Differences in Pain Assessments Between Inpatients and Nurses Leads to Considerable Misestimated Pain

BACKGROUND

Pain assessments are an important aspect of health care quality because the high prevalence of pain in inpatients may contribute to complications. Several studies revealed a gap in the pain intensity evaluated by nurses (PEN) and patients (PEP). The aim of the present study was to analyze the correlation and agreement between pain assessments conducted by nurses and patients, and to determine patients at high risk of misestimated pain.

OBJECTIVES

To compare the difference of pain intensity between the questionnaires conducted by additional assessors and electronic records by nursing staff.

STUDY DESIGN

A retrospective study.

SETTING

A medical center in Taichung, Taiwan.

METHODS

We approached 1,034 patients admitted from January 1, 2018 to December 31, 2018 in our hospital. We compared the assessments of pain intensity using questionnaires conducted by additional assessors with those entered into electronic records by nursing staff. Continuous data were reported as the mean (± standard deviation). The analysis of agreement and correlation were performed by kappa statistics or weighted kappa statistics, and correlation (Spearman rank correlation method).

RESULTS

Among the 1,034 patients, 307 patients were excluded. Thus, the final analysis included 686 patients. Patients' median pain intensity was 5 in PEP and 1 in PEN. The patients' pain intensity was underestimated (PEN < PEP) in 539 patients (78.6%), matched (PEN = PEP) in 126 patients (18.3%), and overestimated (PEN > PEP) in 21 patients (3.1%). The surgical interventions (chi squared = 7.996, and P = 0.018) and pain in the past 24 hours (chi squared = 17.776, and P < 0.001) led to a significant difference.

LIMITATIONS

The limitation of the study was the single-center and retrospective design.

CONCLUSIONS

The gap in pain assessments between inpatients and nurses is an important issue in daily practice. The underestimations of pain were more common than overestimations (78.6% vs 3.1%). Surgical interventions and persistent pain lasting over 24 hours were high risk factors for underestimation, but patients' gender, receiving anesthesia, type of anesthesia, and patient-controlled analgesia did not contribute significantly to differences in pain estimation.

Impact of Gender and Age on Claim Rates of Dread Disease and Cancer Insurance Policies in Taiwan

In this paper, the impact of both gender and age on the claim rates of dread disease and cancer insurance policies were examined using unique data taken from Taiwan's private health insurance policies issued by non-life insurers during the 2012 to 2015 policy years. Those aged 30-39 served as the reference group. For the total number of dread disease policies, male insureds had a higher non-cancer claim probability than female insureds, while an age under 20 was associated with much lower claim rates for dread disease policies than for ages over 50. The claim rate for dread disease policies increased rapidly beginning at age 40 for both cancerous and non-cancerous diseases amongst male insureds. Amongst female insureds, those under 20 had much lower claim rates for dread disease policies. Only those aged 50-59 had a higher claim rate for non-cancerous diseases. For the total number of cancer insurance policies, male insureds had lower claim rates than female insureds, with an upward trend being associated with age. For male (female) insureds aged over 40 (20), the claim rates of cancer increased with age.

Pain prevalence in hospitalized patients at a tertiary academic medical center: Exploring severe persistent pain

Objective

The pain prevalence of inpatients is not a well-studied medical issue in Asia. We have aimed to evaluate pain prevalence and characterize those patients who have suffered from severe, persistent pain.

Methods

We investigated pain prevalence using a quota sampling from 19 general wards during the year 2018. Using a structured questionnaire, eight interviewers visited patients at an age ≥ 20 years, and who had been staying in general wards for ≥ 3 days. Those patients were excluded if they were unable to respond to the interview questions. If they reported pain during hospitalization, the maximum pain level and the duration of pain suffered in the past 24 hours were assessed. Care-related pain was also surveyed.

Results

A total of 1,034 patients (M/F, 537/497) completed the survey. Amongst them, 719 patients (69.5%) experienced pain, with moderate and severe pain levels being 27.3% and 43%, respectively. Surgery was considered as it related to pain, including significantly severe pain. The top 3 care-related pain causes were needle pain, wound dressing, and change in position/chest percussion. Change in position/chest percussion and rehabilitation were associated with severe, persistent pain.

