Blood-brain barrier in vitro models as tools in drug discovery: assessment of the transport ranking of antihistaminic drugs.

In the course of our validation program testing blood-brain barrier (BBB) in vitro models for their usability as tools in drug discovery it was evaluated whether an established Transwell model based on porcine cell line PBMEC/C1-2 was able to differentiate between the transport properties of first and second generation antihistaminic drugs. First generation antihistamines can permeate the BBB and act in the central nervous system (CNS), whereas entry to the CNS of second generation antihistamines is restricted by efflux pumps such as P-glycoprotein (P-gP) located in brain endothelial cells. P-gP functionality of PBMEC/C1-2 cells grown on Transwell filter inserts was proven by transport studies with P-gP substrate rhodamine 123 and P-gP blocker verapamil. Subsequent drug transport studies with the first generation antihistamines promethazine, diphenhydramine and pheniramine and the second generation antihistamines astemizole, ceterizine, fexofenadine and loratadine were accomplished in single substance as well as in group studies. Results were normalised to diazepam, an internal standard for the transcellular transport route. Moreover, effects after addition of P-gP inhibitor verapamil were investigated. First generation antihistamine pheniramine permeated as fastest followed by diphenhydramine, diazepam, promethazine and second generation antihistaminic drugs ceterizine, fexofenadine, astemizole and loratadine reflecting the BBB in vivo permeability ranking well. Verapamil increased the transport rates of all second generation antihistamines, which suggested involvement of P-gP during their permeation across the BBB model. The ranking after addition of verapamil was significantly changed, only fexofenadine and ceterizine penetrated slower than internal standard diazepam in the presence of verapamil. In summary, permeability data showed that the BBB model based on porcine cell line PBMEC/C1-2 was able to reflect the BBB in vivo situation for the transport of antihistaminc drugs and to distinguish between first and second generation antihistamines.

Serum-derived immunoglobulins alter amyloid beta transport across a blood-brain barrier in vitro model.

Since passive immunization with serum-derived immunoglobulins (intravenous immunoglobulins) showed several positive effects in some patients with Alzheimer's disease (AD), intravenous immunoglobulins (IVIG) are discussed as a possible treatment option. IVIG, an antibody product derived from human plasma, contains natural antibodies against amyloid beta(Abeta) peptide. Until now it is not known, how IVIG interferes with pathogenesis in AD, but several proposed mechanisms are in discussion. Receptor types which are involved in transport processes at the BBB are LRP, RAGE and hFcRn. We were looking for an in vitro BBB model expressing these receptors and studied the alteration of transport of Abeta peptides across this model under the influence of immunoglobulins. Cell line ECV304 was found to be suitable for our experiments. We found evidence for involvement of an improved clearance of Abeta across the BBB as well as a decreased Abeta influx from blood to the brain probably following complex formation of immunoglobulins with free Abeta in the periphery. Furthermore, we were able to confirm the activity of IVIG preparations which acted the same way but showed slightly less efficacy in comparison to monoclonal anti-Abeta antibodies. Based on these results we suggest multiple mechanisms responsible for the efficacy of immunotherapy in Alzheimer's disease.

Applying blood-brain barrier in vitro models to study the influence of drugs on endothelial cells--effects of selected COX-inhibitors.

The influence of three cyclooxygenase (COX) inhibitors (indometacin, lornoxicam and celecoxib) with different COX-1/COX-2 profiles on endothelial cells using in vitro blood-brain barrier (BBB) models was investigated. For the experiments two BBB mimicking cell lines (PBMEC/C1-2 and ECV304) and primary human umbilical vein endothelial cells (HUVEC) were used. In preliminary tests the two cell lines and HUVEC were characterized by cell ELISA in respect of the presence of the tight junction proteins occludin and zonula occludens protein-1 (ZO-1), the adhesion molecules ICAM-1 and VCAM-1 and the endothelial marker von Willebrand factor (vWF). Then, the influence of indometacin, lornoxicam and celecoxib on the expression of occludin, ZO-1, ICAM-1 and vWF of the two cell lines and HUVEC was analysed by cell ELISA. The COX inhibitors caused an effect on PBMEC/C1-2 and HUVEC but no influence was observed on ECV304. The results of PBMEC/C1-2 and HUVEC indicated that in comparable therapeutical concentrations celecoxib had a higher potential to impair endothelial cells and to decrease the expression of occludin, ZO-1 and ICAM-1 than indometacin and lornoxicam.

p21(waf) correlates with DNA replication but not with prognosis in invasive breast cancer.

