Spontaneous bleeding from liver after open heart surgery.

INTRODUCTION: Intra-abdominal hemorrhage after open heart surgery is very uncommon in routine clinical practice. There are case reports of having bleeding from spleen or liver after starting low molecular weight heparin (LMWH) postoperatively. PRESENTATION OF CASE: Our patient is a 58-year-old man with mitral valve regurgitation, who underwent mitral valve repair and developed intra-abdominal hemorrhage 8h after open heart surgery. The exploratory laparotomy revealed the source of bleeding from ruptured sub-capsular liver hematoma and oozing from raw areas of the liver surface. Liver packing was done to control the bleeding. DISCUSSION: The gastrointestinal complications after open heart surgery are rare and spontaneous bleeding from spleen has been reported. This is the first case from our hospital to have intra-abdominal hemorrhage after open heart surgery. CONCLUSION: Spontaneous bleeding from liver is a possible complication after open heart surgery. We submit the case for the academic interest and to discuss the possible cause of hemorrhage.

Right upper lobe consolidation: an unusual complication of an uneventful endotracheal intubation.

A 28 year old fit and healthy Caucasian man had a Bankart's repair of the left shoulder under general anaesthetic for a recurrent dislocation of the shoulder. The operative procedure was uneventful. Following extubation he was tachycardic and saturation dropped in the recovery room. The chest radiograph revealed shadowing in the right lung and he was diagnosed to have right middle lobe collapse. Subsequently the radiograph was reported as right upper lobe consolidation by the radiologist. We wish to report this unusual complication and the difficulty in diagnosis of such a complication occurring following an uneventful anaesthetic.

Efficacy and tolerance of atrisin in degenerative and inflammatory joint disorders.

In a randomized multi-centre clinical trial the efficacy and tolerance of a herbal product Atrisin three capsules/day was evaluated in 65 patients (31 male, 34 female) suffering from osteoarthritis and rheumatoid arthritis, during a period of 2 months. Assessment of pain and functional disability were made on a 10 cm horizontal visual analogue scale. The severity of osteoarthritis was evaluated by Lequesne's index.Spontaneous pain showed significant improvement. Similarly there was progressive and significant reduction in the Lequesne's functional index. At the completion of the study patients taking Atrisin were using less NSAIDs. Atrisin was tolerated well by the patients and there were no adverse cardiovascular or gastric effects reported. There was feeling of general well-being and compliance by the patients.

Re-evaluation of hyaluronidase in peribulbar anaesthesia.

AIMS/BACKGROUND: Hyaluronidase can augment the actions of local anaesthetics in peribulbar anaesthesia. However, evidence suggests satisfactory anaesthesia can be achieved using mixtures without hyaluronidase. A randomised double blind study was conducted on 50 patients, undergoing peribulbar anaesthesia, to validate this observation. METHODS: Patients received a standard mixture of local anaesthetic (0.5% bupivacaine and 2% lignocaine in a 1:1 ratio) with or without hyaluronidase (25 IU/ml of mixture), pH values 5.16 and 5.24 respectively. Time taken to establish satisfactory anaesthesia to allow surgery was noted. RESULTS: The onset time to globe akinesia in the control group ranged from 2 to 15 minutes (mean 5.64 and median 4 minutes) and in the hyaluronidase group from 2 to 12 minutes (mean 4.64 and median 4 minutes). The volume of local anaesthetic injected to achieve satisfactory anaesthesia ranged from 8 to 16 ml (mean 10.96, SD 1.95) in the control group and 10 to 18 ml (mean 11.64, SD 2.8) in the hyaluronidase group. A Mann-Whitney test to compare onset times to globe akinesia between groups gave a p value = 0.6 and 95% confidence interval (-1 to 2 minutes). CONCLUSION: Addition of 25 IU/ml of hyaluronidase to a standard pH unadjusted local anaesthetic mixture does not significantly reduce the time to the onset of satisfactory globe akinesia.

N-acetyl cysteine attenuates ethanol induced hypertension in rats.

All known pathways of ethanol metabolism result in the production of acetaldehyde, a highly reactive compound. N-acetyl cysteine, an analogue of the dietary amino acid cysteine, binds acetaldehyde, thus preventing its damaging effect on physiological proteins. This study examined the effect of oral N-acetyl cysteine on the increased blood pressure, platelet cytosolic free calcium, blood acetaldehyde and adverse renal vascular changes induced by chronic ethanol treatment in rats. Twenty-four male Wistar-Kyoto (WKY) rats, age 7 weeks were divided into four groups of six animals each. Animals in group I were given water and group II 5% ethanol in water for the next 14 weeks. Animals in group III were given 5% ethanol + 1% N-acetyl cysteine for 4 weeks followed by 5% ethanol + 2% N-acetyl cysteine for the next 10 weeks. Animals in group IV were given 5% ethanol for 7 weeks; at that time ethanol was withdrawn and animals were placed on water with 2% N-acetyl cysteine for the next 7 weeks. After 14 weeks systolic blood pressure and platelet cytosolic free calcium were all significantly higher (p<0.001) in rats given ethanol as compared to rats in other groups. N-acetyl cysteine treatment, along with ethanol, significantly (p<0.001) attenuated the increased blood pressure and platelet cytosolic free calcium and adverse renal vascular changes. Discontinuation of ethanol treatment for 7 weeks along with N-acetyl cysteine supplementation also significantly lowered the blood pressure and platelet cytosolic free calcium and attenuated adverse renal vascular changes. There was no significant difference in aortic malonaldehyde among four groups. Increase in blood acetaldehyde with ethanol treatment was significantly attenuated with N-acetyl cysteine treatment. These results suggest that acetaldehyde may be the cause of ethanol-induced hypertension and elevated cytosolic free calcium and renal vascular changes.

