CKD). </sec> <sec id="st2"> <title>OBJECTIVE</title> To investigate the relationship between CKD at all stages and the risk of incident TB. </sec> <sec id="st3"> <title>METHODS</title> We conducted a cohort study using 100 058 participants of a community-based health screening programme in northern Taiwan, 2005-2008. Renal function was ascertained at baseline using serum creatinine level and the urine dipstick test. The occurrence of active TB was ascertained using the National Tuberculosis Registry. Cox proportional hazards regression was used to estimate the association between CKD and TB. </sec> <sec id="st4"> <title>RESULTS</title> During a median follow-up of 7.5 years, TB incidence was 472. In the Cox regression analyses, individuals with Stage 1-4 CKD had a 25% increase in TB hazard than those without disease (adjusted hazard ratio [aHR] 1.25, 95%CI 1.02-1.54). A positive correlation between CKD stage and TB was observed (P = 0.02 for trend). TB risk increased by 5.1% with every 10 ml/min/1.73 m² decrease in the estimated glomerular filtration rate (aHR 1.05, 95%CI 0.99-1.12). </sec> <sec id="st5"> <title>CONCLUSIONS</title> Our results suggested an increased risk of TB in early-stage CKD. TB prevention efforts should consider individuals with earlier stages of CKD. </sec>.

Oral health behaviours of older Australian men: the Concord Health and Ageing in Men Project

BACKGROUND

The Concord Health and Ageing in Men Project (CHAMP) is a cohort study of the health of a representative sample of older Australian men. The aim of this paper is to describe the oral health behaviours and dental service use of CHAMP participants and explore associations between oral health behaviours with and general health status.

METHOD

Information collected related to socio-demographics, general health, oral health service-use and oral health behaviours. Key general health conditions were ascertained from the health questionnaire and included physical capacity and cognitive status.

RESULTS

Fifty-seven percent of the men reported visiting a dental provider at least once or more a year and 56.7% did so for a "dental check-up". Of those with some natural teeth, 59.3% claimed to brush their teeth at least twice or more a day. Most men (96%) used a standard fluoride toothpaste. Few participants used dental floss, tooth picks or mouth-rinses to supplement oral hygiene. Cognitive status and self-rated general health were associated with dental visiting patterns and toothbrushing behaviour.

CONCLUSIONS

Most older men in CHAMP perform favourable oral health behaviours. Smoking behaviour is associated with less favourable dental visiting patterns, and cognitive status with toothbrushing behaviour.

Pericellular colocalisation and interactive properties of type VI collagen and perlecan in the intervertebral disc

The aim of this study was to immunolocalise type VI collagen and perlecan and determine their interactive properties in the intervertebral disc (IVD). Confocal laser scanning microscopy co-localised perlecan with type VI collagen as pericellular components of IVD cells and translamellar cross-bridges in ovine and murine IVDs. These cross-bridges were significantly less abundant in the heparin sulphate deficient Hspg2 exon 3 null mouse IVD than in wild type. This association of type VI collagen with elastic components provides clues as to its roles in conveying elastic recoil properties to annular tissues. Perlecan and type VI collagen were highly interactive in plasmon resonance studies. Pericellular colocalisation of perlecan and type VI collagen provides matrix stabilisation and cell-matrix communication which allows IVD cells to perceive and respond to perturbations in their biomechanical microenvironment. Perlecan, at the cell surface, provides an adhesive interface between the cell and its surrounding extracellular matrix. Elastic microfibrillar structures regulate tensional connective tissue development and function. The 2010 Global Burden of Disease study examined 291 disorders and identified disc degeneration and associated low back pain as the leading global musculoskeletal disorder emphasising its massive socioeconomic impact and the need for more effective treatment strategies. A greater understanding of how the IVD achieves its unique biomechanical functional properties is of great importance in the development of such therapeutic measures.

