Comparison of Sedation Requirements for Cataract Surgery under Topical Anesthesia or Retrobulbar Block

PURPOSE

Topical anesthesia is increasingly being used for cataract surgery. However, it is believed that topical anesthesia causes an increased risk of intraoperative complications from unrestricted eye movement and insufficient pain control and more need for sedation. It is difficult to compare pain and anxiety experienced by individual patients; therefore, the authors used the method of patient-controlled sedation to determine whether there is a difference in sedation requirements under topical or retrobulbar anesthesia.

METHODS

In this prospective study, patients received either topical anesthesia (n=87) or retrobulbar block (n=104) and self-administered a mixture of midazolam (0.5 mg) and fentanyl (25 microg) in increments using a patient controlled analgesia infuser to achieve sedation. At the end of surgery, patients rated their pain on a 10-point numerical rating scale and their comfort on a 5-point scale. The number of demands and deliveries were noted from the patient controlled analgesia infuser display.

RESULTS

Pain scores were between 0 and 2 in 95.4% in the topical and in 94.2% in the retrobulbar group (p>0.05). Patient comfort was equal in both groups with 2.94+/-0.92 in the topical group and 2.92+/-0.99 in the retrobulbar group (p>0.05). Mean sedation requirements were similar in both groups: 26.4% of patients in the topical group and 19.2% in the retrobulbar group did not request any sedation (not significant, p>0.05).

CONCLUSIONS

Sedation requirements were similar for cataract surgery under topical and retrobulbar anesthesia.

Marking of nonpalpable breast lesions using a custom carbon suspension

Purpose: To review results of carbon marking in non-palpable breast lesions using a different type of a carbon suspension containing 0.5% polyoxyethylene sorbitan monooleate (PSM).

Material and Methods: Sixteen lesions of 16 patients with indeterminate or suspicious mammographic findings underwent stereotaxic carbon marking. With the aid of tracing of the carbon stains surgery was then performed.

Results: Pathology revealed malignancy in 26% of the cases and the missed rate by carbon marking was 6% (1 lesion). Carbon marking is an easier application compared to hook-wire systems in localizing occult breast lesions. PSM added to a 4% carbon suspension results in a more homogeneous suspension, prevents early precipitation and eases injection. Animal studies have shown that no local or peripheral tissue reactions are elicited with either pure PSM or in a mixture with carbon.

Conclusion: We recommend addition of PSM to carbon marking suspensions.

Chest Sonography

Ultrasonography was used to evaluate 53 patients with equivocal juxta-diaphragmatic and/or lateral densities in chest radiographs. An air bronchogram, fluid bronchogram, and scattered echogenic foci due to residual air in the consolidated lung parenchyma were used as US criteria of pulmonary parenchymal consolidation. One or more of these signs were observed in 39 patients with a clinical or bacteriologic diagnosis of pneumonia. The US air bronchogram was seen in 32 of the 39 patients (82 %), the fluid bronchogram in 37 patients (94%) and the scattered echogenic foci in 30 (77%). In 14 patients, pleural effusion was diagnosed sonographically and verified by aspiration of fluid. The final diagnoses in these cases were pulmonary tuberculosis in 11 patients, staphylococcal empyema in 2, and tuberculous empyema in one patient. It is concluded that US criteria provide a useful differentiation of pulmonary parenchymal consolidation from pleural effusion.

Correlation between breast density in mammography and background enhancement in MR mammography

PURPOSE

We aimed to analyse the influence of mammographic breast density on background enhancement (BE) at magnetic resonance (MR) mammography in pre- and postmenopausal women. In addition, we questioned predictability of contrast-enhancement dynamics of normal fibroglandular tissue (NFT) at MR mammography according to mammographic breast density.

MATERIALS AND METHODS

Twenty-six patients (mean age 51.54+/-11.5 years; range 37-79 years) who underwent both MR mammography and conventional mammography were included in this retrospective study. Fourteen patients were premenopausal and 12 were postmenopausal. The ethics committee of our institution approved the study. The mammograms were retrospectively reviewed for overall breast density according to the four-point scale (I-IV) of the Breast Imaging Reporting and Data System (BI-RADS) classification. Two radiologists, who were unaware of the clinical data, separately assessed the MR mammography images. Images were assessed for enhancement kinetic features (enhancement kinetic curve and the early-phase enhancement rate) and BE. MR mammography and conventional mammography findings were compared according to BI-RADS breast density category and menopausal status.

RESULTS

Percentage of increased signal intensity values during the first minute did not change according to mammographic breast density, and the mean early-phase enhancement rate scores were similar among breast density groups (p=0.942). There was no significant difference between pre- and postmenopausal groups. Enhancement kinetic features of the different groups based on BI-RADS breast density category and menopausal status were similar. There was no correlation between breast density and BE in either premenopausal (p=0.211) or in postmenopausal (p=0.735) groups.

CONCLUSIONS

We determined no correlation between mammographic breast density and so-called BE in MR mammography in either premenopausal or postmenopausal women. NFT at MR mammography cannot be predicted on the basis of mammographic breast density.