Hyperkalaemia: a complication of warm heart surgery.

A case is presented of hyperkalaemia (13.6 mEq.L-1) occurring during cardiopulmonary bypass using warm blood cardioplegia (K+ 40-60 mEq.L-1). Treatment with epinephrine, calcium chloride, sodium bicarbonate, and furosemide reduced K+ to 6.5 mEq.L-1 within 30 min and myocardial performance was enhanced with amrinone and cardiac rhythm was controlled with A-V segmental pacing. It is believed that the hyperkalaemia resulted from a combination of the surgical procedure (mitral valve replacement) and the use of warm cardioplegia. The purpose of this report is to increase the awareness of the possibility of hyperkalaemia with warm cardioplegia and to describe a successful therapeutic regimen.

Fentanyl and lidocaine versus lidocaine for Bier block.

BACKGROUND AND OBJECTIVES: The present study was designed to assess the efficacy of fentanyl combined with dilute lidocaine solution for intravenous regional anesthesia of the arm. METHODS: In ten volunteers, the nondominant arm was exposed to three treatments: 100 mg lidocaine, 42 ml; 100 mg lidocaine plus 100 micrograms fentanyl, 42 ml; and 100 micrograms fentanyl, 42 ml. Each subject was tested on three occasions with three or more days between experiments. Sensory and motor function was tested to determine whether the neural effects of the particular treatments differed. RESULTS: When lidocaine and lidocaine plus fentanyl results were compared, no significant differences were found. However, anesthesia, analgesia, and loss of motor function generally were less complete and slower in onset with the fentanyl alone treatment. Two subjects became nauseated after tourniquet cuff deflation when lidocaine plus fentanyl was tested, as did one subject when fentanyl was tested. CONCLUSION: Results of this and other studies indicate there is no value in adding fentanyl to local anesthetics for intravenous regional anesthesia.

In vivo isocenter dose in two hip prosthesis patients.

Hip prostheses may cause irradiation dose inhomogeneities in conventional four-field target volumes to the pelvis. Two patients, with bilateral and unilateral prostheses, were subjected to thermoluminescent dosimetry measurements in the prostatic urethra during 24 MV photon portal exposures. The results suggested a 13% decrease in absorbed dose only for conventional four-field beam geometry with bilateral prostheses, as compared to oblique four-field beam geometry or unilateral prosthesis. This supports the suggestion that beam technique modifications may be warranted for patients with hip prostheses.

Oral premedication in children. A comparison of trimeprazine with a trimeprazine, droperidol and methadone mixture.

One hundred children who presented for minor general surgical procedures were randomly assigned to receive one of two oral premedications. Those in group A (n = 50) were given 3 mg/kg of trimeprazine and those in group B (n = 50) a mixture of trimeprazine 1.0 mg/kg, droperidol 0.15 mg/kg and methadone 0.08 mg/kg. Patients in group B were more likely to be asleep on arrival in the anaesthetic room (p less than 0.02) and were less likely to be distressed at induction of anaesthesia (p less than 0.02). Thiopentone requirements were less in group B (p less than 0.001). The incidence of side effects was similar in the two groups. It is concluded that the mixture produces more satisfactory sedation than trimeprazine.

Calibration and use of the Wisconsin kVp test cassette.

The Ardran-Crooks kVp test cassette is widely used in diagnostic radiology to provide a rapid, simple, noninvasive measurement of x-ray tube potential. A modified version of this cassette called the Wisconsin kVp Test Cassette was introduced commercially in the U. S. in 1972. Since then, the method of calibration of these cassettes has changed significantly. Wisconsin kVp Test Cassettes calibrated by the manufacturer prior to August 1982 may yield underestimates of kVp measurements, particularly when using the 90-110 and 110-130 kVp regions with single-phase units. In August 1982 significant improvements in the calibration methods were implemented. The resultant change in calibration is demonstrated by data from the Centers for Radiological Physics. Present calibration methods are believed to be accurate within the greater of +/- 2 kVp or 2% of actual peak tube potential. Proper use of the cassette is necessary to achieve this level of accuracy.

Backscatter radiation at bone-titanium interface from high-energy X and gamma rays.

