The use of iloprost in early pregnancy in patients with pulmonary arterial hypertension

In patients with pulmonary hypertension, pregnancy is associated with a high risk of maternal death. Such patients are counselled to avoid pregnancy, or if it occurs, are offered early interruption. Some patients, however, decide to continue with their pregnancy and others may present with symptoms for the first time whilst pregnant. Pulmonary vasodilator therapy provides a treatment option for these high-risk patients. The present study describes three patients with pulmonary arterial hypertension of various aetiologies who were treated with the prostacyclin analogue iloprost during pregnancy, and the post-partum period. Nebulised iloprost commenced as early as 8 weeks of gestation and patients were admitted to hospital between 24-36 weeks of gestation. All pregnancies were completed with a duration of between 25-36 weeks and all deliveries were by caesarean section under local anaesthetic. All patients delivered children free from congenital abnormalities, and there was no post-partum maternal or infant mortality. In conclusion, although pregnancy is strongly advised against in those with pulmonary hypertension, the current authors have achieved a successful outcome for mother and foetus with a multidisciplinary approach and targeted pulmonary vascular therapy.

Evaluation of a local anaesthesia regimen following mastectomy

Breast surgery can be emotionally distressing and physically painful. Acute pain following surgery is often related mainly to the axillary surgery and is aggravated by arm and shoulder movement. We conducted a prospective double-blind, randomised, placebo-controlled trial to determine the influence of local anaesthetic irrigation of axillary wound drains on postoperative pain during the first 24 h following a modified Patey mastectomy (mastectomy with complete axillary node clearance). The treatment group received bupivacaine irrigation through the axillary wound drain 4-hourly for 24 h postoperatively. Controls received irrigation with normal saline. Morphine via a patient controlled analgesia pump was used for postoperative analgesia. Morphine consumption, visual analogue and verbal rating pain scores were recorded. There were no statistical differences in morphine requirements or pain scores between the two groups, nor were there differences in anti-emetic or supplemental analgesic consumption. Bupivacaine irrigation used in this manner does not appear to offer an effective contribution to postoperative analgesia.

Adrenal axis testing and corticosteroid replacement therapy in septic shock patients--local and national perspectives

Recently, there has been renewed interest in corticosteroid therapy for patients with septic shock. The cortisol response to a tetracosactide stimulation test, otherwise known as a short synacthen test, may identify which patients are most likely to benefit from corticosteroid replacement. Controversy over interpretation of the cortisol response and the correct tetracosactide dose remains. We retrospectively analysed all septic shock patients who had full cortisol results following a 1- micro g short synacthen test. All cortisol results were re-evaluated by three common ways of interpreting the cortisol response to a short synacthen test. The thresholds were a cortisol rise >/= 250 nmol x l(-1), a peak cortisol >/= 550 nmol x l(-1) and a peak cortisol >/= 700 nmol x l(-1). We found a significant relationship between the peak cortisol results and haemodynamic improvement in patients given corticosteroids. There was no association between a cortisol rise >/= 250 nmol x l(-1) and haemodynamic improvement after corticosteroids. A postal questionnaire was sent to adult intensive care units in the United Kingdom to assess national practice. Sixty per cent of intensive care units use corticosteroids in septic shock patients, but only 22% use a short synacthen test to guide therapy.

Regeneration of nerve fibres in the anterior medullary velum of neonatal and weanling rats

The responses to injury of myelinated central axons in neonatal (5-day) and weanling (30-day) rats were compared, using the trochlear nerve fibres in the anterior medullary velum (AMV) as an experimental system. In intact animals, fibres of the trochlear nerve decussate completely in the AMV, to enter the contralateral nerve. Sprouting from proximal axon stumps was seen within 36 h after injury in silver-stained, whole mounts of mid-sagittally lesioned AMVs from weanlings. Subsequent growth produced a tangled axon mass which persisted until 15-20 days post-lesion (d.p.l.) but then began to degenerate. By 50 d.p.l., the majority of surviving axons looped within the AMV to enter the ipsilateral trochlear nerve; few axons remained growing randomly within the AMV. Axonal debris persisted within the velum 50 d.p.l. In neonatal rats, lesioned trochlear axons initially developed axon sprouts, but then degenerated with rapid clearance of debris, leaving the AMV devoid of both axons and degeneration products by 6 d.p.l. From 8 d.p.l., the velum became repopulated by axons which either grew randomly or looped to enter the ipsilateral peripheral nerve. Both patterns of axon growth were still observed 50 d.p.l. In both experimental groups, horseradish peroxidase injection to the right superior oblique muscle 40 d.p.l. indicated that at least some of the looping fibres observed within the lesioned AMVs originated in the ipsilateral trochlear nucleus. The origin of those axons growing randomly within the AMVs of neonatally-lesioned animals is unknown. The results are discussed with reference to current ideas concerning regeneration-inhibiting elements in the CNS, and regeneration-promoting factors in the PNS.