Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis.

The aim was to evaluate the efficacy and safety of volatile anaesthetic for postoperative sedation in adult cardiac surgery patients through a systematic review and meta-analysis. We retrieved randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Web of Science, clinical trials registries, conference proceedings, and reference lists of included articles. Independent reviewers extracted data, including patient characteristics, type of intraoperative anaesthesia, inhaled anaesthetic used, comparator sedation, and outcomes of interest, using pre-piloted forms. We assessed risk of bias using the Cochrane Tool and evaluated the strength of the evidence using the GRADE approach. Eight studies enrolling 610 patients were included. Seven had a high and one a low risk of bias. The times to extubation after intensive care unit (ICU) admission and sedation discontinuation were, respectively, 76 [95% confidence interval (CI) -150 to - 2, I2=79%] and 74 min (95% CI - 126 to - 23, I2=96%) less in patients who were sedated using volatile anaesthetic. There was no difference in ICU or hospital length of stay. Patients who received volatile anaesthetic sedation had troponin concentrations that were 0.71 ng ml-1 (95% CI 0.23-1.2) lower than control patients. Reporting on other outcomes was varied and not suitable for meta-analysis. Volatile anaesthetic sedation may be associated with a shorter time to extubation after cardiac surgery but no change in ICU or hospital length of stay. It is associated with a significantly lower postoperative troponin concentration, but the impact of this on adverse cardiovascular outcomes is uncertain. Blinded randomized trials using intention-to-treat analysis are required. PROSPERO registry number: 2016:CRD42016033874. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016033874.

Vaginal template implant for cervical carcinoma with vaginal stenosis or inadvertent diagnosis after hysterectomy.

PURPOSE: For cervical carcinoma patients with poor geometry for conventional intracavitary radiotherapy, a simple vaginal template for interstitial implantation as a substitute was used. This template has also been used to treat patients who had hysterectomy done without knowledge of an early tumor in the cervix, and for patients with recurrent disease. This is a report of the treatment results. METHODS AND MATERIAL: A total of 21 patients were treated over from July 1987 to June 1991 with this vaginal template implant forming part of the treatment, 12 of these were performed for vaginal stenosis. The applicator consists of a front piece and an end piece. Holes were drilled in the front piece to guide the implantation of the cervix or vaginal vault. The diameter of applicators varied from 2 cm to 3.5 cm. Depending on the diameter of the applicators, six to eight needles on the periphery, or eight peripheral plus one central needle were used. The activity of the needles were around 8 mCi with a total length of 5.5 cm. The end piece was locked onto the front piece by a bayonet-type locking device. The purpose of the end piece was two-fold: to make up the length of the whole applicator to fit the vagina and to keep the implanted needles in place without being extruded. The implantation was performed under general anesthesia. RESULTS: One of the twelve patients treated with the vaginal template implant for vaginal stenosis had relapsed centrally but subsequently died of intercurrent disease. Two other patients died of intercurrent disease at 26.2 and 41.9 months, respectively, without evidence of relapse. Nine other patients had been followed with no evidence of local relapse for 23.7 to 54.6 months. CONCLUSION: This vaginal template implantation is a satisfactory means of treating patients with vaginal stenosis and those who had hysterectomy done without knowledge of an early tumor in cervix.

The effect of oral contraceptives on coagulation and fibrinolytic parameters in the Chinese--a prospective study.

Thirty-two Chinese and 7 Caucasians were studied prospectively for 12 months for the effects of oral contraceptives (OC) on certain coagulation and fibrinolytic parameters. In both ethnic groups there was an increase in alpha 1 antitrypsin level. There was no significant change in antithrombin III concentration measured either by radioimmunoassay (At-III-RIA) or chromogenic assay (anti Xa-chromogenic) in the Chinese, but a significant decrease in anti Xa-chromogenic at 7 months and At-III-RIA at 12 months in the Caucasians. Also, alpha 2 plasmin inhibitor (alpha 2 PI) levels were unchanged in the Chinese but a significant increase occurred in the Caucasians at 12 months. Enhanced fibrinolytic response to venous occlusion was demonstrated in the Chinese at 12 months but not in the Caucasians.