BACKGROUND/AIMS: p21(waf) plays a central role both in the regulation of the cell cycle and in DNA replication. Accordingly, p21(waf) is a putative tumour suppressor. The role of p21(waf) expression in breast cancer is still unclear, particularly with respect to the clinical situation. Therefore, this retrospective study was designed to investigate the value of immunohistochemically detected p21(waf) expression in invasive breast cancer. METHODS: Cellular expression of p21(waf) was assessed in 307 breast cancer tissues by immunohistochemistry using the monoclonal antibody, clone 4D10. The data were correlated to established and functional factors of prognosis (age, menopausal status, tumour size, nodal status, tumour grade, receptor status, proliferating cell nuclear antigen (PCNA) expression, Her-2/neu expression, and p53 expression), and to clinical follow up (median observation time, 82 months). RESULTS: Ninety nine of 307 (32.2%) tumour tissues were considered p21(waf) positive (nuclear staining). In the entire study group, p21(waf) expression correlated only with increased PCNA expression (chi(2) test: p = 0.029), and with none of the other investigated markers. In node negative patients (n = 134), p21(waf) expression correlated with increased tumour size and increased PCNA expression, whereas the node positive subgroup (n = 161) showed no correlation with these parameters (lymphonodectomy was done in 295 women). With respect to clinical outcome, p21(waf) expression showed a definite favourable trend in both subgroups (N0: p21(waf) negative, 23 of 87; p21(waf) positive, nine of 43. N+: p21(waf) negative, 63 of 107; p21(waf) positive, 23 of 52), but this observation was not significant (p > 0.05). Multivariate analysis for disease free survival as indicated by Cox regression analysis included all factors investigated. The most striking parameters were nodal status (relative risk (RR), 1.74; p = 0.00001), receptor status (RR, 0.59; p = 0.0085), tumour size (RR, 1.42; p = 0.02), and Her2/neu expression (RR, 1.56; p = 0.033). p21(waf) expression was not significant in the multivariate analysis (p > 0.05). CONCLUSIONS: p21(waf) expression is an independent factor but fails to be of prognostic or predictive value in multivariate analysis. These data confirm the hypothesis of a p53 independent p21(waf) induction and suggest a functional role in the inhibition of PCNA mediated DNA replication.

Immunohistochemical detection of epidermal growth factor receptor lacks prognostic significance for breast carcinoma.

OBJECTIVE: We sought to determine whether the immunohistochemical detection of epidermal growth factor receptor (EGF-R) in primary cancer tissues is of prognostic significance in patients with breast carcinoma. METHODS: Paraffin-embedded tissues from 244 study subjects with primary breast carcinomas were tested immunohistochemically for the presence of EGF-R and were compared in a retrospective study with clinical outcome. RESULTS: Epidermal growth factor receptor was detected in the tumors of 49 (20.1%) of the 244 study subjects. The incidence of EGF-R detection was comparable in subjects with disease-free lymph nodes (T1-4, N0, M0, n = 111; EGF-R present 22.5%) or those whose nodes contained carcinoma (T1-4, N+, M0, n = 133; EGF-R present 18.9%). No reliable correlation was found in either group between EGF-R detection and clinical, functional, or morphologic prognostic indicators that included age, menopausal status, tumor size, tumor grade, nodal status, and hormone receptor status. Relapse-free survival and overall survival (median observation time 62.5 months) did not differ between patients with EGF-R-positive or EGF-R-negative breast carcinoma specimens. CONCLUSIONS: In our experience, the immunohistochemical determination of EGF-R in routine formalin-fixed, paraffin-embedded tumor specimens fails to provide useful information concerning the prognosis of patients with primary breast carcinoma.

Prognostic factors for preoperative consultation of women desiring sterilization: findings of a retrospective analysis.

