Postoperative outcome in Chinese patients having primary total knee arthroplasty under general anaesthesia/intravenous patient-controlled analgesia compared to spinal-epidural anaesthesia/analgesia.

OBJECTIVE: To compare postoperative outcomes in patients having primary total knee arthroplasty receiving general or regional anaesthesia. DESIGN: Randomised prospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: Patients having primary total knee replacement were randomised to either general anaesthesia followed by postoperative intravenous patient-controlled analgesia with morphine, or combined spinal-epidural anaesthesia followed by postoperative epidural infusion of bupivacaine 0.1% with fentanyl 2 microg/mL. MAIN OUTCOME MEASURES: Visual analogue scale pain scores, perioperative blood loss, time to first meal and ambulation, and prevalence of postoperative complications. RESULTS: Sixty consecutive patients were enrolled in this study. Postoperative median pain scores were consistently lower at 1 (P<0.0001), 6 (P=0.08), 12 (P=0.003), 24 (P=0.14), and 48 hours (P=0.007) in those given regional anaesthesia. Although there was a trend towards fewer complications in the latter group, there were no statistically significant differences between the two groups with respect to the incidence of postoperative blood loss, haemodynamic instability, pruritus, nausea, vomiting, urinary retention, or other surgical/medical complications. Postoperatively, patients given regional anaesthesia also resumed meals earlier (P<0.0001), and showed a trend towards earlier ambulation and hospital discharge. CONCLUSION: Chinese patients undergoing total knee arthroplasty with regional anaesthesia/regionally delivered analgesia enjoyed better postoperative pain relief and resumed meals earlier than those receiving general anaesthesia/intravenous patient-controlled analgesia. The former also showed trends towards less adverse effects, postoperative complications, earlier ambulation, and earlier hospital discharge.

Stereotaxic treatment of seizure disorder.

Individuals with intractable epilepsy have a murky existence, fraught with medical helplessness, social rejection and personal despair. Drugs control many, but unfortunately not all, cases of epilepsy. An attempt to elucidate on the indications, selections and rationale for the stereotaxic interruption is made. Three cases of intractable epilepsy treated by stereotaxic Fields of Forel Interruptions are reported with special emphasis on pre and postoperative evaluations. Based on the data so far available, it appears that a significant number of patients with medically intractable epilepsy who are not candidates for "standard" neurosurgical interventions, can be helped further by stereotaxic interruptions with minimal morbidity.

Effects of posture on respiratory mechanics in obesity.

Increased abdominal mass in obesity should enhance normal gravitational effects on supine respiratory mechanics. We have examined respiratory impedance (forced oscillation over 4-26 Hz applied at the mouth during tidal breathing), maximum inspiratory and expiratory mouth pressures (MIP and MEP), and maximum effort flow-volume curves seated and supine in seven obese subjects (O) (mean age 51 yr, body mass index 43.6 kg/m2) and seven control subjects (C) (mean age 50 yr, body mass index 21.8 kg/m2). Seated mean total lung capacity was smaller in O than in C (82 vs. 100% of predicted); ratio of functional residual capacity (FRC) to total lung capacity averaged 43% in O and 61% in C (P < 0.01). Total respiratory resistance (Rrs) at 6 Hz seated was higher in O (4.6 cmH2O.l-1.s) than in C (2.2 cmH2O.l-1.s; P < 0.001); total respiratory reactance (Xrs) at 6 Hz was lower in O than in C. In C, on changing to the supine posture, mean Rrs at 6 Hz rose to 2.9 cmH2O.l-1.s, FRC fell by 0.68 liter, and Xrs at 6 Hz showed a small fall. In O, despite no further fall in FRC, supine Rrs at 6 Hz increased to 7.3 cmH2O.l-1.s, and marked frequency dependency of Rrs and falls in Xrs developed. Seated, MIP and MEP in C and O were similar; supine there were small falls in MEP and maximum expiratory flow in O. The site and mechanism of the increase in supine Rrs and reduction in supine Xrs and the mechanism maintaining supine FRC in obesity all need further investigation.

