Biliscrotum and retroperitoneal biloma: spontaneous rupture of the biliary system presenting as an incarcerated inguinal hernia.

Spontaneous rupture of the biliary system is a well documented condition in infants but is rare in adults. We report the case of a 73-year-old gentleman who presented with clinical signs and symptoms mimicking that of a strangulated right inguinal hernia. At emergency operation the scrotum was found to contain bile. Following radiological imaging and exploratory surgery, a large retroperitoneal biloma was found. We discuss the clinical signs associated with biliscrotum and retroperitoneal biloma and describe our operative management of this patient. We review the previously reported cases of these rare clinical entities. We found that our case exhibited similarities in terms of the age of presentation and presence of distal common bile duct stones. This is, to our knowledge, the only reported case of a patient presenting with biliscrotum secondary to the assumed spontaneous rupture of the common bile duct and development of a retroperitoneal biloma.

99Tcm-MAG3: in vitro stability and in vivo behaviour at different times after preparation.

A kit for preparing technetium-99m mercaptoacetyltriglycine (99Tcm-MAG3), a new radiopharmaceutical for gamma camera renography, is available commercially. A drawback to the use of this kit is the recommended 1h expiry for 99Tcm-MAG3. This short expiry is a consequence of the possible growth of an impurity which undergoes hepatobiliary excretion and might interfere with renal imaging. Radiochemical purity of 99Tcm-MAG3 was measured by high performance liquid chromatography at 0, 1 and 6 h after preparation and was found to be consistently greater than 95. 99Tcm-MAG3 was shown to contain five impurities, one of which increased from 0.5% to 1% over 6 h. Dilution of 99Tcm-MAG3 eliminated this effect. A two-part clinical study was undertaken. For Part I, 99Tcm-MAG3 was prepared at 400 MBq/4 ml. For Part II, 99Tcm-MAG3 was prepared at 1 GBq/4 ml then subdivided and diluted to give single doses of 175 MBq/2.5 ml. In both parts, 10 patients were injected within 1 h after preparation and 10 were injected 5-6 h after preparation. From gamma camera images of the abdomen acquired 30 min after injection, the % injected 99Tcm in gall bladder and liver were calculated. In both parts, the % injected 99Tcm in gall-bladders and livers of the 1 h group were compared with those in the 5-6 h group and not found significantly different (p greater than 0.05). In conclusion, 99Tcm-MAG3 prepared according to the methods described, can be used up to 6 h after preparation.

One hundred cases of anaesthesia for extracorporeal shock wave lithotripsy.

One hundred cases of anaesthesia for Extracorporeal Shock Wave Lithotripsy (ESWL) are described. Epidural or general anaesthesia was used. Anaesthetic complications were mainly cardiovascular, namely hypotension and bradycardia. With increased experience, it was noted that the use of minimal concentrations of general anaesthetic agents, or epidural anaesthesia supplemented with ephedrine, decreased the incidence of these problems. There was a low incidence of nausea or vomiting or analgesic requirements postoperatively, and the average length of stay in hospital postoperatively was 3 days.

Morbidity and mortality associated with anaesthesia.

The incidence of serious complications associated with Anaesthesia appears to have decreased in recent years. There are many reasons for this-better anaesthetic drugs and equipment, widespread availability of modern monitoring devices, improved standards of pre-, intra- and postoperative care, increasing interest in techniques to identify and control common risk factors and increased number of qualified anaesthetists. Nevertheless, accidents continue to occur. The most common cause of death or serious injury is still failure to ventilate the patient. All recent studies agree that the majority of accidents in modern practice are the consequence, not of equipment failure or adverse drug reactions, but of human error. Mistake, lack of vigilance, inexperience, inadequate supervision and failure of communication are identified as recurring problems. These problems need to be addressed if anaesthesia-related complications are to be further decreased. It seems reasonable to suggest that the use of anaesthesia simulators to train and test anaesthetists in difficult situations should be given a higher priority-both in basic training and in continued postgraduate education. Furthermore, since anaesthesia-related adverse outcomes are rare, strict safety procedures must be applied to thousands of patients in order to prevent one catastrophe. During times of increasing competition for health care money, anaesthetists must be resolute in defending and improving standards of training, monitoring and clinical care. Otherwise the substantial improvement in anaesthesia practice accomplished over recent years may quickly be lost again.

Injectable aspirin as a postoperative analgesic.