A review of models relevant to road safety

It is estimated that more than 1.2 million people die worldwide as a result of road traffic crashes and some 50 million are injured per annum. At present some Western countries' road safety strategies and countermeasures claim to have developed into 'Safe Systems' models to address the effects of road related crashes. Well-constructed models encourage effective strategies to improve road safety. This review aimed to identify and summarise concise descriptions, or 'models' of safety. The review covers information from a wide variety of fields and contexts including transport, occupational safety, food industry, education, construction and health. The information from 2620 candidate references were selected and summarised in 121 examples of different types of model and contents. The language of safety models and systems was found to be inconsistent. Each model provided additional information regarding style, purpose, complexity and diversity. In total, seven types of models were identified. The categorisation of models was done on a high level with a variation of details in each group and without a complete, simple and rational description. The models identified in this review are likely to be adaptable to road safety and some of them have previously been used. None of systems theory, safety management systems, the risk management approach, or safety culture was commonly or thoroughly applied to road safety. It is concluded that these approaches have the potential to reduce road trauma.

Hepatotoxicity due to first-line anti-tuberculosis drugs: a five-year experience in a Taiwan medical centre

BACKGROUND

Hepatotoxicity with first-line drugs, a major complication of anti-tuberculosis treatment, has not been studied by time-dependent analysis.

DESIGN

Adult patients diagnosed with pulmonary tuberculosis (PTB) from 2005 to 2009 were reviewed retrospectively. Hepatotoxicity during anti-tuberculosis treatment was defined by symptomatic elevation of liver transaminases ≥3 times the upper limit of normal, or ≥5 times if asymptomatic. Risk factors for hepatotoxicity were investigated using time-dependent Cox regression analysis.

RESULTS

Of 926 patients identified and followed for 4122.9 person-months (pm), 111 (12.0%) developed hepatotoxicity after a median 38.0 days from start of treatment. Around 3.5% had severe hepatotoxicity. The most common symptoms were general malaise and poor appetite. The incidence rate of hepatotoxicity was 0.59, 0.69 and 3.71/100 pm for isoniazid, rifampicin (RMP) and pyrazinamide (PZA), respectively. Old age, female sex, autoimmune disease, human immunodeficiency virus infection, more days with PZA in the last 8-14 days, and fewer days with RMP in the last 15-21 days before hepatotoxicity were independent risk factors for hepatotoxicity during treatment.

CONCLUSION

A significant number of adult patients on first-line treatment experience hepatotoxicity. PZA is the most common causative drug. For high-risk patients, careful adjustment of the anti-tuberculosis regimen and regular monitoring of liver transaminases are necessary.

Risk factors for 30-day readmission in general medical patients admitted from the emergency department: a single centre study

BACKGROUND

Overcrowding in emergency departments (ED) around the world is an increasingly serious problem with an adverse impact on both patient flow and patient outcomes. A significant contributing factor to ED overcrowding is possibly due to readmission. Risk factors for readmission in patients admitted from ED are rarely studied, particularly in Asian countries where the length of stay is reportedly longer.

METHODS

A retrospective study of patients admitted to general medical wards from the ED of a referral centre in northern Taiwan from November 2009 to April 2010 was conducted. The primary outcome was 30-day hospital readmission and clinical characteristics were analysed for predictors of readmission.

RESULTS

Of the recruited 2698 patients, 451 (16.7%) were readmitted within 30 days after discharge. Age, gender, marital status and the activities of daily living (Barthel's score) were not associated with 30-day readmission. Higher Charlson score ((score 2-4) hazard ratio (HR): 1.42, 95% confidence interval (CI): 1.07-1.89; (score >4) HR: 1.93, 95% CI: 1.37-2.73), longer hospital stay ((8-14 days) HR: 1.51, 95% CI: 1.17-1.95; (15-28 days) HR: 1.64, 95% CI: 1.22-2.19; (>28 days) HR: 1.97, 95% CI: 1.43-2.71), and presence of underlying active malignancy (HR: 1.66, 95% CI: 1.27-2.16) and anaemia (HR: 1.26, 95% CI: 1.02-1.55) were independently associated with readmission.

CONCLUSION

Medical patients admitted from the ED of a referral centre have a 30-day readmission rate of 16.7%. Post-discharge care should focus on patients with higher Charlson score, longer hospitalisation, anaemia and underlying active malignancy, which are independent predictive factors for 30-day readmission.

Use of soluble triggering receptor expressed on myeloid cells-1 in non-tuberculous mycobacterial lung disease

BACKGROUND

Serum biomarkers are rarely studied in patients with non-tuberculous mycobacterial lung disease (NTM-LD).

OBJECTIVE

To investigate the role of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and other inflammatory markers in NTM-LD.