Immunological parameters in gestational trophoblastic neoplasia.

Immunological function were studied in 22 patients with hydatidiform mole and 29 patients with malignant trophoblastic disease before and after treatment; normal pregnant and post-pregnant women served as controls. The only significant abnormality in hydatidiform mole was a low granulocyte chemotaxis before evacuation. In malignant trophoblastic disease the total lymphocyte counts, T-cell counts. B-cell counts, lymphocyte responses to mitogens and serum IgA levels were significantly lower than in normal women 6 wk after pregnancy. In those who responded to chemotherapy, these indices rose to the levels of post-pregnancy controls. An 'immune profile score' based on these indices was found to be a useful prognostic index. All patients with hydatidiform mole who had a score of 7 or less developed malignant trophoblastic disease, while the two patients with malignant trophoblastic disease who died had the lowest scores of the series.

Mixed lymphocyte reaction in gestational trophoblastic disease: presence of a specific plasma inhibitor of the response to paternal alloantigens.

One-way wife-husband and wife-unrelated donor mixed lymphocyte reactions (MLR) were performed for 17 patients with malignant gestational trophoblastic disease (MGTD) and 17 normal pregnant subjects in the first trimester. The response of patients with MGTD to the husbands' lymphocytes did not differ significantly from the response to donors' lymphocytes when the MLR was performed in pooled human serum. Autologous plasma from patients with MGTD suppressed the MLR to husbands' lymphocytes but not that to donors' lymphocytes. Plasma from pregnant subjects in the first trimester did not suppress the wife-husband MLR. It is postulated that the specific plasma blocking activity may contribute to the failure to reject the trophoblastic tumours.

Hepatic metastases in gestational trophoblastic disease.

From 1975 to 1983, 195 patients were treated for persistent or metastatic gestational trophoblastic disease. Fifteen patients with liver metastases were analyzed. All were treated with chemotherapy alone, none received hepatic irradiation, and no patient bled from her hepatic metastases. Thus, the need for prophylactic hepatic irradiation to prevent hemorrhage is doubtful. The good results obtained in the studied patients emphasize the significance of using vigorous primary multiagent chemotherapy in high-risk gestational trophoblastic disease patients.

Plasma prolactin, progesterone, estradiol, and human chorionic gonadotropin in complete and partial moles before and after evacuation.

Plasma prolactin, progesterone, and 17 beta-estradiol were measured by radioimmunoassay in 58 patients with complete moles, 17 patients with partial moles, and the same number of maturity-matched pregnant control subjects. In both complete and partial moles in the first trimester, the pre-evacuation plasma levels of these hormones were similar to those of pregnant control subjects, but in the second trimester they were all significantly lower than those of pregnant controls. There was no significant difference in the regression patterns of these hormones between complete and partial moles, but the serum beta-subunit of human chorionic gonadotropin (beta hCG) was higher in complete moles. Patients who subsequently developed persistent gestational trophoblastic tumors had higher plasma estradiol, prolactin, and serum beta hCG than those without persistent gestational trophoblastic tumors both before and after evacuation, but the difference in plasma estradiol and prolactin disappeared by nine weeks after evacuation. The levels of these hormones in patients with theca-lutein cysts were higher than those without theca-lutein cysts in the first few weeks after evacuation. Plasma estradiol, progesterone, and prolactin returned to normal nonpregnant levels before serum beta hCG, and they were not useful as tumor markers.

Residual trophoblastic disease in association with partial hydatidiform mole.