Conclusions

Pain is common in approximately 70% of inpatients, with surgery being associated with severe pain. Mobilization and rehabilitation may lead to severe, persistent pain. The periodic study of pain prevalence is essential in order to provide precise pain management.

Propofol Improved Glucose Tolerance Associated with Increased FGF-21 and GLP-1 Production in Male Sprague-Dawley Rats

Anesthetics, particularly volatile anesthetics, have been shown to impair glucose metabolism and cause hyperglycemia, closely linking them with mortality and morbidity as related to surgery. Beyond being an anesthetic used for general anesthesia and sedation, intravenous hypnotic propofol displays an effect on glucose metabolism. To extend the scope of propofol studies, its effects on glucose metabolism were evaluated in male Sprague-Dawley rats of various ages. Unlike chloral hydrate and isoflurane, propofol had little effect on basal glucose levels in rats at 2 months of age, although it did reduce chloral hydrate- and isoflurane-induced hyperglycemia. Propofol reduced postload glucose levels after either intraperitoneal or oral administration of glucose in both 7- and 12-month-old rats, but not those at 2 months of age. These improved effects regarding propofol on glucose metabolism were accompanied by an increase in insulin, fibroblast growth factor-21 (FGF-21), and glucagon-like peptide-1 (GLP-1) secretion. Additionally, an increase in hepatic FGF-21 expression, GLP-1 signaling, and FGF-21 signaling, along with a decrease in endoplasmic reticulum (ER) stress, were noted in propofol-treated rats at 7 months of age. Current findings imply that propofol may turn into insulin-sensitizing molecules during situations of existing insulin resistance, which involve FGF-21, GLP-1, and ER stress.

The benefits of radiological imaging for postoperative orthostatic headache: a case report

Background

Traditionally, the diagnosis of post-dural puncture headache (PDPH) relied upon the patient’s history regarding dural puncture and symptoms, such as orthostatic headache. However, such evidence may not always be reliable or specific. We report an unexpected diagnosis with spontaneous intracranial hypotension (SIH), which was confirmed upon examination of Magnetic Resonance (MR) images in a patient who was initially suspected to have PDPH because he had recently undergone a uncertain dural puncture.

Case presentation

A 45-year-old man had undergone a thoracic epidural catheter insertion for perioperative analgesia prior to general anesthesia induction. Due to intermittent dripping of fluid while the epidural needle was being advanced, a dural puncture was suspected. The patient complained of an orthostatic headache after recovery from surgery, therefore a PDPH was suspected. MR images revealed signs of SIH: dural sinus engorgement, contrast enhancement along the neural sleeves of the left C6–7, bilateral C7-T1, T1–2, T2–3, T3–4, T4–5, and T5–6. Computed tomography-guided epidural blood patching (EBP) was performed the following day, with the patient experiencing immediate relief of the headache.

Conclusion

The benefits of radiological imaging in this case included confirming the correct diagnosis, guiding the accurate level and proper approach of EBP, distinguishing the epidural space from the intrathecal space, and ultimately increasing the likelihood of successful EBP.

Disability benefits as an incentive for hysterectomy: Uterine fibroid patients in Taiwan

Worker compensation insurance in Taiwan ensures that a woman under the age of 45 years who has her uterus removed can receive disability compensation benefits. The present study investigated whether such a compensation policy was related to a woman's inclination to have a hysterectomy. We extracted the records of 16,030 women diagnosed with uterine fibroids (UF) between 2000 and 2010 from the Longitudinal Taiwan Health Insurance Database. Each younger and older age group had a significantly lower hysterectomy rate compared to that of the 44-year-old age group. Moreover, significantly more patients with lower monthly wages had had hysterectomies than those with higher monthly wages. Policy makers should be aware that worker compensation regulations in Taiwan might encourage women with economic need to undergo hysterectomy surgery when approaching the age of 45 years.

Outcomes after Stroke in Patients with Previous Pressure Ulcer: A Nationwide Matched Retrospective Cohort Study

BACKGROUND

Factors associated with poststroke adverse events were not completely understood. The purpose of this study was to investigate whether stroke patients with previous pressure ulcers had more adverse events after stroke.

METHODS

Using the claims data from Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study matched by propensity score. Three thousand two first-ever stroke patients with previous pressure ulcer and 3002 first-ever stroke patients without pressure ulcer were investigated between 2002 and 2009. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of complications and 30-day mortality after stroke associated with previous pressure ulcer were calculated in the multivariate logistic regressions.

