Do we still need to restrict preoperative fluid administration in ambulatory anorectal surgery under spinal anaesthesia?

BACKGROUND: This study was undertaken to determine the effect of a restricted versus a standard intravenous fluid regimen on urinary retention and readiness for discharge after surgery for benign anorectal disease. METHODS: A total of 41 ASA I-II patients were randomized into a standard fluid regimen group (group S, n=21) or a restricted fluid regimen group (group R, n=20). Spinal anaesthesia was performed with hyperbaric ropivacaine. Haemodynamic variables were noted. Hypotension, headache, analgesia requirement, nausea and vomiting, thirst and urinary retention were evaluated postoperatively. The Mann-Whitney U and chi-squared tests were used. RESULTS: Patient demographics were comparable between the groups. The area under heart rate versus time curve was higher in group R than in group S (p=0.002). Additional fluid and ephedrine requirements were similar between the groups. First voiding time was longer in group R (p=0.045). CONCLUSION: In minor anorectal surgery under spinal anaesthesia with ropivacaine, standard fluid regimen provides stable haemodynamic variables without urinary retention.

Preoperative use of selective COX-II inhibitors for pain management in laparoscopic nissen fundoplication.

BACKGROUND: This randomized, double-blind, prospective, placebo controlled study was planned to determine the effectiveness of selective COX-II inhibitors used preoperatively to alleviate pain after Nissen fundoplication surgery. METHODS: For this study, 60 patients were allocated to four groups at random: group C (celecoxib, 200 mg by mouth), group R (rofecoxib, 50 mg by mouth), group P (placebo, pill), or group D (diclophenac sodium, 75 mg intramuscularly). Postoperative abdominal and shoulder pain experienced by the patient at rest, with motion, and with coughing were assessed. Side effects and postoperative analgesic requirement (tramadol, intramuscular) also were recorded. RESULTS: The median tramadol requirement in the 1st h and total tramadol requirement at the 24th h were higher in group P than in the other study groups (p < 0.01). The pain scores in the first postoperative hour were higher in group P (p < 0.05). CONCLUSIONS: The preoperative use of celecoxib, rofecoxib, or diclophenac in laparoscopic Nissen fundoplication surgery decreases pain intensity and tramadol requirement in the first postoperative hour and has a trarnadol sparing effect in the first 24 h.

Efficacy of omeprazole plus two antimicrobials for the eradication of Helicobacter pylori in a Turkish population.

Omeprazole combined with 2 antimicrobials has been suggested as a first-line option for Helicobacter pylori eradication in recent years. However, controversy exists regarding the efficacy of this protocol. This open-label, prospective clinical study investigated the efficacy of omeprazole-based triple therapy for H pylori eradication in 518 patients with H pylori-positive functional dyspepsia with or without duodenal ulcer. Amoxicillin, macrolides (clarithromycin or roxithromycin), and nitroimidazoles (metronidazole, ornidazole, or tinidazole) were the antibiotics used in the study. Nonulcer patients were randomly assigned to 1 of 8 different treatment protocols and duodenal ulcer patients were randomly assigned to 1 of 4 different treatment protocols consisting of omeprazole (20 mg once daily for nonulcer patients, 20 mg twice daily for ulcer patients for 14 days) with a combination of 2 of the above antimicrobials (for 10 days). H pylori infection was assessed by histologic findings and a rapid urease test before therapy and 4 weeks after therapy ended. Four hundred fifty-nine patients completed their regimens; 327 had functional dyspepsia (180 men, 147 women; median age, 39 years; range, 18 to 70 years) and 132 had ulcers (81 men, 51 women; median age, 40 years; range, 18 to 70 years). Eradication of H pylori was achieved in 58.8% (270 of 459) of all patients, 58.1% (190 of 327) of nonulcer dyspeptic patients, and 60.6% (80 of 132) of duodenal ulcer patients. The eradication rate varied from 47.2% to 69.4% in different treatment protocols. There were no statistically significant differences in eradication rates in any treatment group. All drugs were generally well tolerated in all groups, and no patient discontinued treatment because of side effects. Therapy with omeprazole and 2 antimicrobials for H pylori had limited efficacy in a Turkish population. The reason for these results, which conflict with those of other studies, is not clear. Further investigations of regimens for the eradication of H pylori in our population are necessary.

Postoperative analgesia in children using preemptive retrobulbar block and local anesthetic infiltration in strabismus surgery.