DESIGN

From April 2009 to March 2010, patients with NTM culture-positive respiratory specimens who were clinically and radiographically suspected of NTM-LD were evaluated for serum levels of sTREM-1, C-reactive protein, procalcitonin and interferon-gamma.

RESULTS

Of the 86 patients enrolled, 60 fulfilled the diagnosis of NTM-LD. Using the receiver-operating characteristics curve analysis, serum sTREM-1 had the highest discriminative power for NTM-LD and colonisation (area under the curve = 0.714). Using a cut-off value of 180 pg/ml, the sensitivity and specificity of sTREM-1 were respectively 58% and 89%. Logistic regression analysis revealed that Mycobacterium avium complex, M. kansasii, positive sputum acid-fast smear and higher serum sTREM-1 level were independent risk factors for NTM-LD. Age >65 years and higher serum sTREM-1 level were associated with worse 6-month survival.

CONCLUSION

In patients with respiratory specimens that are culture-positive for NTM with clinical suspicion of NTM-LD, serum sTREM-1 level measurements may be helpful in diagnosing and predicting outcome for NTM-LD.

Expression of toll-like receptor 2 and plasma level of interleukin-10 are associated with outcome in tuberculosis

Toll-like receptor (TLR) 2-mediated innate immunity is an important defense system against Mycobacterium tuberculosis infection. Studies on TLR2 protein expression and downstream cytokines in tuberculosis patients are lacking. TLR2 expression in the peripheral blood monocytes of 87 tuberculosis patients and 94 healthy subjects was evaluated using flow cytometry. TLR2 expression and its downstream cytokines, including interleukin (IL)-6, IL-10, tumor necrosis factor (TNF)-alpha, and interferon-gamma, were correlated with the clinical manifestations and outcomes of tuberculosis. The TLR2 expression in peripheral blood monocytes was higher in tuberculosis patients than in healthy subjects. Among the tuberculosis patients, those aged ≥70 years with disseminated tuberculosis or aged <70 years with symptom duration ≥14 days had lower initial TLR2 expression. After two months of treatment, TLR2 expression decreased in most patients, except in those whose sputum samples remained culture-positive for M. tuberculosis. Proportional hazards regression analyses revealed that high initial TLR2 expression and IL-10 plasma level were associated with shorter survival. TLR2 may play an important role in the course of tuberculosis. Its expression on peripheral blood monocytes and the plasma level of the downstream anti-inflammatory cytokine IL-10 may be important outcome predictors and have potential use in the management of tuberculosis patients.

Non-tuberculous mycobacterial pleurisy: an 8-year single-centre experience in Taiwan

OBJECTIVE

To investigate the clinical characteristics and outcomes of patients with pleurisy due to non-tuberculous mycobacteria (NTM), which are currently unclear.

DESIGN

From 2000 to 2007, patients with NTM and Mycobacterium tuberculosis isolated from pleural effusion (PE) samples were identified and compared.

RESULTS

Thirty-five NTM patients and 140 tuberculosis (TB) patients were reviewed. Patients with NTM pleurisy were less likely to have lung involvement and receive anti-mycobacterial treatment compared with those with tuberculous pleurisy. NTM pleurisy had a higher PE leukocyte count and a lower percentage of lymphocytes. M. avium complex (MAC) was the most common pathogen in NTM pleurisy. Patients with MAC pleurisy were younger and tended to have more extra-pleural involvement and immune dysfunction. One-year mortality in the NTM pleurisy group was 37%, and anti-NTM treatment was associated with better survival. Patients with additional diagnostic evidence were more likely to receive anti-NTM treatment.

CONCLUSION

NTM pleurisy is common and has a high 1-year mortality rate. Anti-NTM treatment may provide better 1-year survival and should be considered once NTM pleurisy is diagnosed.

The role of chest radiography in the suspicion for and diagnosis of pulmonary tuberculosis in intensive care units

BACKGROUND

The role of chest radiography (CXR) in the clinical diagnosis and suspicion of pulmonary tuberculosis (PTB) remains uncertain in the intensive care unit (ICU) setting.

DESIGN

This case-control study compared the radiographic findings between ICU patients with and without co-existing PTB to define any predictive patterns for the diagnosis of PTB. Further analysis aimed to elucidate the impact of CXR on the clinical suspicion of PTB.