Clinical evaluation of a depth electroencephalography electrode.

Stereo depth electroencephalography (EEG) is of proven benefit in lateralizing and localizing seizure origin in select cases of epilepsy. There are potential hazards and technical considerations inherent with depth EEG, however, that have limited the general applicability of this technique. A new depth EEG electrode with materials and design features that facilitate safe insertion and artifact-free recording has been developed. The design features and technique for inserting the electrode are described. The electrode was evaluated during 2600 hours of implantation and recording in seven patients. With the use of stereotactic techniques, the electrode could be positioned accurately within precise anatomical landmarks such as the amygdaloid nucleus and the hippocampus. After insertion, no hemorrhage or edema was detected along the electrode tracts by third generation computed tomographic scanning. There was no evidence of pyrogenicity or infection. Electrode migration was not observed. A large electrical field could be sampled because of the relatively large surface of the cylindrical depth electrode contacts.

Waldenstrom's macroglobulinemia presenting with pleuropulmonary and gastric manifestations.

A case of Waldenstrom's macroglobulinemia is reported in which the main clinical presentation was related to pulmonary infiltrations and pleural effusion. Serum protein studies demonstrated the characteristic monoclonal increase in immunoglobulin M (IgMK). Pleural and percutaneous lung biopsies showed dense lymphocytic infiltration. Gastric biopsy also showed focal atypical lymphoid hyperplasia. There was good clinical and radiological response to treatment with chlorambucil and prednisolone.

The breathing patterns in Chinese and Indian adult males in the supine posture.

The breathing patterns in the supine posture during inspiration from functional residual capacity (simulating the "liver palpation" manoeuvre) were studied in two groups of young adult male Chinese and Indians with each group comprising 30 subjects. Both groups were matched for age, height and weight. Although the findings did not reach a statistically significant level, Indian subjects were found to breathe more with their abdomen compared to the Chinese during the manoeuvre. The two groups behaved similarly when they breathed with increasing amplitude from their resting tidal volume to full inspiratory capacity. There was also no difference between the two groups when they performed the total lung capacity manoeuvre.

Group G streptococcal endocarditis and bacteraemia--a report of 3 cases.

Three patients with Group G Streptococcal infection presenting with endocarditis and septicaemia are reported. All had underlying cardiac disease, and one had diabetes mellitus and a colonic carcinoma. Our three patients responded to intravenous crystalline penicillin.

A case of primary diffuse tracheobronchial amyloidosis treated by laser therapy.

We report a case of primary diffuse tracheobronchial amyloidosis in a 72-year-old lady who presented with a long history of recurrent cough, dyspnoea, wheezing, haemoptysis and chest infection. She was treated successfully with three sessions of laser therapy. There were improvements in both clinical symptoms and measurements of airway obstruction. Bronchodilators and oral prednisolone were not required after treatment.

Evaluation of the efficacy of sequential intravenous-oral administration of pefloxacin in community-acquired lower respiratory tract infections in patients with underlying conditions.

We studied the efficacy of sequential intravenous-oral pefloxacin therapy in community-acquired lower respiratory tract infection in 24 patients with one or more underlying conditions. Twenty-eight patients were enrolled into the study but only 24 patients were evaluated. There were 16 males and 8 females with a mean age of 66.9 +/- 11.2 years (mean +/- SD, range 46 to 87 years). The underlying conditions present were bronchiectasis, chronic obstructive lung disease and diabetes mellitus. Patients who were older than 70 years but without any underlying condition were also enrolled. All received 4 days of intravenous pefloxacin 400 mg twice a day followed by oral pefloxacin 400 mg twice a day for another 10 days. Assessment of success was based on clinical, microbiological and radiological improvement. Pefloxacin produced 79.2% clinical cure rate. Another 8.3% showed improvement. Pefloxacin was well tolerated. There were few adverse effects and none of the patients required a change of antibiotic. Pefloxacin was an effective and well tolerated treatment for respiratory tract infection and had the advantage of broad in-vitro antibacterial activity, twice daily dosing and sequential availability in an intravenous and oral formulation.