BACKGROUND AND OBJECTIVES: Postoperative pain management in pediatric strabismus patients is infrequently studied. Pediatric patients can be mobilized earlier if postoperative pain is minimized. In this study, two different regional anesthetic techniques, retrobulbar block and local infiltration, were compared with a "no block" control group for the postoperative management of pain in pediatric patients undergoing elective strabismus surgery. METHODS: Thirty patients were randomly allocated to one of the study groups: group 1 (n=10) control, group 2 (n=10) retrobulbar block, and group 3 (n=10) subconjunctival bupivacaine infiltration. The parameters that were evaluated during the early postoperative period (6 hours) were circulatory, pain scores by Visual Analog Scale (VAS) and Modified Pediatric Objective Pain Scale (MPOPS), additional analgesic requirement, nausea, and vomiting. The parameters that were evaluated after discharge from the hospital (on postoperative days 1 and 2) through questionnaires were additional analgesic requirement, nausea, vomiting, sleep disturbances, activity, and appetite. RESULTS: Group 3 had significantly higher VAS and MPOPS scores at postoperative 120, 180, 240, 300, and 360 minutes than groups 1 and 2 (P < .05). Patients in group 2 seemed to have a higher incidence of nausea and vomiting both in the early (6 hours) and late postoperative (postoperative days 1 and 2) periods; however, the difference was not statistically significant. Group 2 required less analgesic compared with groups 1 and 3 during the late postoperative period. Late postoperative activity and appetite were better in groups 2 and 3. CONCLUSIONS: Because there was no significant difference in terms of postoperative analgesia in the retrobulbar block or subconjunctival local anesthetic infiltration groups compared with the control group, we suggest that conventional methods of pain treatment are adequate for postoperative analgesia in strabismus surgery.

The relationship between the treatment of congenital dislocation of the hip and avascular necrosis.

The most important complication following the treatment of congenital dislocation of the hip is avascular necrosis. The potential sequelae that may arise after the onset of avascular necrosis are worse than if the hip remained dislocated. We evaluated 38 hips in which avascular necrosis developed after reduction. The average patient age at the time of reduction was 4.3 years, with a follow up of 6 to 15 years. Twelve hips had closed reduction and 26 had open reduction. Following reduction, 8 hips had Type I, 6 had Type II, 9 had Type III, and 15 had Type IV avascular necrosis. In this article, we evaluate our cases and review current literature on the subject. Close follow up and timely interventions can reduce potential sequelae to a minimum.

Effects of pregnancy and lactation on bone mineral density, and their relation to the serum calcium, phosphorus, calcitonin and parathyroid hormone levels in rats.

The aim of this study was to evaluate the net changes in bone mineral density (BMD) during the reproductive cycle, and their relation with changes in serum calcium (Ca), phosphorus (P), PTH and calcitonin levels in rats. Twenty-seven female Wistar rats were included in this study. They were divided into three groups as pregnant, lactating and control groups. BMDs of lumbar vertebrates, femoral and tibial bones, and Ca, P, calcitonin and PTH levels were measured at the end of pregnancy, at the end of lactation and in nulliparous controls. In the pregnant group, the BMDs of rats were significantly higher in lumbar vertebrates, femoral and tibia bones than those of the control group (p<0.05). Their PTH and Ca levels were significantly lower than the control group (p<0.05). However, no statistically significant difference was found regarding P and calcitonin levels when compared to those of the control group. In the lactating group, the BMDs were significantly lower in lumbar vertebrates, femoral and tibia bones than those seen in the control and pregnant groups (p<0.05). Ca and PTH levels were significantly higher in lactating rats than in those of pregnant rats (p<0.005). Normal pregnancy increases BMD in rats, whereas lactation decreases it. Change in PTH levels is supposed to contribute to the mineralization and demineralization of the skeleton during pregnancy and lactation, respectively.

Action of short-term cycloheximide administration associated with colchicine on nuclear and chromosome structure in cleaving Newt eggs. Reappearance of chromomeres?

Association of short-term cycloheximide (CHM) administration (1/3, 1/2 or 1 cycle) with long-term treatment by colchicine (Co) confirms the results obtained by CHM alone under similar conditions, namely the striking relationship between the starting-time of treatment and the type of nuclei obtained (centred telophasic or non-centred prophasic). This relationship is highly significant. Various nuclear structures were observed: they correspond to a special evolution of the abnormal nuclei during telophase, telo-prophase and prophase which is very different from that in untreated ones. A difference in evolution of the central and peripheral parts of the same nucleus explains their centred structure. On the contrary, this difference disappears at prophase. The association CHM-Co favours the unveiling of beads which are interpreted as prophasic chromomeres. These beads are of different size, spacing and form according to the moment of the prophasic evolution attained. Electron microscopy study confirms the strong dispersion of chromatin by CHM and the beaded appearance of chromosomes by CHM and Co. Simultaneously, many dense bodies are accumulated in the centrospheres, as after quinoline and glutaraldehyde administration. The mechanisms of production of centred nuclei and of the beaded appearance of chromosomes are discussed.

