Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery: effects on diaphragmatic and respiratory function.

BACKGROUND: The authors compared the effects of patient-controlled interscalene analgesia (PCIA) with ropivacaine 0.2% and patient-controlled intravenous analgesia (PCIVA) with opioids on hemidiaphragmatic excursion and respiratory function after major shoulder surgery. METHODS: Thirty-five patients scheduled for elective major shoulder surgery were prospectively randomized to receive either PCIA or PCIVA. All patients received an interscalene block before surgery. In the PCIA group, a catheter was introduced between the anterior and middle scalene muscles. Six hours after the initial block, patients received for 48 h either a continuous infusion of 0.2% ropivacaine through the interscalene catheter at a rate of 5 ml/h plus a bolus dose of 3 or 4 ml with a lockout time of 20 min (PCIA group) or a continuous intravenous infusion of nicomorphine at a rate or 0.5 mg/h plus a bolus dose of 2 or 3 mg with a lockout time of 20 min (PCIVA group). Hemidiaphragmatic excursion and respiratory function were assessed with the patient in a 45 degrees semirecumbent position the day before the operation and 20 min (in the operating room), 24 h, and 48 h after the initial block by means of ultrasonography and spirometry, respectively. Pain relief was regularly assessed, side effects were noted, and patient satisfaction was rated 6 h after the end of the study. RESULTS: Hemidiaphragmatic excursion was similar in the two groups 20 min after interscalene block. Hemidiaphragmatic excursion was increased in the PCIA group on the nonoperated side 24 and 48 h after the interscalene block (P < 0.05). Pulmonary function was similar in the two groups at each time. Pain was better controlled in the PCIA group at 12 and 24 h (P < 0.05). The incidence of nausea and vomiting were 5.5% versus 60% for the PCIA and PCIVA groups, respectively (P < 0.05). Patient satisfaction was greater in the PCIA group (P < 0.05). CONCLUSIONS: The use of PCIA or PCIVA techniques to provide analgesia after major shoulder surgery is associated with similar effects on respiratory function. In the PCIA group, hemidiaphragmatic excursion showed a significantly greater amplitude 24 and 48 h after the initial block on the nonoperated side. The PCIA technique provided better pain control, a lower incidence of side effects, and a higher degree of patient satisfaction.

Loss of circadian blood pressure variability in complete tetraplegia.

Blood pressure (BP) and heart rate (HR) were monitored over 24 h utilising an ambulatory blood pressure monitoring (ABPM) system in 33 subjects with spinal cord injury: 11 patients with complete tetraplegia, 13 patients with incomplete tetraplegia and nine patients with complete paraplegia. Measurements were analysed for overall levels of BP and HR, presence of a physiological day/night cycle and events of autonomic dysreflexia. Paraplegic patients exhibited normal BP and HR levels with a physiological circadian rhythm. In complete tetraplegic patients the circadian rhythm was abolished for BP but preserved for HR, while in patients with incomplete tetraplegia circadian rhythm was preserved for both BP and HR. Complete tetraplegic patients with autonomic dysreflexia revealed a typical pattern in ABPM with multiple hypertensive episodes and concomitant bradycardia. Under adequate treatment these episodes could be reduced or abolished, while the disturbed circadian BP rhythm persisted. These observations shed further light on mechanisms of central BP and HR control. In tetraplegic patients ABPM is an efficient method to assess treatment for autonomic dysreflexia.

[Determinants of quality of life and health status in outpatients]. / Determinanten der Lebensqualität und des Gesundheitszustandes bei ambulanten Patienten.

Quality of daily life is of growing interest in medicine. In an outpatient setting in internal medicine the key factors influencing quality of life have been studied. Non-somatic disorders, such as depression, anxiety, insomnia and dizziness were strong negative factors. Despite increased morbidity in the elderly, quality of life was still preserved. Since only the patient can judge his own quality of life, his needs should receive increasing consideration in everyday practice.

[Differential diagnosis of acute consciousness disorders]. / Differentialdiagnose der akuten Bewusstseinsstörung.

The most important causes of syncope and coma are discussed. Syncope may be due to cardiac, vascular or cerebral disease. A cause of syncope is not established in up to 50% of cases. Where a diagnosis is possible the patient's history, physical examination, ECG and prolonged ECG monitoring serve to establish the underlying disease in most cases. Additional diagnostic tests should only be performed in patients with possible cardiac syncope, since these cases show a higher mortality rate than patients with non-cardiac syncope. Coma may be caused by metabolic disorders, intoxication or cerebral diseases, which are easily identified by history, physical examination and simple laboratory tests in most cases. Further evaluation of patients with unknown cause of coma depends on whether focal neurologic signs, meningeal irritation and fever are present.

[Steroid therapy and course of blood sedimentation rate in de Quervain's thyroiditis]. / Steroidtherapie und BSR-Verlauf bei Thyreoiditis de Quervain.