A 10-year retrospective study was carried out of cases diagnosed as hydatidiform mole at the University of Hong Kong. Strict morphologic criteria established in a previous report were used to study the association of the partial mole syndrome with residual trophoblastic disease. Of the total of 138 cases available, 13 were found to be partial moles, 1 of which was followed by trophoblastic disease that required chemotherapy. This subsequently proved to be an invasive (partial) mole, the first example of its kind to be verified by pathology. The extent of the association between partial mole and subsequent trophoblastic disease and the spectrum of the pathologic lesions actually underlying the latter remain to be determined by further retrospective and prospective studies.

Postmenopausal uterine bleeding of nonorganic cause.

Eighty-nine patients with postmenopausal uterine bleeding were studied focusing on the nonorganic causes of bleeding. Atrophic endometrium was found in 82%, proliferative endometrium in 7%, and secretory endometrium in 1% of patients. Carcinoma was uncommon, found in only 7% of patients. Hysteroscopy was an invaluable adjunct to dilatation and curettage in diagnosing bleeding due to atrophic endometrium as 42% of such cases yielded no tissue on curettage. The clinical entity of bleeding atrophic endometrium is discussed.

Stimulation of the zona-free hamster ova penetration efficiency by human spermatozoa after 17 beta-estradiol treatment.

17 beta-Estradiol (E2) stimulated the zona-free hamster ova penetration by human spermatozoa from both fertile and subfertile men after 5 hours of incubation in vitro. For spermatozoa samples from fertile men, the mean penetration rates increased significantly (P less than 0.05), from 35.6% +/- 3.5% (control) to 60.1% +/- 5.8% (E2 = 50 ng/ ml) and 50.5% +/- 2.6% (E2 = 100 ng/ml), respectively. E2 also increased the mean penetration rates of spermatozoa samples from subfertile men significantly (P less than 0.05), from 10.2% +/- 1.8% (control) to 30.5% +/- 7.2% (E2 = 50 ng/ml) and 33.1% +/- 6.6% (E2 = 100 ng/ml), respectively. These findings indicate that E2 can affect the fertilizing ability of human spermatozoa in vitro.

Intrascleral dissemination of infectious scleritis following pterygium excision.

AIMS: To assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision. METHODS: The records of patients with infectious scleritis after pterygium excision who developed multifocal scleral abscesses presenting from 1988 to the end of 1995 were reviewed. Early culture of abscesses was performed, and topical, systemic antimicrobials, or both were given to all patients. Fourteen eyes were operated on in addition to antimicrobial treatment. RESULTS: The initial culture reports of scleral ulcers identified Pseudomonas species in 12 of these 18 patients, Aspergillus in one, Mycobacterium fortuitum in one, and mixed organisms in four. Subsequent abscess cultures were taken from 15 of the infected eyes, and revealed the same organism as the initial culture in 12. Associated complications included four serous retinal detachments, three choroidal detachments, two double detachments, five complicated cataracts, and four recurrences of the initial infection. Four eyes required eventual enucleation and 11 eyes regained useful vision. CONCLUSIONS: With subsequent abscess cultures proving to be the same organism as found in the initial ulcer, the abscess formation appears to represent intrascleral dissemination. Early diagnosis and appropriate, prolonged topical plus systemic antimicrobial treatment are essential to halt the progression of such severe infections.

The prevalence and clinical significance of pulmonary infection due to non-tuberculous mycobacteria in Hong Kong.

An unexpected increase in positive sputum cultures of non-tuberculous mycobacteria (NTM) was noted in Hong Kong in 1990 compared to previous years, in contrast to a steady decline in the number of positive cultures of Mycobacterium tuberculosis. A retrospective case note study was therefore undertaken to ascertain the clinical importance of the rise in NTM isolates. A representative sample of 183 of the 675 patients with NTM isolates from sputum during 1990 was identified. Cases were assigned to groups according to whether there was evidence of progressive pulmonary disease due to NTM (group 1), persisting colonization without evidence of progressive disease (group 2) or transient isolation of NTM without evidence of progressive disease (group 3). Of 168 cases with adequate clinical and radiological records, 28 (16.7%) represented progressive disease due to NTM and 6 (3.6%) represented persisting colonization. The remainder were both transient and clinically insignificant. Most patients (71%) with progressive pulmonary disease due to NTM had pre-existing lung damage, and 50% had received anti-tuberculous therapy for documented M. tuberculosis previously. The commonest organism involved was the M avium complex. Eighty-six percent of patients with progressive disease and 83% of those with persisting colonization had at least one smear positive sputum specimen, whereas only 2% of patients with sputum contamination had a smear positive sputum sample (P < 0.0001). M. malmoense, M. xenopi and M. fortuitum all appear to be rare causes of significant NTM disease in Hong Kong. However, M. chelonei caused four cases of progressive disease within the study population, two of which were fatal.(ABSTRACT TRUNCATED AT 250 WORDS)

