Effect of sugammadex or neostigmine neuromuscular block reversal on bispectral index monitoring of propofol/remifentanil anaesthesia.

BACKGROUND: Sugammadex is a modified γ-cyclodextrin with a novel mechanism of action for reversing the steroidal neuromuscular blocking agent rocuronium. Bispectral index (BIS) is an EEG-derived measure which can be sensitive to frontal electromyographic (EMG) artifacts. We compared BIS values before and after sugammadex or neostigmine neuromuscular block (NMB) reversal in patients with or without high EMG activity. METHODS: During stable propofol/remifentanil anaesthesia and rocuronium-induced block, 48 patients were randomly allocated to receive sugammadex 4 mg kg(-1) or neostigmine 50 µg kg(-1)/glycopyrrolate 10 µg kg(-1), 10 min after the end of surgery. RESULTS: Five minutes after sugammadex administration, mean BIS 50.1 (10.3) increased (P=0.018) to 61.7 (7.9) in 11 patients with high EMG activity. In contrast, BIS 49.3 (4.9) remained at 51.9 (5.4) in 13 patients who had no EMG activity. Fifteen minutes after neostigmine administration, mean BIS 51.9 (8.1) increased (P=0.007) to 63.9 (8.1) in 13 patients who had reappearance of muscle activity. However, in 11 patients who had no EMG activity, BIS 52.3 (7.4) remained at 53.3 (6.8). There was no significant difference between the sugammadex and neostigmine groups over time. CONCLUSIONS: We have shown that reversal of NMB with sugammadex or neostigmine increased BIS values dependent on the presence of EMG activity. Thus, the effect of muscle activity reappearance during rocuronium NMB reversal spuriously increasing the BIS value should be taken into consideration when relying on BIS monitoring for evaluating propofol/remifentanil recovery.

No regional difference in cisatracurium dose-response and time-course-of-action between patients in China and Bosnia.

BACKGROUND: Variability in drug response could result from a variety of genetic and environmental factors that are often hard to define or quantify. A number of studies demonstrated regional geographic variations in potency of neuromuscular blocking agents (NMBAs). The aim of our study was to compare dose-response and time-course-of-action of cisatracurium besylate, an NMBA eliminated via the Hoffman degradation, in two countries with different life habits, diet, and ambient conditions; being Han Chinese in China and Caucasians in Bosnia. METHODS: Neuromuscular block of cisatracurium 20 µg kg(-1), followed by four incremental 10 µg kg(-1) doses, and the remainder of 100 µg kg(-1) was evaluated using the Relaxometer mechanomyograph (Groningen University, Groningen, The Netherlands). Dose-response curves were created using log-dose-probit-response transformation. RESULTS: There were no significant differences in cisatracurium mean (95% confidence intervals) ED(50), ED(90), and ED(95) (effective doses for 50%, 90%, and 95% first twitch depression) in Caucasian [39.1 (35.7-42.3), 50.6 (45.5-54.3), and 54.4 (49.8-58.9) µg kg(-1)] compared with Chinese patients [39.2 (35.1-43.1), 52.4 (47.9-56.8), and 56.9 (52.8-61.9) µg kg(-1)], respectively. There were no significant differences in mean (sd) Dur(25) and Dur(0.9) (time until 25% first twitch and 0.9 train-of-four ratio recoveries) in Caucasian [47.1 (6.4) and 77.5 (9.1) min)] compared with Chinese patients [(45.9 (4.7) and 72.3 (9.1) min)], respectively. CONCLUSIONS: Cisatracurium dose-response relationship and time-course-of-action were not influenced by geographic location. Thus, cisatracurium would not require dose adjustments between patients living in the two geographic locations.

Comparison of a new neuromuscular transmission monitor compressomyograph with mechanomyograph.