RESULTS

Eighty-nine (89) patients with PTB and an equal number of matched controls were evaluated. Consolidation was the most frequent radiographic pattern. There were no specific predictors for diagnosing PTB in the ICU. Of 89 patients, 55 (62.9%) had a delay in clinical suspicion of PTB. The time from ICU admission to TB diagnosis was significantly delayed in the group without clinical suspicion (30.7 vs. 5.3 days, P < 0.001). In multivariate analysis, a history of PTB was significantly associated with the clinical suspicion of PTB (OR 7.94, P = 0.012), but CXR patterns were not.

CONCLUSION

CXR does not contribute as much as expected in the clinical diagnosis and suspicion of PTB in the ICU setting.

Effect of active and passive cigarette smoking on CYP1A2-mediated phenacetin disposition in Chinese subjects

The effect of active and passive cigarette smoking on CYP1A2-mediated phenacetin disposition was evaluated in a controlled study of 36 healthy Chinese subjects. Each subject was administered a single oral dose of phenacetin (900 mg), and frequent blood samples were taken for up to 12 hours for simultaneous high-pressure liquid chromatography determinations of plasma concentrations of phenacetin and metabolically derived paracetamol. Compared with values observed in controls not exposed to cigarette smoking, subjects who smoked 7 to 40 (median, 20) cigarettes per day exhibited a 2.5-fold higher phenacetin apparent oral clearance (7.2, 4.3-12.0 L x h(-1) x kg(-1) vs 2.9, 1.8-4.6 L x h(-1) x kg(-1) [geometric means, 95% confidence intervals]; n = 12, p < 0.05). In subjects exposed to passive smoking, phenacetin's apparent oral clearance (3.6, 2.0-46.6 L x h(-1) x kg(-1), n = 12) was intermediate between the values observed in the two other groups. Plasma paracetamol levels were moderately lower in active smokers than in passive smokers and controls. These results demonstrated that, in contrast to results found in previous studies, Chinese subjects were fully susceptible to the inducing effect of cigarette smoke on CYP1A2 activity.

Comparison of diuretic effects of glycerol with furosemide after transurethral prostatectomy

BACKGROUND

Diuretic therapy after transurethral prostatectomy (TURP) is primarily intended to induce diuresis against water intoxication and cystic clot retention. This study was undertaken to compare the diuretic effects of glycerol with furosemide after TURP.

METHODS

Thirty patients (ASA I or II) undergoing TURP were studied. Spinal anesthesia was induced with bupivacaine. At the end of prostatic resection, the patients were randomly allocated into two groups. In one group (n = 15) the patients received furosemide 30 mg i.v., while in the other group (n = 15) they received glycerol 0.5 g/kg i.v. Blood samples were collected for measurements of osmolality, hematocrit, sodium and glucose concentration before anesthesia and after surgery. Urine output was also recorded after surgery in each group.

RESULTS

Plasma osmolality in glycerol group was higher than furosemide group at 30 min (295.3 +/- 10.6 vs. 283.8 +/- 5.6 mOsm/kg, p < 0.01) and 1 h after operation (294.9 +/- 8.7 vs 286.3 +/- 6.7 mOsm/kg, p < 0.01). Blood glucose was higher in glycerol group than that in furosemide group at 2 h after operation (195.6 +/- 121.9 vs 152.9 +/- 70.1 mg/dl, p < 0.05). Measured urine output was significantly greater in furosemide group at 30 min after operation (904.6 +/- 491.5 vs. 248.4 +/- 143.4 ml, p < 0.05) but was greater in glycerol group at 12 h after operation.

CONCLUSIONS

Since urine output is significantly less in glycerol group at 1 h after operation, glycerol is inferior to furosemide for preventing cystic clot retention after TURP. But glycerol may protect against water intoxication better for its merit of producing higher plasma osmolality.

Magnesium sulfate has negligible effect on middle cerebral artery blood flow velocity in response to endotracheal intubation

BACKGROUND

Pretreatment of magnesium sulfate (MgSO4) attenuates pressor response associated with endotracheal intubation. Vasodilating effect of MgSO4 may increase cerebral blood flow, which upsets the known benefit to cardiovascular hemodynamic. In the present study, we evaluated the effect of MgSO4 on the changes of cerebral blood flow in response to endotracheal intubation.