RESULTS

Patients with pressure ulcer had significantly higher risk than control for poststroke urinary tract infection (OR: 1.56, 95% CI: 1.38-1.78), pneumonia (OR: 1.35, 95% CI: 1.16-1.58), gastrointestinal bleeding (OR: 1.31, 95% CI: 1.04-1.66), and epilepsy (OR: 1.84, 95% CI: 1.83-1.85). Stroke patients with pressure ulcer had increased 30-day poststroke mortality (OR: 2.01, 95% CI: 1.55-2.61), particularly in those treated with debridement (OR: 2.87, 95% CI: 1.85-4.44) or high quantity of antibiotics (OR: 4.01, 95% CI: 2.10-7.66). Pressure ulcer was associated with poststroke mortality in both genders and patients aged 60 years or older.

CONCLUSIONS

This study showed increased poststroke complications and mortality in patients with previous pressure ulcer, which suggests the urgent need for monitoring stroke patients for pressure ulcer history.

Adverse Outcomes after Non-Chest Surgeries in Patients with Pulmonary Tuberculosis: A Nationwide Study

BACKGROUND

The association between pulmonary tuberculosis (TB) and postoperative outcomes remains unknown. This study investigated outcomes following non-chest surgeries in patients with previous pulmonary TB.

METHODS

Using Taiwan's National Health Insurance Research Database, we analyzed 6911 patients (aged ≥ 20 years) with preoperative diagnosis of pulmonary TB and 6911 propensity score-matched controls receiving non-chest surgeries in 2008-2010. Postoperative outcomes were compared between patients with or without pulmonary TB by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in the multivariate logistic regressions.

RESULTS

Surgical patients with pulmonary TB had a significantly higher postoperative complication rates than controls, including septicemia, pneumonia, acute renal failure, deep wound infection, overall complications, and 30-day postoperative mortality (OR 1.41; 95% CI 1.07-1.86). The ORs of patients with low-income status were as high as 2.27 (95% CI 1.03-5.03). Preoperative use of TB drugs and TB-related medical expenditure also associated with higher postoperative mortality among surgical patients with pulmonary TB.

CONCLUSIONS

Surgical patients with pulmonary TB have significantly increased risks of postoperative complications and mortality after non-chest surgeries. This study suggests the need to improve postoperative care for surgical patients with pulmonary TB.

The association between occupational characteristics and hysterectomies for treating uterine fibroids in Taiwan

This study examined the relationship between the occupational characteristics of women with uterine fibroids (UFs) and the decision to have a hysterectomy. Data from the Longitudinal Taiwan Health Insurance Database (LTHID) from 2000 to 2009 were analyzed to investigate the association between occupation and hysterectomies. Multivariable logistic regression analysis showed that, compared with white-collar UF patients, the odds ratio (OR) for hysterectomy surgery was 1.21 (95% confidence interval (CI) = 1.11-1.32) for blue-collar UF patients. Moreover, non-government employees with UFs also had significantly increased odds of having a hysterectomy compared to government employees with UFs (OR = 1.19, 95% CI = 1.04-1.36). This study provides information regarding the extent to which differences in occupation and decision-making processes might affect the marked variations in the use of hysterectomies for UFs.

Survival analysis of postoperative nausea and vomiting in patients receiving patient-controlled epidural analgesia

BACKGROUND

Postoperative nausea and vomiting as well as postoperative pain are two major concerns when patients undergo surgery and receive anesthetics. Various models and predictive methods have been developed to investigate the risk factors of postoperative nausea and vomiting, and different types of preventive managements have subsequently been developed. However, there continues to be a wide variation in the previously reported incidence rates of postoperative nausea and vomiting. This may have occurred because patients were assessed at different time points, coupled with the overall limitation of the statistical methods used. However, using survival analysis with Cox regression, and thus factoring in these time effects, may solve this statistical limitation and reveal risk factors related to the occurrence of postoperative nausea and vomiting in the following period.

METHODS

In this retrospective, observational, uni-institutional study, we analyzed the results of 229 patients who received patient-controlled epidural analgesia following surgery from June 2007 to December 2007. We investigated the risk factors for the occurrence of postoperative nausea and vomiting, and also assessed the effect of evaluating patients at different time points using the Cox proportional hazards model. Furthermore, the results of this inquiry were compared with those results using logistic regression.