BACKGROUND: We developed a new neuromuscular transmission monitor, the compressomyograph (CMG, European patent number: EP 06018557.6, US patent number: US 60/824.541). This is the first preliminary report comparing neuromuscular block monitored by CMG and the Relaxometer mechanomyograph (MMG). METHODS: The two monitors were randomly allocated to the left or right hands of 16 patients. T1, first twitch of the train-of-four (TOF) expressed as percentage of control response, and the TOF ratio (T4:t1) were used to evaluate the neuromuscular block produced by rocuronium 0.6 mg kg(-1). RESULTS: The CMG monitor exhibited no pre-relaxation reverse fade (T4>T1) or T1 exceeding 100%. There was no significant difference in mean (SD) onset time, Dur(25) (time to T1 25% recovery), or Dur(0.9) (time to 0.9 TOF ratio recovery) measured by the CMG [2.4 (0.9), 22.6 (4.1), 43.1 (10.3) min, respectively] compared with MMG [2.1 (0.9), 22.9 (3.3), 43.3 (10.0) min, respectively]. According to Bland and Altman analysis, the bias (upper and lower limits of agreement) for T1% was -0.3% (+13.4% and -13.8%) and for TOF ratio was -0.009 (+0.068 and -0.085). CMG showed 100% sensitivity and 75% specificity in indicating full relaxation for tracheal intubation, and 80% sensitivity with 86% specificity in predicting MMG 0.9 TOF ratio. CONCLUSIONS: The CMG could be a reliable clinical monitor in the daily anaesthesia practice that does not require time to set up or rigid support of the arm.

Sensitivity and specificity of bispectral index for classification of overt hepatic encephalopathy: a multicentre, observer blinded, validation study.

BACKGROUND: The severity of hepatic encephalopathy is currently graded clinically using West Haven criteria and psychometric tests. OBJECTIVE: To assess the discriminative power of the bispectral index (BIS) monitor to classify the degree and progression of hepatic encephalopathy. DESIGN: A consecutive, multicentre, observer blinded validation study. SETTING: Medical University of Graz (Graz, Austria), Zhejiang University First Affiliated Hospital (Hang Zhou, China), and Cairo University (Cairo, Egypt). PATIENTS: 28 consecutive patients with hepatic encephalopathy were first enrolled at Medical University of Graz as a test set. The estimated BIS cut off values were subsequently tested in a validation set of 31 patients at Zhejiang University First Affiliated Hospital and 26 patients at Cairo University; 18 patients were reassessed later in a longitudinal study. Fifteen of 85 patients (18%) were excluded from the final analysis (11 became too agitated with high electromyographic activity; four fell asleep during the recording). RESULTS: Applying the Austrian BIS cut off values of 85, 70, and 55 for discriminating West Haven grades 1 to 4 yielded agreement between BIS classification and West Haven grades in 40 of the 46 validation patients (87%), and in 16 of the 18 follow up patients (89%). Mean (SD) BIS values differed significantly between patients with West Haven grade 1 (90.2 (2.5)), grade 2 (78.4 (6.6)), grade 3 (63.2 (4.8)), and grade 4 (45.4 (5.0)). CONCLUSIONS: BIS is a useful measure for grading and monitoring the degree of involvement of the central nervous system in patients with chronic liver disease.

Influence of acute normovolaemic haemodilution on the dose-response relationship and time course of action of cisatracurium besylate.