The effectiveness of lysine acetyl salicylate (LAS) 1.8 g, equivalent to aspirin 1 g, in relieving severe, immediate, postoperative pain has been compared with that of morphine 10 mg in comparable groups of patients. A single injection of LAS 1.8 did not give effective or consistent relief of pain, while morphine was both effective and consistent in its action. However, LAS was shown to have some analgesic activity.

The quantitative evaluation of acute lung injury.

The lung represents a complex barrier between air and blood. Subtle changes in the permeability of this barrier can be brought about by injury and only later do they become clinically and radiologically detectable. Techniques using radioactive traces offer a way of quantifying the degree of lung injury and so will aid the development of new forms of therapy.

Intramuscular midazolam. A comparison of midazolam with papaveretum and hyoscine for intramuscular premedication.

Midazolam, administered intramuscularly was compared with papaveretum and hyoscine for premedication in patients undergoing gynaecological surgery. Midazolam proved to be a satisfactory agent for premedication compared with papaveretum and hyoscine, producing a similar degree of sedation and anxiolysis, but causing significantly more anterograde amnesia.

The effects of one month high fructose intake on plasma glucose and lipid levels in non-insulin-dependent diabetes.

The effects of a high fructose diet on the control of blood glucose and serum lipids were studied in 10 non-insulin-dependent diabetic patients (mean age 64.4 years, mean duration of diabetes 5.6 years). Comparison was made following 28 days on the usual diabetic diet and 28 days during which 25% of the usual carbohydrate was substituted with fructose. There was no change in mean (+/- SEM) fasting plasma glucose (on usual diet 9.2 +/- 0.5 mmol/l, on fructose diet, 9.1 +/- 0.4 mmol/l), but there was a fall in mean plasma glucose levels at 30, 60, and 120 min in a 75 g OGTT following the fructose diet. There was no significant change in fasting lipids: on usual diet mean serum cholesterol 5.8 +/- 0.2 mmol/l, on fructose diet 5.6 +/- 0.2 mmol/l; serum triglyceride, on usual diet 1.3 +/- 0.1 mmol/l, on fructose diet 1.3 +/- 0.1 mmol/l; HDL cholesterol on usual diet 1.4 +/- 0.1 mmol/l, on fructose diet 1.4 +/- 0.1 mmol/l. Mean body weight did not vary significantly between the two diets. Incorporation of fructose into the diabetic diet may lower post-prandial glucose levels without disturbing serum lipids.

Local anaesthetic infiltration for surgical exodontia of third molar teeth: a double-blind study comparing bupivacaine infiltration with i.v. ketorolac.

We studied 40 patients undergoing surgical removal of at least two third molar teeth under general anaesthesia. Patients were allocated randomly to one of two groups: group B (n = 20) received bupivacaine up to 2 mg kg-1, infiltrated around the inferior alveolar nerves bilaterally, and group K (n = 20) received ketorolac 10 mg i.v. at the start of surgery. There were no significant differences between the two groups in postoperative pain scores measured at 1 h using a visual analogue scale. Group K had a significantly lower incidence of side effects related to intraoral anaesthesia. Swallowing, speech and oral continence were significantly better. Group K scored higher for overall patient satisfaction, measured using a visual analogue scale. We failed to demonstrate any difference in early postoperative recovery (coughing, laryngospasm, stridor or arterial oxygen desaturation) between the groups. We conclude that the use of 0.5% bupivacaine infiltration was no more effective than a single 10-mg injection of ketorolac while giving rise to a higher rate of "minor" airway complications and lower patient acceptability.

Tetanic fade during neuromuscular blockade produced by atracurium in the rat diaphragm preparation.

In the present investigation, we studied and measured the phenomenon of tetanic fade and peak tetanic tension depression in the rat diaphragm preparation in the presence of a blocking concentration of atracurium (e.g., 10 mumol.l-1). Atracurium (10 mumol.l-1) produced a pronounced tetanic fade (i.e., 47-69% reduction of total sustained tetanic tension) at a time (15 s) when it reduced the peak tetanic tension by only 25%. The time course for total tetanic fade was 30-35 s, whereas the time taken for complete peak tetanic tension depression was 3-3.5 min, suggesting that the two effects were produced via different mechanisms, involving presynaptic and postsynaptic mechanism. It was concluded that atracurium produces a profound tetanic fade, with respect to its effect on twitch or tetanic tension, suggesting that the drug is a potent neuromuscular blocker, with rapid onset of blockade.

Effects of atropine and glycopyrrolate on neuromuscular transmission in the rat phrenic nerve-diaphragm preparation.