RESULTS

The overall incidence of postoperative nausea and vomiting in our study was 35.4%. Using logistic regression, we found that only sex, but not the total doses and the average dose of opioids, had significant effects on the occurrence of postoperative nausea and vomiting at some time points. Cox regression showed that, when patients consumed a higher average dose of opioids, this correlated with a higher incidence of postoperative nausea and vomiting with a hazard ratio of 1.286.

CONCLUSION

Survival analysis using Cox regression showed that the average consumption of opioids played an important role in postoperative nausea and vomiting, a result not found by logistic regression. Therefore, the incidence of postoperative nausea and vomiting in patients cannot be reliably determined on the basis of a single visit at one point in time.

Depression-like effect of prenatal buprenorphine exposure in rats

Studies indicate that perinatal opioid exposure produces a variety of short- and long-term neurobehavioral consequences. However, the precise modes of action are incompletely understood. Buprenorphine, a mixed agonist/antagonist at the opioid receptors, is currently being used in clinical trials for managing pregnant opioid addicts. This study provides evidence of depression-like consequence following prenatal exposure to supra-therapeutic dose of buprenorphine and sheds light on potential mechanisms of action in a rat model involving administration of intraperitoneal injection to pregnant Sprague-Dawley rats starting from gestation day 7 and lasting for 14 days. Results showed that pups at postnatal day 21 but not the dams had worse parameters of depression-like neurobehaviors using a forced swimming test and tail suspension test, independent of gender. Neurobehavioral changes were accompanied by elevation of oxidative stress, reduction of plasma levels of brain-derived neurotrophic factor (BDNF) and serotonin, and attenuation of tropomyosin-related kinase receptor type B (TrkB) phosphorylation, extracellular signal-regulated kinase (ERK) phosphorylation, protein kinase A activity, cAMP response element-binding protein (CREB) phosphorylation, and CREB DNA-binding activity. Since BDNF/serotonin and CREB signaling could orchestrate a positive feedback loop, our findings suggest that the induction of oxidative stress, reduction of BDNF and serotonin expression, and attenuation of CREB signaling induced by prenatal exposure to supra-therapeutic dose of buprenorphine provide evidence of potential mechanism for the development of depression-like neurobehavior.

Prenatal buprenorphine exposure decreases neurogenesis in rats

Perinatal opioid exposure has a negative effect on neurogenesis and produces neurological consequences. However, its mechanisms of action are incompletely understood. Buprenorphine, a mixed opioid agonist/antagonist, is an alternative medication for managing pregnant opioid addicts. This study provides evidence of decreased neurogenesis and depression-like consequences following prenatal exposure to buprenorphine and sheds light on mechanisms of action in a rat model involving administration of intraperitoneal injection to pregnant rats starting from gestation day 7 and lasting for 14 days and a cultured neurosphere model. Results of forced swimming test and tail suspension test showed that pups at postnatal day 21 had worse parameters of depression-like neurobehaviors, independent of gender. Neurobehavioral changes were accompanied by reduction of neuronal composition, biochemical parameters of neural stem/progenitor cells, brain-derived neurotrophic factor (BDNF) expression, tropomyosin-related kinase receptor type B phosphorylation, protein kinase A (PKA) activity, and cAMP response element-binding protein phosphorylation. Results of parallel cell studies further demonstrated a negative impact of buprenorphine on cultured neurospheres, including proliferation, differentiation, BDNF expression and signaling, and PKA activity. Taken together, our results suggest that prenatal exposure to buprenorphine might result in depression-like phenotypes associated with impaired BDNF action and decreased neurogenesis in the developing brain of weanlings.

Hypoxemia during one-lung ventilation for robot-assisted coronary artery bypass graft surgery

BACKGROUND

Robot-assisted coronary artery bypass grafting requires continuous one-lung ventilation (OLV) to evacuate the thoracic cavity. Whether this ventilatory mode subjects patients to serious hypoxemia remains underinvestigated.

