Randomised controlled trial of combined spinal epidural vs. spinal anaesthesia for elective caesarean section: vasopressor requirements and cardiovascular changes.

BACKGROUND AND OBJECTIVES: Combined spinal and epidural anaesthesia (CSEA) has previously been shown to result in a higher sensory block than equivalent single shot spinal anaesthesia (SSSA). In nonpregnant patients, hypotension was also more pronounced in the CSEA group. The aim of this randomized trial was to compare the haemodynamic stabilities of CSEA and SSSA during elective caesarean section when the same dose of anaesthetic was administered. This was studied directly by measuring the noninvasive arterial blood pressure (BP) and indirectly by the amount of ephedrine required to maintain baseline BP. Systemic vascular resistance index (SVRI) and cardiac index (CI) were also measured using thoracic impedance cardiography. METHODS: Seventy women received hyperbaric bupivacaine (12.5 mg) and diamorphine (0.3 mg) intrathecally via either CSEA or SSSA. Noninvasive arterial BP, CI and SVRI were measured every 2 min. The total ephedrine used was calculated. RESULTS: There were no significant differences between the groups in ephedrine requirements (P = 0.38), intraoperative mean arterial pressure (P = 0.77), CI (P = 0.17) or SVRI (P = 0.10). CONCLUSION: CSEA placement appears to offer no haemodynamic benefits compared with SSSA when the same dose of local anaesthetic is administered.

Randomized comparison of uterine artery embolization (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): subanalysis of 5-year MRI findings.

PURPOSE: To report 5-year contrast-enhanced magnetic resonance imaging findings of the REST trial recruits who underwent either uterine artery embolization (UAE) or myomectomy. METHODS: A total of 157 patients were randomized to UAE or surgery (hysterectomy or myomectomy). Ninety-nine patients who had UAE and eight patients who had myomectomy were analyzed. MRI scans at baseline, 6 months, and 5 years were independently interpreted by two radiologists. Dominant fibroid diameter, uterine volume, total fibroid infarction (complete 100 %, almost complete 90-99 %, partial <90 %), and new fibroid formation were the main parameters assessed and related to the need for reintervention. RESULTS: In the UAE group, mean ± standard deviation uterine volume was 670 ± 503, 422 ± 353, and 292 ± 287 mL at baseline, 6 months, and 5 years, respectively. Mean dominant fibroid diameter was 7.6 ± 3.0, 5.8 ± 2.9, and 5 ± 2.9 cm at baseline, 6 months, and 5 years. Fibroid infarction at 6 months was complete in 35 % of women, almost complete in 29 %, and partial in 36 %. Need for reintervention was 19, 10, and 33 % in these groups, respectively (p = 0.123). No myomectomy cases had further intervention. At 5 years, the prevalence of new fibroid was 60 % in the myomectomy group and 7 % in the UAE group (p = 0.008). CONCLUSION: There is a further significant reduction in both uterine volume and dominant fibroid diameter between 6 months and 5 years after UAE. Complete fibroid infarction does not translate into total freedom from a subsequent reintervention. New fibroid formation is significantly higher after myomectomy.

Metastases to breast from primary lung cancer.

Metastatic disease to the breast from extra mammary sites is uncommon and has an incidence of 0.5 to 3%. It is important to make an accurate diagnosis as this has an impact on the therapeutic planning and management. Clinically, it can be difficult to differentiate between primary breast cancer and a metastatic disease. An incorrect diagnosis can lead to unnecessary surgical interventions. Immunohistochemistry has a significant role in identifying the primary origin of tumor and has to be considered in the presence of unusual cytologic patterns. We report three cases of metastatic disease to breast from primary lung tumors. The cases demonstrate the difficulties encountered in the diagnosis and the impact on the management of these patients.