METHODS

Twenty four ASA class I or II patients who randomly received either normal saline 5 ml or MgSO4 (60 mg/kg, i.v.) 3 min before induction of anesthesia were included in the study. Mean blood flow velocity (VMCA) of the middle cerebral artery was obtained using a transcranial Doppler sonography (TCD) before and after endotracheal intubation. Anesthesia was induced with fentanyl (4 micrograms/kg) and thiopental (5 mg/kg) and endotracheal intubation was facilitated with succinylcholine (1.5 mg/kg).

RESULTS

Before endotracheal intubation, MgSO4 caused a transient decrease in VMCA (98 +/- 6% vs. 76 +/- 3% of baseline) and increase in heart rate (132% vs. 114% of baseline) compared to saline group. However, VMCA and heart rate did not show significant difference in both groups after tracheal intubation. Also, systolic and diastolic blood pressure did not differ during the study.

CONCLUSIONS

Our results suggest that MgSO4 appeared to have negligible effects on cerebral blood flow and hemodynamics in response to tracheal intubation. Its attenuating effect on pressor response induced by endotracheal intubation might be over emphasized.

A protective role for glutathione-dependent reduction of dehydroascorbic acid in lens epithelium

PURPOSE

In view of the antioxidant role of ascorbic acid and the glutathione redox cycle in the lens, the authors have studied the relationship of the cycle to reduction of the oxidized product of ascorbic acid, dehydroascorbic acid (DHA), in lens epithelium.

METHODS

Cultured dog lens epithelial cells and intact rabbit lenses were exposed to various concentrations of DHA in experiments performed at 20 degrees C to minimize hydrolysis of the compound (t1/2 of 5 minutes at 37 degrees C). Levels of glutathione (GSH) and oxidized glutathione (GSSG) were measured in lens cells and whole lens epithelial by electrochemical detection.

RESULTS

Treatment of lens cells with 1 mM DHA for 0.5 to 3 hours in the absence of glucose (glucose is required for the reduction of GSSG through the glutathione redox cycle) produced from 60% to complete oxidation of GSH (controls contained negligible GSSG) and distinct morphologic changes (cell contraction and blebbing), as shown by scanning electron microscopy. Glucose prevented these effects and allowed nearly immediate recovery of GSH after DHA exposure in the absence of glucose. A dose-dependent response was observed for the formation of GSSG in cultured cells from 0.05 to 0.5 mM DHA in the absence of glucose. The results of experiments performed with DHA plus an inhibitor of glutathione reductase mimicked those obtained using DHA minus glucose. DHA produced a 3- to 10-fold stimulation of hexose monophosphate shunt activity in cultured lens cells and whole lenses, which was prevented by the inhibition of glutathione reductase. Treatment of whole lenses with DHA minus glucose also produced oxidation of epithelial GSH and was accompanied by the loss of lens transparency. No evidence was found for dehydroascorbate reductase activity in the lens epithelium.

CONCLUSIONS

The exposure of lenses and lens epithelial cells to DHA under conditions in which the glutathione redox cycle was compromised resulted in the disappearance of GSH in the tissues and the appearance of GSSG. The reduction of DHA was shown to be linked to the glutathione redox cycle by a nonenzymatic interaction between GSH and DHA. Reduction of DHA in the lens is important because of the potential toxicity of this oxidant and/or its degradation products.

Mannitol increases cerebral arteriovenous oxygen difference in patients undergoing craniotomy

BACKGROUND

Monitoring the jugular venous oxygen saturation (SjVO2) and cerebral arteriovenous oxygen difference (AVDO2) is valuable in detecting cerebral ischemia. In the present study, we investigated the effect of mannitol on SjVO2 and AVDO2 in patients undergoing craniotomy.

METHODS

We studied 25 ASA class II-III patients undergoing craniotomy. Anesthesia was induced with thiopental, fentanyl and vecuronium. Immediately after induction, a 16-gauge central venous catheter was placed in the internal jugular vein, ipsilateral to the lesion side with cephalic insertion and anchorage in the jugular bulb. Anesthesia was maintained with continuous infusion of fentanyl (10 micrograms/kg/h), 0.5-1% isoflurane in 60% oxygen (oxygen/air) and supplemental dose of vecuronium for muscle relaxation as needed. Samples of arterial and jugular venous blood were obtained for the measurements of SjVO2 and AVDO2 in the following time intervals: (1) normocapnia (PaCO2 38-40 mmHg); (2) hypocapnia (PaCO2 28-30 mmHg); and (3) 30 min after mannitol (0.5 g/kg) infusion.