METHODS

From 2005 to 2010, all patients receiving robot-assisted coronary artery bypass graft surgery using OLV with active capnothorax for internal mammary artery harvesting and then passive pneumothorax for minithoracotomy direct-vision coronary bypass graft surgery were included. Patients' variables of oxygenation were monitored and compared throughout the whole surgical period. Persistent oxygen desaturation (arterial oxygen pressure <70 mm Hg) refractory to primary managements was defined as a hypoxemic event, and predictors of such events were identified by multivariate regression analysis.

RESULTS

A total of 255 consecutive patients were enrolled. Average oxygen saturation decreased modestly during the first stage of OLV with active capnothorax, causing hypoxemic events in 9 patients (4.3%) leading to death in 2 (0.8%), whereas it dropped drastically in the second stage of OLV with passive pneumothorax, resulting in hypoxemic events in 32 patients (12.6%) and death in 1 (0.4%). Multivariate regression analysis identified high pulmonary vascular resistance and low left ventricular ejection fraction as predictors of hypoxemia during internal mammary artery takedown, whereas prolonged procedure and chronic obstructive pulmonary disease were identified as predictors during minithoracotomy bypass grafting.

CONCLUSIONS

Robot-assisted two-stage coronary artery bypass surgery employing OLV could be complicated by serious hypoxemia especially at the minithoracotomy grafting stage and in patients with specific risk factors. Thus, when managing such patients, invasive monitoring and aggressive treatment of arterial desaturation are mandatory to ensure the patient's safety and procedural smoothness.

Extensive spinal cord ischemia following endovascular repair of an infrarenal abdominal aortic aneurysm: a rare complication

Postoperative paraplegia secondary to spinal cord ischemia (SCI) is an extremely rare and devastating complication of endovascular repair in abdominal aortic aneurysm (AAA) surgery. The reported incidence is only 0.21 % worldwide. This case of postoperative paraplegia occurred in a 60-year-old man immediately following endovascular repair of an infrarenal AAA. Postoperative magnetic resonance imaging showed multiple foci of SCI involvement from C5 to L1. However, neither cerebral spinal fluid drainage nor steroid therapy was effective; he was eventually admitted with no improvement in his neurological status. The mechanism remains multifactorial until now and needs more attention in perioperative management. We report the first case involved in the most significantly extensive SCI after endovascular repair of an infrarenal AAA.

The use of transdermal fentanyl in cancer pain--a compliance study of outpatients in Taiwan

The aim of this study is to investigate cancer patients' response and side effects associated with transdermal therapeutic fentanyl (TTS-F), whose pain was hardly controlled by nonweak/weak opioids in Taiwan. From 2005 to 2006, 822 outpatients received TTS-F to collect pain assessment forms and diaries for 4 weeks. Most (78.7%) patients were initially prescribed 25 microg/h TTS-F. Doses were adjusted weekly at clinicians' discretion, according to pain assessment and side effects. Patients receiving 50 microg/h, 75 microg/h, and > 75 microg/h TTS-F had increased from 17.5% to 32.1%, 1.8% to 3.4%, and 1.9% to 2.2%, respectively, by week 2; further small increases were found in weeks 3 and 4. Pain palliation improved from 60.6% during week 1 to 78.6% at week 4. The common adverse effects were nausea/vomiting. Patient's compliance was >90%. This study found that the TTS-F is effective and well tolerated.

Syndrome of inappropriate antidiuretic hormone secretion and diabetes insipidus in an infant following surgery

Syndrome of inappropriate secretion of antidiuretic hormone and diabetes insipidus occurring in very short order in the same patient is rare. We report a 9 month-old male infant suffering form holoprosencephaly developed syndrome of inappropriate secretion of antidiuretic hormone followed by diabetes insipidus within a relative short time postoperatively after his third operation. Inability to suppress as well as to stimulate arginine vasopressin secretion and anesthetic and surgical stresses, were thought to be the possible causes of this event.

Management of postdural puncture headache by epidural saline delivered with a patient-controlled pump--a case report

Unintentional dural puncture is the most frequent cause of postdural puncture headache (PDPH) in epidural anesthesia and analgesia. Conservative treatments of PDPH include bed rest, oral analgesics, and hydration. When conservative measures fail, epidural blood patch is an effective substitute. However, epidural blood patch carries some risks, such as subdural hematoma, pneumocephalus, exacerbation of PDPH and new dural puncture. Many patients may refuse the procedure due to the risks involved. We describe a female patient who had her PDPH successfully treated with epidural saline delivered by a patient-controlled analgesia device (Abbott Pain Management-APM) without molestation of her daily activities.