In this exploratory study, 37 sterilized women applying for sterilization reversal were questioned thoroughly to establish why they had decided to undergo sterilization and why they now wished for it to be reversed. Taking an interactive behavioral model as our starting point, we concentrated on the psychosocial circumstances leading to the definitive decision to be sterilized. A relationship crisis at the time of sterilization was found to be a prognostically unfavorable factor. Furthermore, 20 of the 37 patients cited new partnerships as their main reason for seeking reversal. Those who felt pressurized by their gynecologist or partner into undergoing sterilization had significantly more problems in overcoming the psychological stress accompanying such an operation than those who, through a series of consultations on contraception, had had sufficient time and opportunity to make their own decisions. Sterilization performed for medical reasons was found to have particularly problematical consequences, especially where the doctor had made the decision largely on his own, failing to give an adequate explanation for the medical necessity of the operation. Regarding the time chosen for sterilization, the study revealed that the patient's postoperative psychological condition was significantly worse when sterilization was carried out immediately after a delivery, after abortion or after Caesarean section, rather than in the interval between pregnancies. The resulting increase in the incidence of psychosomatic complaints and depressive states is also confirmed in the literature. The findings of this study offer practical suggestions for improved preoperative consultation and should help to determine the course of action to be taken when a patient wishes to be sterilized.

PIP: 37 sterilized women who requested sterilization reversal at the department of gynecology and obstetrics at the University of Cologne in Germany completed a questionnaire on why they chose sterilization and later wanted it reversed. The most common reasons for undergoing sterilization were: a crisis in the relationship with their partner (12), social reasons (7), and birth limiting (7). 3 women had been sterilized without their consent. 11 women, including the 3 who were sterilized without their consent, noted that a 3rd person (partner, physician, mother, girlfriend) was the decisive factor leading to sterilization. Key reasons for applying for sterilization reversal included a new relationship (20), renewed desire to have children with original partner (9), and death of a child (5). 23 of the women had undergone postpartum sterilization. They had a greater feeling of having been manipulated by a 3rd person than those who underwent interval sterilization. Only 11 of the 37 women had wanted their last child before sterilization. 65% of all the women sought counseling from a gynecologist about sterilization. The gynecologist apparently influenced the final decision in about 33% of women. In 60% of cases, the women had gone through with the sterilization without the full consent of their partners. 15 women had suffered from depression requiring drug therapy. 18 women believed that the sterilization produced a negative psychosocial situation, especially among postpartum sterilization cases and those who felt they were coerced to undergo sterilization. Sterilization appeared to have a positive effect on sexual well-being. These findings confirm the importance of extensive preoperative consultation, ideally with both partners, and of the need for the woman to make her own decision without any manipulative influence from a third party.

Characterization of two blood-brain barrier mimicking cell lines: distribution of lectin-binding sites and perspectives for drug delivery.

In the present study plant lectins with distinct sugar specificities were applied to two blood-brain barrier (BBB) mimicking cell lines, namely human ECV304 and porcine brain microvascular endothelial cells PBMEC/C1-2 in order to elucidate their glycosylation pattern and to evaluate the lectin-cell interaction for lectin-mediated targeting. The bioadhesive properties of fluorescein-labeled lectins were investigated with monolayers as well as single cells using fluorimetry and flow cytometry, followed by confirmation of the specificity of binding. For PBMEC/C1-2 layers highest binding capacity was found for wheat germ agglutinin (WGA), followed by Dolichus biflorus agglutinin (DBA) whereas single cell experiments revealed a predominance of DBA only. Analyzing ECV304 monolayers and single cells, WGA yielded the strongest interaction without any changes during cultivation. The binding capacities of the other lectins increased significantly during differentiation. As similar results to primary cells and brain sections were observed, both cell lines seem to be suitable as models for lectin-interaction studies. Thus, an additional focus was set on the mechanisms involved in uptake and intracellular fate of selected lectins. Cytoinvasion studies were performed with WGA for human ECV304 cells and WGA as well as DBA for PBMEC/C1-2 cells. For both lectins, the association rate to the cells was dependent on temperature which indicated cellular uptake.

Alteration of the glycocalyx of two blood-brain barrier mimicking cell lines is inducible by glioma conditioned media.

Recent studies showed that glioma conditioned medium is able to induce blood-brain barrier properties in in vitro models. In this regard, it was investigated whether glioma conditioned medium can also influence the lectin-binding capacity of blood-brain barrier in vitro models. For the presented study cell lines PBMEC/C1-2 and ECV304 were chosen because it was previously shown that glioma conditioned medium was able to induce specific blood-brain barrier properties in these cell lines. Six different plant lectins (WGA, STL, LCA, UEA-I, DBA, PNA) with distinct sugar specificities were applied in order to elucidate the glycosylation patterns of cell line PBMEC/C1-2 and ECV304. Lectin-binding studies were carried out with monolayers as well as with single cells. In the case of PBMEC/C1-2 monolayers, results showed a significant increase of the binding of lectins WGA, STL, UEA-I, DBA and PNA after application of 25 pmol lectin when cultured in media containing soluble factors derived from glioma cell line C6, whereas the binding capacity for LCA remained similar. For ECV304 monolayers, a significant decrease of WGA, STL and LCA was observable, whereas UEA-I binding increased in comparison to cells grown in the corresponding basal growth medium without soluble C6 factors. Single cell studies showed less significant, but similar changes in the lectin-interactions with the cell surfaces. In conclusion, it was shown that soluble factors derived from glioma cell line C6 can modulate the "glycocalyx" of blood-brain barrier mimicking cell lines.