Effects of L-carnitine and niacin supplied by drinking water on fattening performance, carcass quality and plasma L-carnitine concentration of broiler chicks

The present study was initiated to determine whether dietary supplemental L-carnitine and niacin affect growth performance, carcass yield, abdominal fat and plasma L-carnitine concentration of broiler chicks. One-day-old broiler chicks (COB500) were used in the experiment. A two by two factorial arrangement was employed with two levels (0 and 50 mg/l) of supplemental L-carnitine and two levels (0 or 50 mg/l) of supplemental niacin in drinking water as main effects. Body weight gain was significantly improved by L-carnitine, or L-carnitine + niacin supplementation during the first 3 weeks. However, supplemental L-carnitine and niacin did not change body weight gain during the last 3 weeks of the experimental period. Supplemental L-carnitine significantly improved feed intake during the first 3 weeks. Supplemental L-carnitine or niacin did not influence carcass weight, carcass yield and abdominal fat weight. L-carnitine content in the plasma was significantly higher in the groups receiving supplemental L-carnitine and L-carnitine + niacin. It is concluded that dietary supplemental L-carnitine or L-carnitine + niacin could have positive effects on body weight gain and feed intake during the early stages of growing. However, supplemental L-carnitine or L-carnitine + niacin were not of benefit regarding the complete growth period.

Effects of dietary supplemental L-carnitine and ascorbic acid on performance, carcass composition and plasma L-carnitine concentration of broiler chicks reared under different temperature

The present study was initiated to determine whether dietary supplemental L-carnitine and ascorbic acid affect growth performance, carcass yield and composition, abdominal fat and plasma L-carnitine concentration of broiler chicks reared under normal and high temperature. During the experiment, two temperature regimes were employed in two experimental rooms, which were identical but different in environmental temperature. The regimes were thermoneutral (20-22 degrees C for 24 h) or recycling hot (34-36 degrees C for 8 h and 20-22 degrees C for 16 h). One-day-old broiler chicks (ROSS) were used in the experiment. A 2 x 2 x 2 factorial arrangement was employed with two levels (0 and 50 mg/kg) of supplemental L-carnitine and two levels (0 or 500 mg/kg) of supplemental ascorbic acid in drinking water under thermoneutral or high temperature regimes. Body weight gain was affected by high temperature. However, body weight gain was significantly improved in animals receiving supplemental L-carnitine, ascorbic acid or L-carnitine + ascorbic acid compared to animals receiving unsupplemented diet under high temperature. On the other hand, supplemental L-carnitine or L-carnitine + ascorbic acid reduced body weight gain under thermoneutral condition. Supplemental ascorbic acid significantly improved feed conversion efficiency, the improvement was relatively greater under high temperature. The L-carnitine content in the plasma was higher in the groups receiving supplemental L-carnitine and ascorbic acid under high temperature, while broilers fed supplemental L-carnitine and ascorbic acid had a decreased level of plasma L-carnitine concentration under normal temperature. It is concluded that dietary supplemental L-carnitine or L-carnitine + ascorbic acid may have positive effects on body weight gain, carcass weight under high temperature conditions.

Magnetic resonance imaging findings in patients with severe neonatal indirect hyperbilirubinemia

The aim of this study was to document the magnetic resonance imaging (MRI) findings of cases with a history of severe neonatal indirect hyperbilirubinemia. Ten cases (eight cases with neurologic findings, two normal cases) with a history of severe neonatal indirect hyperbilirubinemia were studied. Neurologic findings and MRI results were described and correlated. Seven of eight cases with neurologic findings demonstrated symmetric and uniform increased T2 signal changes limited to globus pallidi. MRI scans of two cases without neurologic findings showed no abnormality. Severe neonatal indirect hyperbilirubinemia should be considered in the differential diagnosis of bilateral symmetric hyperintense signal changes in the globus pallidus on MRI. However, high levels of unconjugated bilirubin concentrations in the neonatal period may not always cause such lesions of globus pallidus on MRI despite the presence of neurologic findings.

Pitfalls in the diagnosis of complicated pulmonary hydatid disease

The aim of this study was to present the pitfalls in the diagnosis of complicated pulmonary hydatid disease and to discuss the unusual radiological presentations of this endemic disorder in Turkey. We retrospectively evaluated 34 patients (12 females) aged between 8 and 64 years, who were operated on at our centre between 1991 and 1998 and diagnosed with complicated pulmonary hydatid cyst histopathologically. Computerized tomography (CT) scans of these patients were reviewed double-blind by two radiologists. The patients were then divided into two groups: group 1: initial radiological impression is pulmonary hydatid cyst and group 2: initial radiological impression is not pulmonary hydatid disease. These two groups were evaluated in terms of symptoms, radiographical presentation and laboratory tests. The presence of cystic appearance, water-lily sign, ring enhancement concomitant with intact cysts unanimously led the radiologists to the diagnosis of complicated pulmonary hydatid cyst, whereas solid appearance and presence of bronchial obliteration made the diagnosis unlikely. In such circumstances patient history, laboratory findings and bronchoscopic evaluation helped the diagnosis. In conclusion, in endemic regions like Turkey, atypical radiological presentation of complicated pulmonary hydatid disease should be considered in the differential diagnosis of solid pulmonary lesions.