Latrogenic aortic dissection during mitral valve replacement surgery--a case report

Intraoperative aortic dissection is one of the complications of aortic cannulation, which is potentially lethal with an incidence of about 0.16%. Early diagnosis and treatment can lower the mortality rate effectively. We report a 68 y/o female patient sustaining an acute type A aortic dissection in consequence of aortic cannulation for mitral valve replacement surgery. Induction of general anesthesia and endotracheal intubation were performed smoothly. Transesophageal echocardiography (TEE) has proven itself as an important tool to offer definite diagnosis of aortic dissection. Iatrogenic intraoperative aortic dissection is rare but is potentially a fatal complication. Early diagnosis and prompt treatment are important for survival.

The influence of volatile anesthetics on alveolar epithelial permeability measured by noninvasive radionuclide lung scan

Many volatile anesthetics have long been thought to affect pulmonary functions including lung ventilation (LV) and alveolar epithelial permeability (AEP). The purpose of this study is to examine the influence of volatile anesthetics on LV and AEP by noninvasive radionuclide lung imaging of technetium-99m labeled diethylene triamine pentaacetic acid radioaerosol inhalation lung scan (DTPA lung scan). Twenty patients undergoing surgery and receiving volatile anesthesia with 1% halothane were enrolled as the study group 1. The other 20 patients undergoing surgery and receiving volatile anesthesia with 1.5% isoflurane were enrolled as the study group 2. At the same time, 20 patients undergoing surgery with intravenous anesthesia drugs were included as a control group. Before surgery, 1 hour after surgery, and 1 week after surgery, we investigated the 3 groups of patients with DTPA lung scan to evaluate LV and AEP by 99mTc DTPA clearance halftime (T1/2). No significant change or abnormality of LV before surgery, 1 hour after surgery, or 1 week after surgery was found among the 3 groups of patients. In the control group, the 99mTc DTPA clearance T1/2 was 63.5 +/- 16.4, 63.1 +/- 18.4, and 62.8 +/- 17.0 minutes, before surgery, 1 hour after surgery, and 1 week after surgery, respectively. In group 1, it was 65.9 +/- 9.3, 62.5 +/- 9.1, and 65.8 +/- 10.3 minutes, respectively. No significant change in AEP before surgery, 1 hour after surgery, or 1 week after surgery was found. However, in group 2, the 99mTc DTPA clearance T1/2 was 65.5 +/- 13.2, 44.9 +/- 10.5, and 66.1 +/- 14.0 minutes, respectively. A significant transient change in AEP was found 1 hour after surgery, but it recovered 1 week after surgery. We conclude that volatile anesthesia is safe for LV and AEP, and only isoflurane can induce transient change of AEP.

Rhabdomyolysis-induced acute renal failure after morphine overdose--a case report

The 39-year-old male in this report was a victim of C4 spinal cord injury for 7 years. He was regularly followed up at our pain clinic and psychiatric out-patient department (OPD) for treatment of his chronic pain with morphine, anticonvulsant and sedatives. At the night of December 15, 1997, he took approximately 0.1 gm of morphine and a certain number of flurazepam pills. On the next day, he experienced numbness and paresis in both legs in association with painful swelling of both thighs. Then he sought medical advice at our hospital and was admitted for investigation on December 20, 1997. Laboratory examination revealed elevated creatine kinase activity, increased urine myoglobin concentration and raised plasma creatinine, signifying the development of acute muscle damage. The excreted urine morphine concentration was as high as 6,384 ng/mL. Increased PYP uptake in the proximal portion of both thighs was noted on muscle scan. These abnormalities were resolved gradually over two weeks under conservative treatment. Morphine-induced rhabdomyolysis complicated by acute renal failure was highly suspected.

Role of right hepatic lobectomy in the treatment of isolated right-sided hepatolithiasis

BACKGROUND

The role of right hepatic lobectomy is evaluated in the treatment of selected patients with isolated right-sided hepatolithiasis.

METHODS

During the past 7 years right hepatic lobectomy was performed in five patients who had isolated right-sided hepatolithiasis. The rationale and indications of this procedure are discussed. The efficacy of preoperative evaluations, the operative findings, and the operative results are analyzed.