[Metric growth of the uterus in digenetic trematodes (author's transl)]. / Die Metrik des Uteruswachstums bei digenen Trematoden.

1. The length of the uterus of Dicrocoelium dendriticum, Pleurogenoides medians and Fasciola hepatica at different stages of development is correlated with the corrected size of the body (parallel length x breadth). 2. The data plotted in a log-scale show for all three species a sigmoid curve with linear middle section. 3. The function y = ax + ac(xw - x)3 + b(y = log length of the uterus, x = log length of the body, xw = log length of the body at the turning point) fits very well to the data obtained from Dicrocoelium dendriticum. The constants a, ac and b were determined numerically. The function is valid also for Pleurogenoides medians and Fasciola hepatica but with other constants. 4. The linear middle section of the sigmoid curve may be interpreted by allometric growth. During this phase of development the uterus is tubelike. 5. During the earliest stages of development the uterus forms a solid cord of cells (three-dimensional growth) and grows slower than in a later stage after formation of a cell-free interior (two-dimensional growth). 6. The latest phases of development are characterized by a small increase in length of the uterus due to the three-dimensional dilatation by the produced eggs. 7. The computed function is considered as a modification of the law of allometric growth Y = B . Xa, respectively y = ax + b (log Y = y, log X = x).

[Function of the acetabulum of digenetic trematodes, as exemplified by Dicrocoelium dendriticum]. / Die Arbeitsweise des Bauchsaugnapfes digenetischer Trematoden am Beispiel des Dicrocoelium dendriticum.

The suckers of animals adhere to the substratum either in air or in aqueous fluids. The varying compressibility of these media causes differences in function, the principles of which are described. The ventral arch of the acetabulum of Dicrocoelium dendriticum, like the remaining body, is limited by the integument, basal lamina and skin muscles. The dorsal arch covers a basal lamina, which is close to a plexus of diagonal, longitudinal and circular muscles. The radical muscles, attached at the ventral basal lamina by thin connective tissue, continue in relatively thick contractile fibers, which split up into several fibrils, which also attached by thin connective tissue at the dorsal basal lamina. In this way the tension of the muscles is likewise distributed over the dorsal and ventral arches of the acetabulum. After contact with the substratum the sucker creates a partial vacuum and attachment by means of the pressure of the radial muscles against the wall of the hole. Because of the fluid content of the hole, the volume does not change much. The dorsal arch of the sucker withstands the pressure of the radical muscles, because its surface area is six times greater than that of the ventral arch and consequently the load is six times less. The sucker, covered with basal lamina, has a constant volume; its layer of muscles resists deformation and supports the stability of the arch.

[Wishes, expectations, fears--pregnant women before labor]. / Wünsche, Erwartungen, Angste--Schwangere Frauen vor der Geburt.

The aim of this study was to extend the medical knowledge of the prenatal expectations and wishes of pregnant women with respect to themselves, their partners and the maternity ward selected for the approaching birth, and also of the anxieties arising in this connection. In summary, our study shows that the desire to experience birth in the most natural, undisturbed and unmanipulated form possible is reiterated frequently, but is relativized by the intense need to be reassured of the safety of the unborn child. Fears experienced before the birth were focused accordingly on the condition of the child, although 25% of the women questioned acknowledged a marked fear of helplessness and failure. The obstetric team were expected to offer, as far as possible, the continuous personal supervision of a doctor and a midwife who were prepared to allow the patient the responsibility of being involved in obstetric decisions.

[Spontaneous remission of HELLP syndrome in the 36th week of pregnancy with uterus duplex]. / Spontanremission eines HELLP-Syndroms in der 36.SSW bei Uterus duplex.