BACKGROUND: Acute normovolaemic haemodilution (ANH) is an efficacious blood conservation strategy aiming at avoiding allogeneic blood transfusion. ANH was shown to increase the potency of vecuronium, atracurium, and rocuronium. The aim of our study was to investigate whether cisatracurium potency is altered with ANH. METHODS: Using the Relaxometer mechanomyograph, we compared cisatracurium dose-response relationship and time course of action in 60 patients randomly allocated to the ANH or control groups. Patients in each group were randomly allocated to receive one of three cisatracurium doses (30, 40, 50 microg kg(-1)) followed by a second supplemental dose to reach a total of 100 microg kg(-1). RESULTS: ANH did not result in a significant shift in cisatracurium log dose-probit dose-response curve. There was no significant difference in mean (95% confidence intervals) ED(50), ED(90), and ED(95) (effective doses required for 50, 90, and 95% first twitch depression) between the ANH group [29.5 (27-32), 50.4 (47.4-53.4), 58.7 (55.3-62) microg kg(-1)] and the control group [28.2 (25.3-31), 47.6 (44.9-50.3), 55.3 (52.5-58.1) microg kg(-1)], whereas there was no difference in mean (SD) Dur(25) and Dur(0.8) (time until 25% first twitch and 0.8 train-of-four ratio recoveries) between the ANH group [40.8 (5.9), 64.7 (8.4) min] and the control group [42.2 (7.6), 66.5 (10.7) min]. CONCLUSIONS: Our results demonstrated that unlike other previously reported neuromuscular blocking drugs, ANH did not alter cisatracurium potency. Thus, cisatracurium would be the neuromuscular blocking drug of choice in patients who undergo surgery with ANH, as no dose adjustments are required.

Postweaning duration and body composition changes in Southern elephant seal (Mirounga leonina) pups at King George Island.

Weaning mass in southern elephant seals is highly variable, the heaviest pups being three times as heavy as the lightest ones. After weaning, pups undergo an extensive postweaning period in which they draw on their reserves. To quantify the energy expenditure during the postweaning period, changes in mass, body composition, and postweaning duration were measured in southern elephant seals at King George Island, South Shetland Islands, Antarctica. Overall, mean pup weaning mass was 154 +/- 26 kg (n=117) and did not differ between sexes. Mean minimum postweaning duration was 42.5 +/- 7.5 d. Heavier animals at weaning had lower mass-specific mass loss rates than lighter ones, and a faster depletion of body reserves was associated with a shorter postweaning period. The proportion of body mass represented by fat at weaning was 37% +/- 4% (n=47) and did not differ between sexes. Of these pups, 36 were recaptured after a mean period of 36 d after weaning. On average, total mass loss measured in these animals (39 kg) was composed of 39% water, 47% fat, and 12% protein. The composition of mass loss was not significantly different between sexes and was not related to weaning mass or total body energy reserves. However, fatter animals at weaning lost more fat per kilogram lost than thinner ones. Late in the fast, males and females appeared to be in a similar body condition. Nevertheless, the overall proportion of body mass represented by fat at this time was lower than that presented by the same animals at weaning. We estimated that during the postweaning period pups lost, on average, 30% of their mass at weaning. This comprised approximately 35% of the energy and 32% of the fat in the pup's body.

Osteogenesis imperfecta: clinical symptoms and update findings in computed tomography and tympano-cochlear scintigraphy.

Osteogenesis imperfecta (OI) is an autosomal-dominantly inherited connective tissue disorder characterized by abnormal bone fragility combined with blue sclerae. The association of OI with hearing impairment is commonly known as Van der Hoeve-de Kleyn syndrome. Besides typical symptoms we here report on findings by high resolution CT and by high resolving scintigraphy of the labyrinthine capsule in 3 families (9 patients) with OI, which resemble those in otosclerosis (OS): In 4 of 6 cases with OI and mixed hearing loss, severely decreased peri-cochlear bone density was established by CT. In these cases, increased bone metabolism could be revealed by high resolving tympano-cochlear scintigraphy (TCS) in the cochlear region. In 2 patients with mixed hearing loss and 3 cases without hearing impairment or with slight conductive hearing loss, bone alteration was not detectable by CT and TCS. These results raise the question whether OI and OS lead to similar labyrinthine bone alterations, based on different aetiologies or whether these diseases may co-exist, OS being part of OI.