The effect of fresh orange juice on bronchial hyperreactivity in asthmatic subjects.

We studied 16 mild stable asthmatic subjects to determine if orange juice increases nonspecific bronchial hyperreactivity (NSBH). In 9 subjects, bronchial responsiveness to histamine was assessed before and after water ingestion on the control day, and orange ingestion on a consecutive day. The mean (+/- SD) ratio of log10 PD20 FEV1 after water: log10 PD20 FEV1 before water (1.00 +/- 0.13) was not significantly different from the mean (+/- SD) ratio of log10 PD20 FEV1 after orange: log10 PD20 FEV1 before orange (0.97 +/- 0.12). To avoid the possibility of histamine tachyphylaxis, 7 subjects participated in a second protocol in which histamine PD20 FEV1 was determined on a control day (geometric mean 0.11 mg.) and again two days later, thirty minutes after ingestion of orange juice (geometric mean 0.06 mg). There was no significant difference in the PD20 FEV1 (p = 0.344). Our data show that ingestion of fresh orange juice per se did not heighten NSBH in our subjects. (PD20 FEV1 is the dose of histamine required to produce a twenty percent fall in forced expiratory volume in one second [FEV1]).

Occupational asthma due to spot-welding.

A case of occupational asthma from fumes due to spot-welding is described. The hazards from resistance welding have been considered minimal as compared to other types of welding. This paper illustrates the possible hazards of occupational asthma among welders including those doing spot-welding. It also illustrates the difficulties encountered in identifying the specific causative agent in such cases.

The obstructive sleep apnoea syndrome--experience of a referral centre.

OBJECTIVE: The aims of this study were: (i) to document the presence and severity of obstructive sleep apnoea (OSA) in patients who complained of heavy snoring and other symptoms suggestive of the OSA syndrome; (ii) to examine the correlation between the clinical and polygraphic findings, and (iii) to document the efficacy and compliance of nasal continuous positive airway pressure (CPAP) among these Asian snorers with OSA. METHODS: We analysed our clinical and nocturnal polysomnographic data between January 1986 and December 1995 for physician-referred patients who had complained of snoring and other symptoms suggestive of OSA. RESULTS: A total of 277 diagnostic studies were performed of which 145 (52%) were positive to OSA. For studies performed in the last 2 years (n = 125), 72 of the 125 were positive for OSA. Anthropometric data was not discriminative between the OSA positive snorers and the OSA negative snorers. We found that hypertension and choking were the most significantly related to OSA, conferring a 7 and 4 times relative risk respectively. Nasal CPAP eliminated snoring, apnoeas and oxygen desaturations completely in almost all cases and there were only minor mask-related side effects. CONCLUSION: OSA may not be uncommon among Asian snorers. Of the major traits for OSA risk among our local population, a history of hypertension and reports of nocturnal choking were the most significantly related. We have also shown that nasal CPAP is safe and effective among our local snorers and should be considered a first-line treatment for OSA.

Occupational asthma in Singapore--a review of cases from 1983 to 1990.

One of the newer occupational diseases in Singapore is occupational asthma. As on 31 December 1990 there were 35 confirmed cases of occupational asthma in the official statistics on occupational disease. We report in this paper our observations and experience based on these cases. The problem of under-reporting and the importance of early diagnosis are discussed.

A case of late dumping syndrome.

We report a case of late dumping syndrome in a 49-year-old lady who had partial gastrectomy for bleeding peptic ulcer 11 years ago. She presented with unexplained syncopal attacks which did not have any apparent relationship to meal or posture. An unusual reaction to oral glucose tolerance test ordered by her gynaecologist who was seeing her for uterine fibroid led to the diagnosis. Late dumping syndrome was confirmed by a repeat oral glucose tolerance test. At the second hour of the test, she developed hypoglycaemic coma with a blood glucose level of 50 mg/dL and a hypocount of 47 mg/dL. She regained full recovery after dextrose infusion which raised the hypocount to 123 mg/dL. The dizzy spells and syncopal attacks disappeared with dietary adjustment.