Occasionally head and neck cancer patients treated with high-energy X rays and gamma rays have titanium metal dental implants in their maxillae or mandibles. The resulting effect of the bone-metal interface on the radiation dose is of interest. Ionization measurements for 60Co gamma rays and 6 MV and 25 MV X rays were made. A thin-window parallel-plate chamber was used to determine the magnitude of the dose enhancement that was due to the backscattered electrons from titanium. The results showed that for 60Co there is a 15% increase in dose to solid bone at the entrance side of the titanium. For higher energy X rays, the increase in dose was about the same or slightly lower than for 60Co. Monte Carlo calculations substantiated the measurements. This increase in dose fell off rapidly and became negligible at 1-2 mm from the interface. This backscattered dose should be taken into account when planning radiation therapy treatment for patients with dental implants.

Effect of vitamin A on lung tumorigenesis in irradiated and unirradiated strain A mice.

The effect of vitamin A (retinyl acetate) on lung tumor development in strain A mice exposed to radiation was assessed. Four groups of 75 mice were utilized. Two groups were fed a low vitamin A diet (less than 100 IU/100 g diet) and the other 2 were fed a high vitamin A diet (800 IU/100 g diet). After 2 weeks one group maintained on the high vitamin A diet and one group maintained on the low vitamin A diet were given an acute dose of 500 rad of gamma radiation to the thoracic region. Circulating levels of plasma vitamin A in all 4 groups of mice were monitored. A difference in circulating vitamin A in the mice maintained on high and low vitamin A diet became evident by 20 weeks and continued for the duration of the experiment. Mice were killed 18, 26 and 40 weeks post-irradiation, their lungs were removed and the number of surface adenomas were counted. There was a significant increase in the number of mice bearing lung tumors and the mean number of lung tumors per mouse in the irradiated group maintained on the high vitamin A diet at 40 weeks post-irradiation as compared to the irradiated group maintained on a low vitamin A diet. Under the conditions of this experiment the development of pulmonary adenomas in irradiated strain A mice appears to relate directly to circulating levels of vitamin A.

Lung tumorigenic response of strain A mice exposed to hypoxic cell sensitizers alone and in combination with gamma-radiation.

The influence of metronidazole, misonidazole, and desmethylmisonidazole on the induction of lung adenomas in the strain A mouse was examined. Two dose levels of the hypoxic cell sensitizers, 0.2 and 0.6 mg/g, were used either alone or in combination with 900 rads of gamma-radiation in a fractionated dose schedule of twice a week for 3 weeks. In the groups of mice which received hypoxic cell sensitizers only, the prevalence and the mean number of lung tumors per mouse were somewhat increased (p less than 0.10) in the group receiving the higher dose (0.6 mg/g) of misonidazole but was not significantly different from results for the control animals in the other two sensitizer groups. The combination of hypoxic cell sensitizer and radiation did not show any significant enhancement of lung tumor response when compared with the group which received radiation only. The dose of radiation used in this study significantly enhanced lung tumor formation in mice when compared with that in the control group. Thus, under the experimental exposure conditions used in this investigation, which were somewhat similar to the exposure conditions occurring in clinical treatment, each of the hypoxic cell sensitizers tested failed to sensitize significantly the mice to the carcinogenic effects of gamma-radiation.

Radiation dose and biological effects to mouse testis from sodium 32P-phosphate.

Radiation dose to mouse testis was estimated to be about 1.65 rad per microCi of intravenously injected 32P. This high dose to the organ was due to the incorporation of this isotope into the macromolecules of the testis. Up to 30% of the total testis activity was in DNA molecules. Biologic effects on mouse testis from 32P were determined by testis weight loss and the decrease in the number of sperm heads in the testis. Number of sperm heads reached a minimum of 1.3% of control 36 days after injection of 3.5 microCi/g body weight of 32P. Significant decreases in sperm head counts were observed after as little as 0.2 microCi/g body weight of 32P.

Radiation damage to mouse testis cells from [99mTc] pertechnetate.

The radiation dose and the biologic damage to mouse testis from intravenously administered [99mTc] pertechnetate were studied. The dose was measured for penetrating radiations from Tc-99m, using calibrated thermoluminescent dosimeters and calculations from the uptake of the nuclide in the testis, and was found to be 4.9 rada per mCi of Tc-99. The biologic damage was measured by the decrease in the number of sperm heads in the testis, counted both by hemacytometer and by Coulter counter. In preliminary experiments using external gamma radiation from Cs-137, the number of sperm heads reached a minimum 29 days after irradiation. Twenty-nine days after injection of 5.8 mCi of Tc-99m, which gives 28 rads to the testis, the number of sperm hads decreased to 70% of control. The biologic effect corresponds to that seen after 40 rads of gamma radiation from Cs-137. The damage to mouse testis cells from internally administered Tc-99m as measured in an in vivo system appears to be at least as significant as that from external gamma irradiation, if not more so.