Termination of second trimester pregnancy with sulprostone and mifepristone: a randomized double-blind placebo-controlled trial.

A prospective randomized double-blind placebo-controlled trial was conducted in 13 subjects to find out whether mifepristone treatment could facilitate termination of second trimester pregnancy by sulprostone. The women received either 600 mg oral mifepristone or placebo tablets 36 hours before the administration of intramuscular sulprostone 0.5 mg every 6 hours. The median interval between the administration of sulprostone and abortion in the mifepristone group (4.6 hours) was significantly shorter than that in the placebo group (20 hours). The amount of sulprostone required was also significantly less in the mifepristone group. There was no significant difference in the incidence of side effects or analgesic requirement between the two groups. We conclude that oral mifepristone is useful in facilitating termination of second trimester pregnancies by sulprostone.

PIP: Termination of second trimester pregnancies has been related to side effects. ATtempts have been made to shorten the induction-abortion interval and to lower dosage of the prostaglandins in order to reduce the incidence of side effects. In this study, 13 second trimester patients 18-35 years of age were administered mifepristone before the procedure which called for administration of intramuscular sulprostone; the trial was prospective and randomized and called for double-blind placebo controls. The objective was to determine whether administration of mifepristone would facilitate termination of the pregnancy. 6 women received 600 mg oral mifepristone in an unmarked packet 36 hours before the administration of .5 mg sulprostone intramuscularly every 6 hours until the patient felt strong uterine contractions. 7 women received a placebo in an unmarked packet at the same time as those receiving mifepristone followed by sulprostone. Side effects, uterine contractions, blood pressure, and pulse were recorded every 2 hours. There were no significant differences in mean age of patients or in weight and height. Women were excluded who had any significant past or present medical disorder, who were using prescription drugs regularly, who were nursing or using hormonal contraception during or just before conception, or who were using an intrauterine device. The statistically significant results showed that the induction-abortion interval was shorter and the amount of sulprostone lower in the mifepristone group. 3 patients in the placebo groups did not abort within 24 hours and required administration of oxytocin and further injections of sulprostone. 2 patients (28.6%) in the placebo group required uterine evacuation under general anesthesia, and 4 patients (66.7%) in the placebo group required uterine evacuation due to incomplete abortions, which was not a statistically significant difference. Temperature highs were similar in both groups, but the amount of vomiting or diarrhea and the analgesic requirement was greater in the placebo group, but not significantly so. There was early termination of the study because of unexpected cardiovascular complications in another study; intravenous injection of sulprostone is recommended. The advantages of mifepristone are that it requires no special skills and avoids the complications of the laminaria tent.

Blood loss in termination of early pregnancy by vacuum aspiration and by combination of mifepristone and gemeprost.

Blood loss was measured in 17 subjects undergoing surgical termination of pregnancy and in 96 subjects undergoing medical termination of pregnancy with sequential mifepristone (200 mg, 400 mg, 600 mg) and 1 mg prostaglandin analogue gemeprost. The median blood loss were 53.2, 84.1, 99.9 and 101.4 ml, respectively. There was a statistically significant difference between the surgical and each of the medical termination group of subjects but there was no difference among the subgroups in the medical termination group. The pattern of bleeding was also similar, being heaviest on the day and the days shortly after prostaglandin administration. Majority of them (> 90%) experienced blood loss of < 300 ml and there was no significant drop in hemoglobin level during the 6-week follow-up period. A few women experienced heavy bleeding and, hence, strict supervision on medical termination of pregnancy is recommended.