1. The effects of atropine and glycopyrrolate on neuromuscular transmission and on muscle contraction, were studied, in the rat diaphragm preparation, by analyzing their effects on the indirectly (and directly)-elicited twitch (0.2 Hz), tetanic (50 Hz for 20 sec duration), post-tetanic twitch responses (at 5 sec after the tetanus), and on the phenomenon of post-tetanic twitch potentiation (PTP), which is thought to be of a presynaptic origin, i.e. due to increased transmitter release. 2. Atropine (0.001-10 microM) increased the indirectly-elicited twitch tension by 22 +/- 2.1% (control 0.9 +/- 0.1 g, P less than 0.02), the tetanus by 15 +/- 1.1% (control 3.9 +/- 0.7 g, P less than 0.05), the post-tetanic twitch response by 33 +/- 3.1% (control 1.2 +/- 0.1 g, P less than 0.01) and the PTP value by 36 +/- 1.9% (control 33 +/- 2.3%, P less than 0.01, means +/- SEM = 6). 3. Atropine (0.001-10 microM) had little effect on the directly-elicited twitch tension, but in high concentrations (e.g. 20 microM), it blocked the twitch tension. 4. In contrast, glycopyrrolate (0.1-100 microM) had little effect on the twitch tension (direct or indirect), but it significantly reduced the tetanus (by 38 +/- 3.5%, P less than 0.01), the post-tetanic twitch response (by 17 +/- 1.2%, P less than 0.05) and the PTP values (by 24 +/- 3.1% P less than 0.02). 5. In the presence of hemicholinium (1.3 microM) the responses to atropine and glycopyrrolate were altered (decreased), indicating a possible action on presynaptic mechanism of transmission. 6. It is concluded that atropine and glycopyrrolate produce different (opposite) effects at the rat neuromuscular junction, atropine enhances whereas glycopyrrolate depresses neuromuscular transmission. The effects of these two antimuscarinic drugs may be exerted at the presynaptic nerve terminals, i.e. on presynaptic muscarinic receptors, which are involved in the feedback mechanism of transmitter release.

Comparative effects of atropine and oxotremorine on neuromuscular transmission at the rat hemidiaphragm preparation.

The effects of atropine (0.001-10 microM) and oxotremorine (0.51-51.3 microM) on neuromuscular transmission and muscle contraction were studied by analysing their effects on the twitch, tetanic and post-tetanic twitch responses and on the phenomenon of post-tetanic twitch potentiation (PTP) in a rat phrenic nerve-diaphragm preparation. In addition, the effects of atropine (0.1 microM) and oxotremorine (0.6 microM) were studied on the contractions produced in rat ileum by superfusate from repetitively stimulated phrenic nerve diaphragm preparation. The results showed that atropine had a dual action at the neuromuscular junction; at low concentrations (0.001-1.0 microM) enhanced, whereas at high concentration (greater than 1.0 microM) decreased the twitch, tetanic and post-tetanic twitch responses in the rat diaphragm preparation. Oxotremorine, on the other hand, always reduced these responses and also reduced the contractions produced by diaphragm perfusate and by exogenous acetylcholine (ACh) in the rat ileum. Since atropine enhanced the contractions, in rat diaphragm, to electrical stimulation, and those in rat ileum, to superfusate of stimulated diaphragm preparation, the results may suggest that atropine has a presynaptic action at the rat neuromuscular junction. The presence of more than one type of presynaptic muscarinic autoreceptors is discussed in relation to the results obtained.

Effect of antagonism of mivacurium on recovery of extraocular muscle function.

We have measured extraocular muscle function in 41 patients who received neuromuscular block with mivacurium 0.2 mg kg-1 during anaesthesia with propofol, ketorolac, fentanyl and isoflurane in nitrous oxide and oxygen, which was antagonized at the end of surgery with neostigmine 0.05 mg kg-1 and glycopyrronium 0.01 mg kg-1 in 21 of these patients. Extraocular muscle function was measured before and after surgery in each group with the Maddox Wing apparatus and compared with a control group (n = 20) who breathed spontaneously the same gaseous anaesthetic mixture via a reinforced laryngeal mask airway. In patients where the action of mivacurium was antagonized, extraocular muscle function was improved significantly 20 min after antagonism (P < 0.001) compared with those who received no antagonism. At 60 min after antagonism, there were no differences between the groups. There were no differences between patients who received no neuromuscular blockers and those who received blocker and antagonist.