[Recording the feeding behavior of freely moving animals using the example of freely diving Weddell seals (Leptonychotes weddellii)]. / Registrierung des Fressverhaltens beim frei beweglichen Tier am Beispiel der freitauchenden Weddellrobbe (Leptonychotes Weddellii).

During the antarctic summer 1990, the pattern of food intake in comparison to diving-activity was investigated on adult Weddell seals. Diving depths were recorded by a time-depth recorder (TDR). The TDR is a free programmable electronic datalogger, which can store data on up to 5 channels. It was fixed on the fur of the seal, ensuring that no longer lasting irritation of the animal was caused. The pattern of food-intake was monitored by measuring the jaw-movements, using strain gauges for recording the deformation of the muscles by mastication. After electronic amplification and filtering, the frequency of jaw-activity within a measuring period was recorded one channel of the TDR. By simultaneously observing the diving depths, these data may lead to conclusions about chewing patterns of the seal in water depths where they catch prey. The graph of these data and the mathematical evaluation by Fourier analysis and Plexogramme show a close correlation between diving depth and jaw-activity.

Superconductivity at 45 k in rb/tl codoped c60 and c60/c70 mixtures.

The appearance of superconductivity at relatively high temperatures in alkali metal-doped C(60) fullerene provides the challenge to both understand the nature and origin of the superconductivity and to determine the upper limit of the superconducting transition temperature (T(c)). Towards the latter goal, it is shown that doping with potassium-thallium and rubidium-thallium alloys in the 400 to 430 degrees C temperature range increases the T(c) of C(60)/C(70) mixtures to 25.6 K and above 45 K, respectively. Similar increases in T(c) were also observed upon analogous doping of pure C(60). Partial substitution of potassium with thallium in interstitial sites between C(60) molecules is suggested by larger observed unit cell parameters than for the K(3)C(60) and K(4)C(60) phases. Contrary to previous results for C(60) doped with different alkali metals, such expansion does not alone account for the changes in critical temperature.

[Occupational medicine aspects of cutaneous leishmaniasis]. / Arbeitsmedizinische Aspekte der kutanen Leishmaniose.

Cutaneous Leishmaniasis as an Occupational Disease We report 2 cases of cutaneous leishmaniasis with special regard to its significance for occupational health. Preventive measures are discussed as well as the difficulties in clarifying the diagnosis and therapeutic possibilities.

[Cochleomeatal scintigraphy]. / Die cochleomeatale Szintigraphie--CMS.

High resolution cochleomeatal scanning has proven to be a simple and inexpensive diagnostic method in tumors of the inner auditory canal, resp. of the cerebello- pontineangle . In 112 neurotologic patients (37 with proven acoustic neuromas) there were no false positives or false negatives. Therefore, the use of invasive or expensive tests in suspicion of tumors of the 8th cranial nerve should be restricted to those cases with positive scans. CMS is of special diagnostic value in patients with absent air insufflation of the basal cisternae in gas computerised tomograms and in suspected tumor recurrences. Dynamic studies with determination of the radiopharmacokinetics of radiopharmacology reveal further differential diagnostic aspects.

Cochleomeatal scintigraphy--a new tool in modern neuroradiological diagnosis of acoustic neuroma.

Cochleomeatal scintigraphy (CMS) and CT or air CT cisternography are today the methods of choice for the detection or exclusion of a neuro-otologically suspect acoustic neuroma. Whereas CT as a morphological method of investigation provides better preoperative information, CMS is likely to be superior to CT as a functional investigation technique in relapse diagnosis.

[Single-dose mezlocillin prophylaxis and postoperative morbidity after vaginal hysterectomy: pharmacokinetic and clinical results]. / 1-Dosis-Mezlozillin-Prophylaxe und postoperative Morbidität nach vaginaler Hysterektomie: pharmakokinetische und klinische Ergebnisse.