This study presents a retrospective analysis of clinical and laboratory results of 22 patients--predominantly younger women--with thyroiditis de Quervain. Diagnosis is based on clear leading symptoms like swelling and tenderness of the thyroid on pressure, swallowing with pain radiating to mandible and/or ears, fever and increased erythrocyte sedimentation rate (ESR). Half of the patients had slight anemia, leucocytosis without shift to the left, lymphopenia and thrombocytosis. The therapy of choice was prednisone, starting with an initial dose of usually 50 mg, reduced stepwise over 3 months under control of the clinical picture and the sedimentation rate. In a third of the patients clinical symptoms of the disease that had disappeared transiently redeveloped under reduction of prednisone without increase of the erythrocyte sedimentation rate. Raising the dose of prednisone for a short while led to prompt disappearance of symptoms. The ESR thus supports diagnostic investigations; however, it fails as a control parameter for the course of disease under treatment.

[Work analysis of residents in the medical outpatient clinic of the Zurich University Hospital]. / Arbeitsanalyse von Assistenzärzten an der Medizinischen Poliklinik Universitätsspital Zürich.

Modern medical practice has led to progressive use of time-intensive, highly technical diagnostic and therapeutic measures. Meanwhile, the long working hours of hospital residents are reduced stepwise. In order to preserve adequate patient care, daily routine will have to be economized. We evaluated the present state of daily routine of residents at the outpatient clinic of the department of internal medicine, University Hospital, Zurich. Patient care consisted of roughly half the daily work, administrative matters occupied one third, and one sixth consisted of staff meetings, postgraduate teaching and other work. The main target optimization lies in the administrative area. Residents could be trained in more efficient time systems. Of particular interest would be the establishment of small strategic units adapting to their current use in private enterprise.

Pulmonary nocardiosis concurrent with Pneumocystis carinii pneumonia in two patients undergoing immunosuppressive therapy.

Two cases with concomitant pulmonary nocardiosis and Pneumocystis carinii pneumonia are described. The first patient developed pneumonia 3 months after heart transplantation while undergoing standard immunosuppressive therapy with cyclosporin, azathioprine and prednisone. The second patient was treated with chemotherapy and subsequent radiotherapy of the mediastinum for a malignant epithelial tumour. He also received prednisone for paraneoplastic dermatomyositis. Chest X-rays of both patients showed a bilateral interstitial pattern and broncho-alveolar lavage revealed P. carinii. Additional dense and localised pulmonary infiltrates led to suspicion of a further infectious agent, namely, Nocardia asteroides, which was isolated from both patients. Since nocardiosis calls for prolonged treatment, extensive diagnostic measures are needed for its early detection.

In vivo release of endogenous glutamate and aspartate in the rat striatum during stimulation of the cortex.

The release of endogenous glutamate and aspartate from corticostriate neurons in the anaesthetized rat was investigated. Efflux of glutamate, aspartate and leucine in push-pull cannula perfusates of the striatum was measured in 1 min fractions collected before, during and after a 4 min stimulation period of ipsilateral frontal cortex. Efflux of the putative excitatory amino acid transmitters, glutamate and aspartate, determined during the first minute of stimulation, was significantly elevated above prestimulation resting level (by 167% and 316%, respectively), while efflux of leucine, a non-transmitter amino acid, remained unchanged. Efflux of glutamate and aspartate during the last 3 min of stimulation dropped rapidly, indicating the activation of a regulatory mechanism, presumably re-uptake. The data further support the hypothesis that glutamate and/or aspartate act as transmitters or are metabolites of transmitters in the corticostriate pathway.

Ventricular cerebrospinal fluid concentrations of putative amino acid transmitters in Parkinson's disease and other disorders.

Concentrations of putative neuroactive substances glutamate, aspartate, gamma-aminobutyric acid, glycine, proline and ethanolamine were determined in ventricular cerebrospinal fluid collected in patients suffering from Parkinson's disease, pain syndromes or cerebellar tremor. Values are similar to those given in the literature for lumbar cerebrospinal fluid. A decrease in gamma-aminobutyric acid in Parkinson patients, as reported in lumbar cerebrospinal fluid, could not be observed. Further evidence for a rostro-caudal gradient for gamma-aminobutyric acid is supplied. New insights into pathophysiological mechanisms in any of the investigated syndromes may not be derived.

Release of ethanolamine, but not of serine or choline, in rat pontine nuclei on stimulation of afferents from the cortex, in vivo.

Release of ethanolamine, serine, and choline in rat pontine nuclei on electrical stimulation of afferents from the cortex was investigated using in vivo push-pull cannula techniques. Ethanolamine was determined by using gas chromatographic techniques; serine was measured with a HPLC system; and choline was assayed with a luminescence method. Resting elution rates of ethanolamine, serine, and choline were 50.8 +/- 8.4, 34.8 +/- 12.6, and 1.16 +/- 0.20 pmol/5 min, respectively. Stimulation of the cortico-pontine tract evoked a highly significant 3.4-fold increase in release of ethanolamine, whereas serine and choline release was unaffected. Reactions in membrane phospholipids are most likely involved in the stimulation-dependent release of ethanolamine and special consideration was given to base-exchange reactions. Alternatively, a release from intracellular, possibly synaptic stores cannot be excluded.