Cytological characteristics and classification of spindle inhibitors according to their effects on segmentation mitoses.

The effects of spindle inhibitors and of protein synthesis inhibitors on segmentation mitoses allow us to classify them into six groups : 1. Colchicine type : destruction of the whole achromatic apparatus and centrospheres without storing of dense bodies; 2. Quinoline type : same effect on the achromatic apparatus, but blocked centrospheres with accumulation of dense bodies; 3. Chloralhydrate type : Incomplete destruction of achromatic apparatus, spindle residue which maintains the chromosomes in a star shape, inactive centrospheres sequestered by the reticulum, but without accumulation of dense bodies; 4. Phenylurethane type : Incomplete and reversible action, which leads to easy production of pluripolar mitoses; 5. Carboxylic acid type : dissociation of the spindle, sometimes with blocking of the centrosphere, together with profound chromosome changes without primitive breaks; the intensity and quality of their action is related to the number of carbon atoms in the acid considered; 6. Protein synthesis inhibitor type : (cycloheximide, pederin) characterized by a stop of the nuclear cycle at telo-prophase when the action is sufficient, chromosome abnormalities, sometimes, reduced to strings of beads, and freeing of asters; at weaker concentrations mitosis is possible, but the congression of chromosomes at the equator is abnormal because of functional disturbance of the kinetochores. The nature and grading of these effects, their association (or non - association) to chromosome damage, the soundness of the spindle when only the chromosomes are affected (nitrogen mustard) make this one of the tests which gives the most specific data about the action of antimitotic substances.

[Coating of centrospheres by reticulum cisternae and formation of spindle residues in segmentation mitosis under the action of an antitubulin substance: nocodazole]. / Enveloppement des centrosphères par des citernes de réticulum et formation de résidus fusoriaux dans les mitoses de segmentation sous l'influence d'une substance antitubuline, le nocodazole.

When cleaving eggs are treated by nocodazole the reticulum cisternae coat the centrospheres instead of the chromosomes, as normally occurs at the late anaphase. At the same time the spindle is reduced to a common mass or spindle remnant, constituted of unorientated and fragmented microtubules which embed the kinetochores, i. e. the star configuration of the chromosomes. This action is quite similar to that of chloralhydrate but is different from that of colchicine.

[Mechanism of the blocking of the centrosphere by substances similar to quinoline. Its prevention with spindle inhibitors similar to colchicine]. / Le mécanisme du blocage de la centrosphère par des substances semblables à la quinoline. Sa prévention par des inhibiteurs du fuseau semblables à la colchicine

A colchicine-like substance, vincaleukoblastine (2.10-4M, 3 to 6 hours), prevents the blocking of the centrosphere which would be produced by quinoline or by a similar substance (glutaraldehyde), to the extent of the inhibition of polarity by this colchicine-like substance. This is interpreted as due to the fact that each molecule of colchicine-like substance binds to a single subunit (or heterodimer) of tubulin and consequently prevents the constitution of storage structures. It is supposed that on the contrary quinoline-like substances bind to several subunits of tubulin and that they can stabilize the storage structures, binding to them in several points. The ultrastructural study demonstrates that when the centrosphere is blocked by quinoline, there is accumulation, hypertrophy and permanence of the "dense bodies" later than prophase; sometimes they are fused in a large "dense mass". The "dense bodies", and perhaps the "striated bodies", may therefore be interpreted as constituting morphologically the storage structures, which enlarge when all the astral and spindle microtubules completely disappear by action of a quinoline-like substance.

[The effect of formamide on the achromatic apparatus and the chromosomes of dividing pleurodele eggs: an electron microscope study]. / Action de la formamide sur l'appareil achromatique et les chromosomes dans des oeufs de pleurodèle en segmentation: étude au microscope électronique

Electron microscope studies of blastulae of Pleurodeles waltlii Michah., treated with formamide (0,5 M for 17 hours), show various abnormalities concerning centrospheres, chromosomes and microtubules as well. At the prophase stage, the centrospheres may display at their outer region an accumulation of dense bodies, which shows a temporary blocking of these centrospheres. At metaphase the poles of pluripolar mitoses appear more or less separated from the material which contains the chromosomes of the equatorial region. Each of these poles contains an unique centriole and therefore it is considered as resulting of the subdivision of a normal anaphasic pole. Astral and spindle microtubules are very reduced in number and more or less shortened. The chromosomes are without any recognizable kinetochcre, they show various degrees of condensation. All these electron microscope observations confirm the light microscope ones, and we may conclude that formamide has a double action on microtubules formation and on the ultrastructure of chromosomes, the latter perhaps by a direct action on DNA protein complexes.