In this prospective, randomized study we evaluated the prophylactic administration of 5 g Meclocillin in a single dose. 100 patients undergoing vaginal hysterectomies were observed. Clinical parameters as well as Meclocillin concentrations in serum and myometrium were compared. We found a sufficient Meclocillin concentration in serum and myometrium 30 minutes after intravenous administration. In the control group (n = 50) 8 patients had a febrile postoperative course whereas there was 1 patient only in the treated group. A more detailed analysis regarding predisposing risk factors, urinary tract infections and pathogens of the vaginal wound secretions is presented. The single dose administration had no significant effect on the incidence of postoperative urinary tract infections. The preliminary result of our study reveals the single dose treatment to be a remarkable alternative to the three-dose-perioperative regimen. Regarding the general question of prophylactic antibiotic treatment at time of vaginal hysterectomy especially individual factors as well as preoperative risk factors have to be taken into account.

[Nuclear medicine demonstration of intraocular tumors using gamma-radiating radionuclides. 1st clinical results]. / Nuklearmedizinische Darstellung intraokularer Tumoren mittels gammastrahlender Radionuklide. Erste klinische Ergebnisse.

A non-invasive method of detecting intraocular mass lesions is described which uses 67gallium citrate and 99m-technetium pertechnetate. It was used in 33 cases. In 73.7% of the patients with malignant melanoma of the eye there was a significant increase in the storage of the tracer. There was no difference in the results obtained with 67gallium citrate and 99m-technetium pertechnetate. Small, flat and peripheral tumors may not be detected. In some cases old intraocular hemorrhages may also lead to false-positive results. In contrast to the 32P-test the method described can be used in cases with opaque media. The radiation dose is about one-tenth of that given with the 32P-test.

[Identification of metastases in the infant skeleton--comparison of methods of roentgenology and scintigraphy (author's transl)]. / Metastasennachweis im kindlichen Skelett--ein Vergleich röntgenologischer und szintigraphischer Verfahren.

Conventional x-ray examination and a whole body scintigram were performed within four weeks in 40 children with tumours. The findings obtained by both methods were subjected to a comparative analysis. Pathological findings were revealed in eleven children; in eight of these, the findings were partly confirmed as metastases. Of 39 metastases confirmed by x-ray film, 16 were found to be negative according to scintigraphy. On the other hand, 34 of a total of 60 scintigraphically pathological findings could not be confirmed by x-ray examination six months later. The falsely negative scintigraphic findings were mainly localised in the region of the ribs, the pelvis and the long bones near the epiphysis. Our own case material demonstrated these findings.

[Isolated cardiac tumor metastasis of an osteogenic sarcoma in the heart; a case report on diagnosis and control of treatment (author's transl)]. / Isolierte Herzmetastase eines osteogenen Sarkoms; ein kasuistischer Beitrag zur Diagnostik und Therapiekontrolle.

The case of an isolated metastatic tumor of the heart from a primary osteogenic sarcoma as well as its presentation and control under therapy by investigations of nuclear medicine are reported. Both the intravital diagnosis of an isolated metastatic tumor of the heart from an osteogenic sarcoma and the presentation of a heart tumor by bone scanning are not described to this day.

[Noncontact detection of intraocular lesions by means of a gamma scintillation camera]. / Nicht-invasiver Nachweix intraokularer Veränderungen mit einer Gamma Szintillationskamera.

A gamma scintillation camera is used for noncontact detection of intraocular mass lesions. A double aperture pinhole collimator was designed for this special application. The collimator projects a magnified image of the radioactivity present in each eye onto the detector crystal of the camera. Details of the collimator design are described. The image-making properties of a double aperture pinhole collimator for ocular scintigraphy in regard to resolution and response were studied and demonstrated by phantom experiments. So far we have studied 50 cases with this new nuclear medicine procedure, using mainly technetium-pertechnetate as the radioindicator. Case histories and records of some typical results are presented. Better designed radiopharmaceuticals with appropriate tumor-seeking properties should be developed. Labeled melanin precursors are promising for detection of these lesions.