An unusual localization of massive portasystemic collaterals: CT angiographic demonstration

This article presents a patient with portal hypertension in whom an unusual localization for portosystemic collaterals have incidentally been found. Upper abdominal sonography revealed tubular structures filling the whole perirenal and partially the perihepatic area, and their venous nature was demonstrated with duplex Doppler sonography. Spiral CT angiography identified the right-sided retroperitoneal location and mesenteric-lumbar route of the collaterals. Upper gastrointestinal endoscopy with antral biopsy and percutaneous liver biopsy were performed. Laboratory results and specimen evaluation revealed chronic active hepatitis due to hepatitis-B infection. Attention is drawn to the abnormal location of these vessels, together with the noninvasive nature and competence of CT angiography in demonstrating vascular pathologies.

Microcatheter CSA in a young woman with Fontan repair undergoing elective sterilization

We present the case of a 28-yr-old woman with Fontan anastomosis undergoing elective sterilization. Because of concerns about laparoscopic surgery with capnoperitoneum and positive-pressure ventilation, a mini-laparotomy was performed in microcatheter spinal anaesthesia. Tiration of small doses of plain bupivacaine 0.5% supplemented with 5 microg sufentanil provided high cardiocirculatory and respiratory perioperative stability in this patient.

CT in lobar atrophy of the liver caused by alveolar echinococcosis

We reviewed the CT findings of 13 patients with histologically proved alveolar echinococcosis of the liver. Seven of these patients had hilar involvement, which caused dilatation of intrahepatic bile ducts and invasion of the portal vein or portal branches. In two of these patients we found marked atrophy of the right lobe and in one patient marked atrophy of the left lobe in addition to various CT findings previously reported for alveolar echinococcosis of the liver. The occurrence of lobar atrophy of the liver caused by alveolar echinococcosis has not been previously reported. We concluded that, when a mass lesion with hilar infiltration causing lobar atrophy is found in endemic areas, alveolar echinococcosis should be considered in the differential diagnosis in addition to malignant neoplasms.

Purely cystic hydatid disease of the liver: treatment with percutaneous aspiration and injection of hypertonic saline

Percutaneous aspiration of purely cystic liver lesions was performed in 15 patients aged 11-56 years. After aspiration under guidance with computed tomography (CT) in 12 patients, a membrane that is diagnostic for hydatid disease was visible in the lumen of the cyst on CT scans. Hypertonic saline was injected in the cystic cavities of these patients as a scolecidal agent. No major complications occurred during or after the procedures. In the follow-up period of 6-16 months, control CT and ultrasound scans revealed a progressive decrease in the size of the lesions and no evidence of peritoneal seeding. It is concluded that percutaneous aspiration and hypertonic saline injection for purely cystic hydatid disease of the liver seem to be an effective form of treatment and may eventually prove to be an alternative to surgical intervention.

Preoperative CT staging of colon carcinoma (excluding the recto-sigmoid region)

Twenty-eight patients with colon carcinoma (excluding the recto-sigmoid region) underwent preoperative staging with computed tomography (CT). The CT had a sensitivity and a specificity of 60 and 67% for detection of extramural invasion, 75% sensitivity and specificity for lymph node metastases and a sensitivity of 87% and specificity of 95% for liver metastases. Compared with the modified Dukes classification, CT correctly staged 50% of the patients with Dukes A lesions; 40% with Dukes B; 75% with Dukes C and 85% with Dukes D lesions. The data presented in this study showed that CT has limitations in the sensitivity and accuracy of staging local colonic carcinoma. However, we recommend its use for patients who are clinically suspected of having extensive disease.

Chest sonography. Differentiation of pulmonary consolidation from pleural disease

Ultrasonography was used to evaluate 53 patients with equivocal juxta-diaphragmatic and/or lateral densities in chest radiographs. An air bronchogram, fluid bronchogram, and scattered echogenic foci due to residual air in the consolidated lung parenchyma were used as US criteria of pulmonary parenchymal consolidation. One or more of these signs were observed in 39 patients with a clinical or bacteriologic diagnosis of pneumonia. The US air bronchogram was seen in 32 of the 39 patients (82%), the fluid bronchogram in 37 patients (94%) and the scattered echogenic foci in 30 (77%). In 14 patients, pleural effusion was diagnosed sonographically and verified by aspiration of fluid. The final diagnoses in these cases were pulmonary tuberculosis in 11 patients, staphylococcal empyema in 2, and tuberculous empyema in one patient. It is concluded that US criteria provide a useful differentiation of pulmonary parenchymal consolidation from pleural effusion.

Balloon dilatation of iatrogenic urethral strictures

Balloon dilatation of the urethra was performed in five patients with iatrogenic urethral strictures. The urethral strictures were successfully negotiated and dilated in all patients. Redilatation became necessary in a period ranging from 3 to 10 months. The authors believe that balloon dilatation of the urethra can be safely and successfully performed; the procedure produces minimal trauma and immediate relief of symptoms.