Ultrastructure of segmentation mitoses in cleaving newt eggs after blocking of centrospheres by quinoline.

In quinoline treated blastomeres of Triturus helveticus Raz. and Pleurodeles waltlii Michah., microtubules disappear and around the centrioles markedly enlarged dense bodies accompanied by striated bodies are accumulated, from prophase beyond metaphase. It is concluded that these bodies in untreated cells play a role in the formation of the spindle microtubules. - During metaphase the chromosome are smooth-surfaced and show a pronounced tendency to stickiness. During ana-telophase they become surrounded by nuclear membranes and form caryomeres. - Qinoline does not interfere with centriole replication, but prevents the separation if diplosomes that have been already formed, if it acts before that separation. - Some centrioles exhibit different degrees of ultrastructural disarrangement.

Use of the laryngeal mask airway during ophthalmic surgery results in stable circulation and few complications: a prospective audit.

BACKGROUND: This study was performed to investigate airway complications related to Laryngeal Mask Airway (LMA) use in a selected group of paediatric patients undergoing ophthalmic surgery. METHODS: Ninety-four paediatric patients were enrolled. LMA was inserted under deep general anaesthesia with the standard technique previously described by Brain. Complications during induction, insertion of the LMA, maintenance of anaesthesia, removal of the LMA, emergence and on the first postoperative day were recorded. Failure of insertion, desaturation, laryngospasm, bronchospasm, vomiting, bucking, dislocation of the LMA, breath-holding, and coughing were noted. RESULTS: There was no significant age-related difference in successful insertion ratio of the LMA. In two patients (2%), the LMA could not be inserted with three attempts and tracheal intubation was performed. Laryngospasm was recorded in three patients (3%), leading to desaturation in two patients (SaO2 < 95%) during insertion of the LMA. During maintenance of anaesthesia bucking occurred in one patient (1%). After removal of the LMA, incidence of early desaturation following upper airway suctioning was higher in patients with a history of frequent upper respiratory tract infection (P < 0.01). Five patients (5%) had laryngospasm following the LMA removal; breath-holding and coughing were noted in 21 (22%) patients. Circulatory reactions to insertion and removal of the LMA were minimal. The incidence of sore throat on the first postoperative day was only 1%. CONCLUSION: LMA can be regarded as a safe product for airway maintenance during ophthalmic surgery with a stable circulation and few complications.

Comparison of prilocaine and bupivacaine for post-arthroscopy analgesia: a placebo-controlled double-blind trial.

Arthroscopic surgery requires early postoperative analgesia for early discharge and early rehabilitation of patients. To accomplish the effectiveness of intraarticular application of local anesthetics, a placebo-controlled double-blind trial was performed. Results were evaluated using the visual analog scale on a blind basis. The mean pain scores were generally lower in the bupivacaine group than in the control or prilocaine group. There were no statistically significant differences between the oral intake of analgesics and the level of analgesia obtained in all three groups. We consider the local application of analgesics to be ineffective for post-arthroscopy analgesia.

Anatomy of the anterior sacroiliac joint with reference to lumbosacral nerves.

There are no detailed descriptions of the neural structures that may be seen during surgical interventions of the pelvis. Anatomic dissections were performed to see which nerves are endangered in approaches to the anterior sacroiliac joint for plate fixations. Sixty cadavers were dissected bilaterally. Fifty-one were male and nine were female. L4 and L5 nerve roots were followed along the sacroiliac joint from the intervertebral foramen to the entrance into the lesser pelvis. Measurements were made between the nerves and sacroiliac joint from the proximal end of the joint to the pelvic brim. The L4 nerve root and the lumbosacral trunk (and not the L5 nerve root) were the nerves most susceptible to injury because of their course and proximity to the sacroiliac joint. As a result, during the anterior approach and fixation of the sacroiliac joint with plates, extreme care should be taken to identify the L4 nerve root or lumbosacral trunk or both at the anteroinferior third of the joint because the distance between the nerve and the joint is less than 1 cm.

Oral ketamine premedication in children (placebo controlled double-blind study).

Ketamine 3-6 mg kg-1 given by mouth to paediatric patients for anaesthetic premedication was evaluated. Forty-three children, ages 2-9 years were randomly allocated to receive either ketamine (3 or 6 mg kg-1) or placebo (cola 0.2 mL kg-1). Oral use of ketamine made separation from the families easier, gave an increased level of sedation, made acceptance of mask application easier and improved the emotional state in the recovery phase. These improvements were present with ketamine 3 mg kg-1 and 6 mg kg-1 in comparison with the placebo. We conclude that 3 mg kg-1 ketamine given by mouth to premedicate paediatric patients is as effective as 6 mg kg-1 but has a decreased incidence of side effects such as nystagmus and vomiting.