Randomized, double-blind comparison of oral aprepitant alone compared with aprepitant and transdermal scopolamine for prevention of postoperative nausea and vomiting.

BACKGROUND: Aprepitant blocks the emetic effects of substance P. Scopolamine antagonizes muscarinic type 1 and histamine type 1 receptors. This study compares monotherapy and multimodal therapy by looking at complete response, nausea, vomiting, and rescue medication in patients at high risk for postoperative nausea and vomiting (PONV) treated with oral aprepitant with or without scopolamine. METHODS: We enrolled 120 patients in this randomized, double-blind trial. Inclusion criteria were: >18 yr old, ASA I-III, two or more Apfel four-point risk factors, undergoing an elective surgical procedure with a high risk of PONV expected to last at least 60 min. The primary outcome variable was complete response, that is, no emesis and no rescue therapy from 0 to 24 h. The outcomes measured included the incidences of nausea, vomiting, their composite, and the need for rescue medication. RESULTS: The aprepitant alone and aprepitant with scopolamine did not differ in complete responses (63% vs 57%, P=0.57) or net clinical benefit (26% vs 19%, P=0.38). The number who did not experience PONV and who used rescue medication did not differ. The incidence of PONV in the post-anaesthesia care unit did not differ nor did the use of rescue medications. CONCLUSIONS: This trial evaluating the effectiveness of aprepitant alone and in combination with scopolamine showed no difference between treatment groups. The primary objective, complete response, and secondary objectives, incidences of nausea, vomiting, their composite, and the need for rescue medication, all showed no statistical difference.

Excursion of the rotator cuff under the acromion. Patterns of subacromial contact.

Nine fresh-frozen, human cadaveric shoulders were elevated in the scapular plane in two different humeral rotations by applying forces along action lines of rotator cuff and deltoid muscles. Stereophotogrammetry determined possible regions of subacromial contact using a proximity criterion; radiographs measured acromiohumeral interval and position of greater tuberosity. Contact starts at the anterolateral edge of the acromion at 0 degrees of elevation; it shifts medially with arm elevation. On the humeral surface, contact shifts from proximal to distal on the supraspinatus tendon with arm elevation. When external rotation is decreased, distal and posterior shift in contact is noted. Acromial undersurface and rotator cuff tendons are in closest proximity between 60 degrees and 120 degrees of elevation; contact was consistently more pronounced for Type III acromions. Mean acromiohumeral interval was 11.1 mm at 0 degrees of elevation and decreased to 5.7 mm at 90 degrees, when greater tuberosity was closest to the acromion. Radiographs show bone-to-bone relationship; stereophotogrammetry assesses contact on soft tissues of the subacromial space. Contact centers on the supraspinatus insertion, suggesting altered excursion of the greater tuberosity may initially damage this rotator cuff region. Conditions limiting external rotation or elevation may also increase rotator cuff compression. Marked increase in contact with Type III acromions supports the role of anterior acromioplasty when clinically indicated, usually in older patients with primary impingement.