Pre-operative cervical dilatation in termination of first trimester pregnancies using 16, 16-dimethyl-trans-delta 2 PGE1 methyl ester vaginal pessaries.

The effect of a prostaglandin E1 analogue on the cervix prior to termination of first trimester pregnancy was studied in a double-blind placebo-controlled trial with 70 primigravid and 125 multigravid patients in the Hong Kong University Gynaecological Unit. One mg of 16, 16-dimethyl-trans-delta 2-prostaglandin E1 methyl ester (ONO 802) in the form of vaginal pessary was inserted 3 hours before vacuum aspiration. The cervical dilatation in patients receiving ONO 802 pessaries was significantly greater than that in patients who received no treatment or placebo pessaries but the difference in dilatation between patients who received no treatment or placebo was not significant. The blood loss during operation in patients receiving ONO 802 pessaries was also significantly less than that in patients receiving placebo pessaries. The side effects due to ONO 802 pessaries were mild and infrequent.

Randomized comparison of different prostaglandin analogues and laminaria tent for preoperative cervical dilatation. World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction: Task Force on Prostaglandins for Fertility Regulation.

In an eleven-centre study, 627 nulliparous subjects in the 8th to 12th week of gestation admitted for termination of pregnancy were allocated to one of five treatments to induce pre-operative cervical dilatation. The treatments were: 0.5 mg PGE2 methyl sulphonylamide; 1.0 mg PGE1 methyl ester; 30 mg 9-methylene PGE2 free acid, 0.5 mg 15-methyl PGF2 alpha; a single medium-sized laminaria tent. The results indicate that the three PGE analogues are at least equally effective as one medium sized laminaria tent and more effective than 0.5 mg 15-methyl PGF2 alpha in producing adequate pre-operative cervical dilatation prior to vacuum aspiration. It is concluded that both pre-treatment with prostaglandin analogues and laminaria tent are effective methods for preoperative cervical dilatation and both types of treatment are associated with a low incidence of side effects. Prostaglandin analogue treatment can be administered by paramedical personnel but laminaria tent insertion has to be performed by medical staff.

Glucose and lipid metabolism with triphasic oral contraceptives in women with history of gestational diabetes.

The glucose and lipid metabolism in a group of women with previous history of gestational diabetes were evaluated before and after 6 months treatment with a low-dose triphasic oral contraceptives pill (TP). This group was compared with a control group of women, also with history of gestational diabetes, using intrauterine devices (IUD). In the TP group, 26.7% of the women developed impaired glucose tolerance which reverted to normal in all but one after cessation of the TP. The IUD group showed no change in glucose tolerance. The integrated insulin response to a 75g OGTT in the TP group increased by 48.3% at 6 months compared with an increase of 23.4% for the same period in the IUD group. In the TP group there was a significant decrease in serum total cholesterol without changes in HDL-cholesterol and triglycerides level. We conclude that even low-dose triphasic oral contraceptive pills can cause glucose intolerance in women with previous gestational diabetes mellitus.

PIP: The glucose and lipid metabolism in a group of 20 women with a previous history of gestational diabetes were evaluated before and after 6 months of treatment with a low-dose triphasic oral contraceptive (OC). Another group of 5 women, also with a history of gestational diabetes but who were given an IUD, served as controls. 26.7% of the women in the triphasic OC group developed impaired glucose tolerance; however, values reverted to normal in all but 1 woman after OC discontinuation. The IUD group showed no change in glucose tolerance. The integrated insulin response to a 75 gm oral glucose tolerance test increased by 48.3% at 6 months in the OC group compared with an increase of 23.4% for the same period in the control group. Also recorded in the OC group but not among controls was a significant increase in serum total cholesterol without changes in high density lipoprotein-cholesterol and triglyceride levels. It was concluded that even low-dose triphasic OCs can cause glucose intolerance in women with previous gestational diabetes mellitus. Thus, the theoretical risk of precipitating permanent diabetes should be weighed against the risk of pregnancy. In cases where OCs are the only reliable method possible, careful and frequent monitoring of carbohydrate metabolism should be performed. Older, heavier women with a family history of diabetes are in particular need of close surveillance and constant monitoring of their glucose and lipid metabolism.