A case of occupational asthma due to barley grain dust.

We report a case of occupational asthma due to barley grain dust, species Hordeum Vulgare L, in a 32-year-old storeman of a trading company's department that dealt with packaging of flour, barley and peanuts. He developed immediate symptoms of sneezing, cough and dyspnoea on exposure to barley only. These symptoms showed work relationship. He became asymptomatic after his transfer to another department dealing with sales only. Bronchial provocation testing to the barley confirmed the diagnosis.

Rapid application development in small unit settings.

Small units with specialised functions often have difficulty in developing information systems because of their unique and dynamic requirements, the smallness of their applications relative to the large inter-organisational networks, and the sheer numbers of such units, especially in government. Personal experience with the difficulty of establishing a suitable information system has led to the development of a methodology for endusers to develop their own applications with only the guidance of information technology professionals (ITPs)--here entitled 'Small Unit Enduser Rapid Application Development' or SERAD. A data base management system (DBMS) is used to manage data about 'focal objects' with status flags and queries/views at interface points through UDA (UserAction, DataEntry, ApplicationAction) cycles. The system which permits data entry almost immediately, not only eventually creates a full application, but also trains endusers in the process. The methodology leads ITPs and ensuers through a sequence of exercises in systems analysis, tailored to minimise the time and effort input of ITPs despite the relative lack of IT training and concepts in endusers, with a view to rapidly creating dynamic, robust and sound information systems.

A survey of infections in stereotactic surgery.

In 365 consecutive intracranial stereotactic procedures over a 6-year period, there were three postoperative infections; 1 case of increased neurological deficit and 1 of fatality. Staphylococcus aureus was the most common organism involved; however, multiple organisms were seen in 2 cases. Multiplicity of organisms necessitated the use of a broad spectrum of antibiotics in the preoperative and postoperative periods. The method described has permitted an infection rate which compares favorably to other reports in the literature. Perioperative antibiotics, antibiotic-containing irrigation solutions, and careful attention to sterile techniques seem to be instrumental in maintaining a low infection rate in our study. Since the new spheroid design has been used, there have been no infections.

Effect of induced bronchoconstriction on nasal airflow resistance in patients with asthma.

1. Reflex bronchial changes have been demonstrated after nasal stimulation in both man and experimental animals. The existence of a pulmonary-nasal reflex is less established. We have examined whether induced narrowing of the intrathoracic airways leads to increases in nasal airflow resistance (Rnaw) in patients with asthma. 2. We have used a non-invasive forced oscillation method to measure total respiratory resistance (Rrs) at 8 Hz during tidal breathing sequentially via the nose (Rrs, na) and via the mouth (Rrs, mo) and derived Rnaw by subtracting Rrs, mo from Rrs, na. We examined whether changes in Rnaw occurred when increases in Rrs, mo were induced by inhaling histamine aerosol via the mouth with the nose occluded in 11 patients with stable, mild asthma (six males, age 28.1 +/- 2.1 years, forced expiratory volume in 1 s 97 +/- 6% of predicted, means +/- SEM). Six of the patients had a history of rhinitis. The patients were first challenged with doubling concentrations of histamine via a dosimeter to establish the dose which reduced the forced expiratory volume in 1 s by > or = 20%. Two hours later when the forced expiratory volume in 1 s had returned to baseline, they were challenged with saline and again 2 h later with the concentration of histamine that had earlier caused a > or = 20% fall in the forced expiratory volume is 1 s. 3. Between 0.5 and 10 min after histamine inhalation, a sustained increase in Rrs, mo was achieved with mean increases averaging 68-77% above baseline over this period (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)