In vitro effects of opioids on pregnant uterine muscle.

Opioids are often used for obstetric analgesia. Ideal obstetric analgesia is attained with optimal pain relief and minimal risk for the parturient. Therefore, investigators in the present study explored the effects of different opioids on the myometrium of pregnant rats. Myometrial strips were exposed to increased concentrations of fentanyl (10(-8) M to 10(-6) M), alfentanil (10(-8) M to 10(-4) M), remifentanil (10(-8) M to 10(-4) M), and meperidine (10(-8) M to 10(-4) M). Decreased contractile activity was observed in myometrial strips isolated from pregnant rats at cumulative concentrations of fentanyl, alfentanil, remifentanil, and meperidine. The amplitude of contractions was reduced with increasing concentrations of opioids; this effect was statistically significant at a concentration of 10(-4) M. When administered at higher concentrations, opioids may decrease contractions in pregnant rat myometrium.

Acute tracheobronchial injuries: early and late term outcomes.

BACKGROUND: To evaluate the early and long-term outcomes of acute tracheobronchial injuries (TBI). METHODS: Twelve patients (10 males, 2 females; mean age 28; range 10 to 65 years) diagnosed as tracheobronchial injury and managed during between December 1997 and December 2004 were evaluated retrospectively. Clinical presentation, diagnostic evaluation, associated traumas, surgical management and outcome were reviewed. Follow-up ranged from 1 to 7 years. RESULTS: All patients underwent surgical debridement and primary repair (anastomosis). There were three tracheal, eight bronchial and one laryngotracheal injury. Accompanying simultaneous traumas were treated at the same session in all cases. One case was discharged from the hospital with permanent tracheostomy. Control bronchoscopies were performed one week and one month after the surgical repair. Bronchiectasia developed in one case after five years and left lower lobectomy was performed. One case died 23rd day after the primary repair. In the remaining ten cases no complication was determined. CONCLUSION: In all cases with a suspicion of TBI, bronchoscopy should be performed immediately by specialist physicians. Early recognition of tracheobronchial injury and expedient institution of appropriate surgical intervention are lifesaving in these potentially lethal injuries. Concomitant injuries are the most important mortality factor.

Remifentanil/midazolam versus tramadol/midazolam use for colonoscopy.

One of the most commonly performed outpatient procedure is colonoscopy. The pain and anxiety is frequently associated with colonoscopy. The aim of this study was to compare the effectiveness of remifentanil/midazolam, and tramadol/midazolam for iv sedation and analgesia during colonoscopy. Twentysix patients (age range 18-65 years) scheduled for ambulatory colonoscopy were included to study. All patients received midazolam 1 mg intravenous. After two minutes in Group R (remifentanil/midazolam, n=18) remifentanil bolus (10 microg) and infusion 0.03 microg kg(-1) min(-1) were administered until adequate sedation level was achieved. In Group T (tramadol/midazolam, n=18) iv tramadol 50 mg was given concurrently. During procedure 2 L/min oxygen was supplemented via face mask to all patients. Haemodynamic variables, respiratory depression, level of sedation, postoperative recovery, patient and gastroenterologist satisfaction were surveyed. Patients were asked to verbally rate their level of pain, on an 10-point numerical rating scale (1=no pain, 10=severe pain). Chi-square, student t test, and mann whitney U test were used for statistical analysis. Colonoscopy was carried out successfully in all patients. There were no episodes of desaturation or airway compromise. Haemodynamic parameters were similar in both groups. Sistolic arterial and diastolic arterial pressures were increased at 10 and 15 minutes in all patients (P<0.05). There were no significant changes in heart rate in both groups. The level of sedation in group R was higher than group T during colonoscopy. The patients in group T had higher pain scores. Gastroenterologist satisfaction and patient satisfaction were similar in both groups. Our results suggests that, sedoanalgesia with midazolam/remifentanil may be an alternative to sedoanalgesia with midazolam/tramadol for colonoscopy.

Patient-controlled epidural analgesia in labour: the addition of fentanyl or clonidine to bupivacaine.

In this study, we studied 45 healthy parturients with singleton vertex presentation. Patients were allocated randomly to receive either 0,125 % bupivacaine with 2 micro g/ml fentanyl or 0,125 % bupivacaine with 1,5 micro g/ml clonidine for epidural labour analgesia. A patient controlled epidural analgesia (PCEA) pump was programmed as follows: basale infusion rate: 6 ml/h, demand bolus: 5 ml, lockout interval: 10 min. Efficacy of analgesia was evaluated using visual analogue scale. Maternal and fetal cardiovascular variables, Apgar scores of the newborn at 1-5 min and umbilical arterial blood gas measurements were recorded. The duration of stages of labour and total analgesic consumption were also noted. Systolic blood pressure decreased significantly at 3rd h in bupivacaine plus fentanyl group. Although all patients experienced a good analgesia, pain scores in bupivacaine plus clonidine group were lower than bupivacaine plus fentanyl group. The analgesic requirement in bupivacaine plus clonidine group was less than the other group. There were no significant differences in fetal heart rate, Apgar scores or umbilical blood gases. In conclusion, the addition of clonidine to epidural bupivacaine for PCEA was superior to bupivacaine plus fentanyl for analgesia and analgesic requirement during labour.