An evaluation of the prognostic factors in metastatic gestational trophoblastic disease.

A retrospective evaluation of prognostic factors in 55 patients suffering from metastatic gestational trophoblastic disease (MGTD) treated by modified Bagshawe's CHAMOCA regimen was done. The prognostic significance of the eight prognostic factors in the WHO scoring system, number of sites of metastasis and FIGO staging were evaluated by univariate analysis using Chi-square test with Yates' correction and odds ratio and by multivariate analysis using Cox proportional hazard analysis and logistic regression analysis. In the univariate analysis, the intervals between antecedent pregnancy and the diagnosis of GTD, (P = 0.004) the level of hCG (P = 0.02) and the number of metastatic sites (P = 0.046) were significantly associated with death. In the multivariate analysis, only the interval between the antecedent pregnancy and the diagnosis and the level of hCG were significantly associated with death. Thus, it seems that the interval between antecedant pregnancy and the diagnosis and the level of hCG were the two most significant factors in predicting mortality in high risk MGTD. The WHO staging was more predictive of poor outcome than that of the FIGO staging in this group of patients.

Clinicopathologic study of 16 cases of primary tubal malignancy.

Sixteen cases of primary carcinoma of the fallopian tube were diagnosed and treated at Queen Mary Hospital, Hong Kong from July 1972 to June 1992 constituting 0.26% of the total gynecologic malignancies seen during that period. The average age was 61 years and the most common presenting symptom was abnormal vaginal bleeding. Preoperative diagnosis is difficult; in only one case was a diagnosis of malignancy made by cervical smear. An adnexal mass was detected in 13 of the cases (81.3%) either by clinical examination and/or ultrasonography. Therapy consisted of surgical resection, usually followed by various combinations of adjuvant radiation therapy and chemotherapy. The cumulative survival was 62%. In addition to the typical form of adenocarcinoma, one case of squamous cell carcinoma and a case of multifocal endometrioid adenocarcinoma were observed. One case of an apparently usual form of adenocarcinoma recurred as a heterologous malignant mixed Müllerian tumor 2 years after diagnosis. This series further emphasises the wide range of differentiation possible in the Müllerian system and the variety of neoplasms which may arise from it.

Problems in the use of urinary hCG-beta-core as a tumor marker in gynecologic cancer.

Urinary human chorionic gonadotrophin beta-core (hCG-betaC) was detected in 55-77% of gynecologic malignancies. The use of spot and early morning urine hCG-betaC as a tumor marker was explored with regard to the stability of the hCG-betaC level in serial spot urine samples collected within 24 hours and in early morning urine collected over 3 days. Thirteen patients with gynecologic malignancies were asked, before treatment, to collect serial urine samples voided within 24 hours. Nine of these 13 patients were also asked to save early morning urine for 2-3 consecutive days. Their urine was assayed for creatinine and hCG-betaC using an immunoradiometric assay. Variation of urine concentration was corrected by using the hCG-betaC/creatinine (betaC/Cr) ratio expressed in pmolg-1. Wide fluctuations of betaC/Cr ratios were found both in the serial spot urine within 24 hours and in early morning urine within 3 days. Eight per cent of the patients had one or more spot hCG-betaC level double or half the median of their own serial urine samples. Neither spot urine nor early morning urine hCG-betaC were suitable for use as a tumor marker for continuous monitoring because of the large fluctuation in hCG-betaC levels. The reason for such a wide fluctuation is not clear.