RESULTS

Hyperventilation resulted in a significant decrease in SjVO2 (96% patients) and increase in AVDO2 (88% patients). Hypocapnia followed by mannitol administration led to a further decrease and increase of SjVO2 and AVDO2 in 72% and 68% patients, respectively.

CONCLUSIONS

Mannitol may produce a further reduction in SjVO2 accompanied by an increase in AVDO2, suggesting a reduction of cerebral blood flow (CBF) during hyperventilation. Therefore, it should be given cautiously in neurosurgical patients under hyperventilation.

Postoperative pain relief: lumbar and thoracic epidural morphine in thoracotomy

Twenty-two patients undergoing thoracotomy were enrolled in a controlled, randomized trial to compare the effects of thoracic (group T) or lumbar (group L) epidural morphine in relieving postoperative pain. Epidural morphine was given as the patient first complained of pain in the recovery room. The effect of epidural morphine on pain relief was assessed by visual analogue scale and subjective grade. All patients were investigated 0, 10, 20, 30, 40, 50, 60, 75, 90, 105 and 120 minutes after a single bolus injection of epidural morphine. In assessment of pain relief by visual analogue scale, the difference between two groups was statistically significant (p < 0.05), evaluated 20, 30 and 40 minutes following treatment. There was no significant difference between two groups with regard to the effect of morphine as assessed by subjective grading. We concluded that thoracic epidural morphine took effect faster than lumbar epidural morphine. However, the effects of both kept similar since 50 minutes after morphine injection.

Sympathetic activity enhances glucose-related ischemic injury in the rat

BACKGROUND

Studies have shown that increased sympathetic activity or increased blood and brain glucose concentration worsen postischemic brain damage. The authors evaluated the interaction of plasma glucose with epinephrine and norepinephrine during incomplete cerebral ischemia in the rat using ganglionic blockade.

METHODS

Rats were anesthetized with 25 micrograms.kg-1.h-1 fentanyl and 70% nitrous oxide in oxygen. Ganglionic blockade was produced in 30 rats using 8 mg/kg hexamethonium intravenously. Three plasma glucose ranges, low < 150 mg/dl, moderate = 150-300 mg/dl, and high > 300 mg/dl, were produced in each group. Ischemia was induced by unilateral carotid ligation and hemorrhagic hypotension to 30 mmHg for 30 min. Plasma norepinephrine and epinephrine were measured by radioimmunoassay. Neurologic outcome was evaluated daily for 3 days after ischemia.

RESULTS

Ganglionic blockade decreased blood pressure before the start of ischemia and plasma epinephrine and norepinephrine during ischemia (P < 0.05). Neurologic outcome was significantly worse in rats with high glucose compared with low glucose concentrations with and without ganglionic blockade (P < 0.05). Neurologic outcome and stroke-related mortality were worse in rats with increased plasma epinephrine and norepinephrine compared with rats with ganglionic blockade when plasma glucose was less than 300 mg/dl (P < 0.05).

CONCLUSIONS

These results indicate that increased concentration of catecholamines enhance glucose-related injury during incomplete ischemia in rats.

The use of ketanserin for postoperative hypertension after abdominal surgery

Eighteen adult patients who developed hypertension (systolic blood pressure greater than 160 mmHg, diastolic blood pressure greater than 90 mmHg or both) at the early recovery period after major abdominal surgery were included in the study. Following intravenous injection of 10 mg ketanserin, eleven out of eighteen patients (61%) had their systolic or diastolic blood pressure fell below the target mark (160 mmHg and 90 mmHg), and the decrease was statistically significant (p less than 0.01 up to 120 min). There was no statistically significant change in heart rate. Four patients (22%) responded to 20 mg of ketanserin. Three patients (17%) did not have significant decrease of the blood pressure after 20 mg of ketanserin and they received other antihypertensives instead. No severe hypotensive episode was noted. We concluded that ketanserin is a moderate, rapid-onset and safe antihypertensive agent in treating postoperative hypertension following major abdominal surgery.