Risk factors of breast cancer-related lymphedema.

INTRODUCTION: Secondary lymphedema is one of the major important long-term complications of breast cancer treatment. The aim of this study is to determine patient- and treatment-related risk factors of lymphedema in breast cancer patients. PATIENTS AND METHODS: Patients, who had been operated on for primary breast cancer at Akdeniz University Hospital and followed regularly between August 1984 and December 2009 were included in the study. In order to evaluate the arm swelling objectively, measurements were performed with a flexible tape measure for both arms, and limb volume was calculated using a truncated cone volume formula. Participants, whose volume difference between the two arms was ≥ 5%, were considered as lymphedema-positive patients. The SPSS program (SPSS inc. Chicago, IL) was used for statistical analysis. RESULTS: The mean age of 455 patients was 50.6 years and the median follow-up time was 53 months. Lymphedema was found in 124 (27%) patients. Most of the patients with a history of postoperative wound infection (52%) and lymphangitis (57%) had lymphedema (p=0.003 and p=0.002, respectively). Addition of radiation therapy increased lymphedema risk 1.83 times (p=0.007). The mean duration of the axillary drainage and number of the removed lymph nodes were 7.8 days and 19, respectively. The rate of lymphedema in patients with early stage breast cancer was less than patients with advanced breast cancer (24% and 35.3%, respectively, p=0.018). Most of the patients (92%) with lymphedema had a high body mass index (BMI ≥ 25 kg/m²), and obesity was another important factor for lymphedema (p<0.001). CONCLUSIONS: The most important treatment and patient-related risk factors for breast cancer-related lymphedema were obesity (≥ 25 kg/m²), axillary lymph node dissection, postoperative radiotherapy, wound infection, history of lymphangitis, and duration of axillary drainage. Elimination or prevention of these risk factors may reduce the incidence of lymphedema.

Systemic toxicity of tacrolimus given by various routes and the response to dose reduction.

PURPOSE: To evaluate the long-term systemic toxicity of tacrolimus (FK-506) administered by various routes, and to assess the effect of dose reduction on toxicity. METHODS: The study animals were 120 experimentally naive adult female Wistar rats weighing 200-250 g each. The rats were randomly divided into 10 equal groups (n=12 in each) and treated with tacrolimus administered topically (in drops, 0.3%, q.i.d.), intravitreally (0.5 mg/kg bodyweight/week), intramuscularly (1 mg/kg bodyweight/week), low-dose intravenously (1 mg/kg bodyweight/week) and in high-dose intravenously (2 mg/kg bodyweight/week) for 3 months. The rats in the control groups (one for each different route of administration) were treated with 0.9% NaCl. The blood concentration of tacrolimus, complete blood count and biochemistry parameters were measured each month for the 3-month study period. RESULTS: The rats in the control groups and experimental groups administered topical and intravitreal tacrolimus did not demonstrate any systemic toxic effects. The rats that developed certain toxic effects (hyperglycaemia, hyperkalaemia and nephrotoxicity) in the groups given low-dose or high-dose i.v. tacrolimus responded well to dose reduction. Following dose reduction, blood glucose concentrations decreased from 247.4 +/- 42.3 mg/dL to 189.6 +/- 37.9 mg/dL (P <0.05), and from 237.4 +/- 41.1 mg/dL to 182.3 +/- 22.7 mg/dL (P <0.05) in the low- and high-dose i.v. tacrolimus-treated rats, respectively. The rats that developed impaired hepatic function after high-dose tacrolimus did not respond to dose reduction. Baseline cholesterol concentrations for the intramuscular and low- and high-dose i.v. tacrolimus-treated groups, demonstrated decreases, respectively, from 87.4 +/- 14.0 mg/dL, 86.4 +/- 14.0 mg/dL and 90.4 +/- 14.3 mg/dL to 53.6 +/- 9.8 mg/dL, 52.1 +/- 12.5 mg/dL and 63.5 +/- 11.7 mg/dL by the end of the second month. The differences were found to be statistically significant (P <0.05 for each result). CONCLUSION: Topical or intravitreal administration of tacrolimus seems to be systemically safe whereas parenteral administration can cause some systemic haematological changes such as dose-dependent decreased serum cholesterol concentrations. Dose reduction may prevent such adverse effects.