We report on a case of an HELLP syndrome in the 36th week of gestation in a primigravida with known uterus duplex cum vagina duplice, which under intensive medical control showed a spontaneous decrease of the elevated liver enzymes and normalisation of platelet count. 12 days after the occurrence of the HELLP syndrome, a Caesarean section was performed because of PROM and breech presentation of the foetus.

[Experiences with definitive contraception--results of a follow-up study of sterilized women]. / Erfahrungen mit der definitiven Kontrazeption--Ergebnisse einer Follow-up-Untersuchung sterilisierter Frauen.

Within the framework of a retrospective analysis, 96 patients who had undergone sterilisation at the Department of Gynaecology at the University of Cologne between 1988 and 1991, had been questioned as to whether they were content about their former decision in favour of a definitive contraception. At present, 94% of these women fully agreed with their former decision. The circumstances influencing the decision for sterilisation before the operation i.e. age, number of children, motivation, situation between partners, date of operation and medical consultation - were compared to those of a number of sterilised women seeking refertilization. We want to stress the importance of a sufficiently long decision process, accompanied by individual medical consultation.

[Alloimmune thrombocytopenia in the newborn infant caused by maternal PlA1 antibodies]. / Alloimmunthrombozytopenie beim Neugeborenen aufgrund mütterlicher Anti-PlA1-Antikörper.

The case of pregnant woman, whose first child was born with neonatal alloimmune thrombocytopenia (NATP) and PlA2/PlA1 constellation, is used as an example to draw up a programme for the care of pregnant women whose children are expected to be born with NATP. In one of 2,000 to one of 3,000 cases, the PlA1-positive foetal platelets cause a sensitization of the PlA1-negative mother. Transplacental passage of maternal IgG alloantibodies leads to accelerated destruction of foetal platelets. The pathophysiologic process is similar to Rh-erythroblastosis foetalis. The infants show symptoms ranging from cutaneous manifestations to intracranial haemorrhages.

[On the value of "informational evening classes for mothers and fathers" within the scope of prenatal care]. / Zum Stellenwert der "Informationsabende für Mütter und Väter" im Rahmen der Schwangerenvorsorge.

In 1989, the Department of Gynaecology and Obstetrics, University of Cologne, questioned the 288 participants of the "informative evenings for mothers and fathers", a primarily preventive measure offered as a preparation for childbirth. The survey aimed at reviewing these evenings, i.e. to make a critical and exact evaluation of their usefulness and quality as one of the numerous events offered to expectant mothers. The following results were obtained: The women who visited the informative evenings were mostly pregnant for the first time, educated above average, for the most part working women and of German nationality. Their attitude towards preventive measures, i.e. regular check-ups during pregnancy as well as smoking behaviour, the wish to breast-feed and the attendance of other birth preparation courses, is well founded. Consequently, this group of women can be described as a highly selected. Their motivation to come to the evenings resulted mostly from the wish to obtain specific clinical information, to become familiar with the maternity ward, to meet midwives and doctors, in order to lose some of their fears and to increase confidence. Contents and structure of these evenings were mostly able to meet the expectations of the visitors. Unsatisfactory, however, was the low number of foreign woman, those with difficult pregnancies and women of a low social status i.e. patients, who above all, need intensive assistance and attention.

[Premature rupture of fetal membranes: problems and obstetric management]. / Der vorzeitige Blasensprung: Problematik und geburtshilfliches Management.

The treatment of a premature rupture of the foetal membrane (prom) has up to now been a subject of controversy. Depending on the stage of gestation, the prompt birth ensuing as a result of prom, involves the risk of immaturity of the child. Conservative waiting by contrast, exposes mother and child to a potential risk of infection. The retrospective study presented, summarises the strategies for treating prom used at the Cologne University Department of Obstetrics and Gynaecology during the period from 1984 to 1989, and attempts to develop from these data proposals for the treatment of prom. With an increase in latency of over 24 hours between prom and delivery, the maternal and neonatal rate of infection also increased significantly. An effective result of a prophylaxis with antibiotics could only be shown in the reduction of incidence of infection in the mother. An effect on the neonatal rate of infection could not be seen. Inducing prepartually lung-maturity with glucocorticoides or ambroxol resulted in a significant decrease of the RDS-rate in new born children up to the 34th week of gestation. Beyond the 34th week of gestation, this effect could not be found. Whereas after completion of the 37th week of gestation, the preferred treatment used by doctors is allowing the shortest possible time of latency between prom and delivery, the expected pulmonary immaturity before the 34th week of gestation has to be treated by prolonging the pregnancy and inducing pulmonary maturity under antibiotic prophylaxis and at the same time controlling infection.(ABSTRACT TRUNCATED AT 250 WORDS)

[An consultation concept for integrating psychosomatic medicine in gynecology]. / Ein praxisnahes Konzept zur Integration psychosomatischer Medizin in der Gynäkologie.

This paper is meant to survey the results of an interdisciplinary concept of psychosomatic patient treatment carried out for two years at the Department of Gynaecology and Obstetrics of the University of Cologne. This integral programme offers a psychosomatic consultation hour taking place once a week at the Department of Gynaecology and Obstetrics. Each first consultation is attended both by a psychosomatic specialist and a gynaecologist. The hypothesis underlying this new programme, which supposes that the integration of the psychosomatic treatment into the everyday routine of the clinic would make it easier for the patients to find access to psychological help, has proved right in view of the experience made so far. In comparison to the former counselling concept, the newly established gynaecologic-psychosomatical programme has increased the attendance by 300%. Thanks to the integrated consultation hour the way of seeing gynaecological problems in a psychosomatic context has increased considerably within the clinic itself so that these problems can now often be solved directly between gynaecologist and patient without making use of the offered consultation hour. Experiences made so far prove that the psychosomatic consultation hours are a valuable contribution to the diagnostic and therapeutic spectrum of the Department of Gynaecology and Obstetrics.

Prenatal expectations and fears in pregnant women.

The aim of this study was to extend the medical knowledge of the prenatal expectations and wishes of pregnant women with respect to themselves, their partners and the maternity ward selected for the approaching birth, and also of the anxieties arising in this connection. In summary, our study shows that the desire to experience birth in the most natural, undisturbed and unmanipulated form possible is reiterated frequently, but is relativized by the intense need to be reassured of the safety of the unborn child. Fears experienced before the birth were focused accordingly on the condition of the child, although 25% of the women questioned acknowledged a marked fear of helplessness and failure. The obstetric team were expected to offer, as far as possible, the continuous personal supervision of a doctor and a midwife who were prepared to allow the patient the responsibility of being involved in obstetric decisions.

[Psychological disease adjustment in breast cancer patients]. / Krankheitsverarbeitung bei Mammakarzinom-Patientinnen.

In a prospective follow-up study, attention was focused on adjustment to disease in breast cancer patients one year after diagnosis. Prebioptic data was collected in the original patient group consisting of 95 women with mammary tissue findings that required clarification. Twenty-nine women with histological confirmation of breast cancer and 37 patients of the control group with benign histological findings were recontacted after an interval of one year. Data was collected by means of psychological test questionnaires (STAI, SVF, FPI, CIP-DS), the patients with breast cancer were given an additional problem-oriented questionnaire about coping with disease, compiled by the author. Most denied having disease-related fears-progression of the disease, premature death; instead, marked sleep disturbances, regularly, recurring nightmares, and depressed states of mind characterized the psychosomatic correlate of the mental burden. The psychological consequences of cancer are related to some extent to the stage of tumour growth at the time of diagnosis; the process of social reintegration appears to be facilitated in women whose biopsy operation did not involve removal of a breast. An clear characterization of breast cancer patients could not be established using psychological testing procedures one year after diagnosis of the disease.

[Horner's syndrome following lumbar epidural anaesthesia--subdural block?]. / Horner-Syndrom bei lumbaler Epiduralanästhesie--Subduraler Block?

A 28 year old primipara (37th gestational week) was scheduled to undergo delivery by caesarean section under epidural anaesthesia. An epidural catheter was easily inserted in the L3/L4 interspace. After a negative aspiration test 5 ml of bupivacaine 0.25% plus adrenaline 1:200,000 were injected and five minutes later 2 x 5 ml of bupivacaine 0.5% plus fentanyl 0.005 mg/ml were given. Ten minutes after the test dose the patient reported warmth and paraesthesia in the right leg and pelvis and numbness in the right periorbital region. The catheter was drawn back 1.5 centimeters and the operation could be performed under regional anaesthesia with supplemental doses of bupivacaine. Sensory level at the end of the operation was Th 4 which decreased continuously in the following two hours. Ocular symptoms (miosis, ptosis, right-sided numbness) as well as numbness in the right hand and leg persisted four hours longer. The most probable explanation for this peripheral Horner's syndrome is a subdural blockade caused by the first bupivacaine doses. The only known prophylaxis is a fractioned epidural injection of local anaesthetics.