RESULTS

All the patients were female with a mean age of 49.2 years (range, 33 to 63 years). The main symptoms were upper abdominal pain (n = 5), fever (n = 4), and jaundice (n = 2). The mean operative time was 166.4 minutes, and the mean blood loss was 880 ml. The complete stone clearance rate was 100%. No operative deaths occurred. Right subphrenic abscess with reactive pleural effusion developed in two patients. Echo-guided percutaneous drainage was applied to one patient, and no surgical intervention was needed. The mean follow-up period from the treatment was 13.4 months (range, 6 to 18 months). During the follow-up period no stone recurrence was found.

CONCLUSIONS

Right hepatic lobectomy is indicated in patients who have localized right-sided hepatolithiasis with irreversible biliary stricture involving the right hepatic duct, an atrophied right lobe of the liver, multiple cholangitic abscesses, or possible presence of cholangiocarcinoma. Preoperative evaluations, including cholangiography, abdominal ultrasonography, and computed tomography, are important for the accurate selection of patients and successful treatment.

A simple, secure and universal pancreaticojejunostomy following pancreaticoduodenectomy

Although the operative mortality of pancreaticoduodenal resection has decreased recently, the operative morbidity resulting from a leaking pancreatic anastomosis remains high. We described our experience in 50 consecutive cases with a simple, secure end to side pancreaticojejunostomy. We used a paediatric nasogastric tube in the pancreatic remnant duct as a temporary external pancreatic drain. There were 29 men and 21 women ranging from 12 to 84 years with a median age of 61 years. Forty-two patients underwent a standard Whipple procedure and eight a pylorus preserving pancreaticoduodenectomy. Average operating time was 270 minutes with a range of 170 to 480 minutes. The pancreaticojejunostomy could be constructed in a mean of 8 minutes. Intraoperative blood loss ranged from 150 to 3500 mL with a mean of 910 mL. Twenty-five patients (50%) received no blood transfusion. The consistency of the pancreatic remnant was hard in 12 patients (24%) and normal in 38 patients (76%). The pancreatic duct was dilated (> 4 mm) in 15 patients (30%). There was no operative mortality and only three (6.0%) minor leaks from the pancreatic anastomosis which healed spontaneously. It was difficult to determine if the leaks were related to the consistency of the pancreatic remnant, the size of the pancreatic duct, the amount of intraoperative blood loss, operating time, sex of the patient or experience of the surgeon, as there were only three leaks. We concluded that our technique for pancreaticojejunal anastomosis following pancreaticoduodenectomy was safe and applicable to, standard Whipple or pylorus preserving pancreaticoduodenectomy, small or dilated pancreatic ducts, normal or fibrotic pancreas.

Co-administration of midazolam decreases propofol dose during anesthesia in endoscopic laryngeal microsurgery

BACKGROUND

Propofol is commonly used in total intravenous anesthesia (TIVA) for brief surgical procedures because it offers rapid recovery and has fewer side effects. However, concomittent use of other adjuvant agents has been considered so that the same anesthetic effects can be achieved at lower doses of propofol which is more expensive without compromising rapid recovery and increasing the adverse effects. This study was therefore designed to evaluate the co-administration of midazolam and propofol during anesthesia for endoscopic microsurgery and test its influences on the consumption of propofol and the quality of anesthesia.

METHODS

Forty-two patients receiving selective endoscopic microsurgery were enrolled in this study. All patients received high frequency jet ventilation (HFJV) under TIVA. The control group (n = 21) received propofol (20 mg/5 s) during induction and 10 mg/kg/h as maintenance. The study group (n = 21) received midazolam (0.06 mg/kg) and propofol (20 mg/5 s) for induction with propofol 8 mg/kg/hr for maintenance. Doses of propofol, vital signs, recovery time, post-anesthetic high cortical function, and adverse events were evaluated and compared.

RESULTS

Co-administration of midazolam and propofol in TIVA could reduce the induction dose and the total dose of propofol by 51% and 26% respectively but still achieve the same anesthetic effects. Vital signs and recovery were not influenced, and incidence of adverse effects did not increase.

CONCLUSIONS

Our result suggests that co-administration of midazolam and propofol in TIVA appears to be safe, effective, and economic alternative to that with propofol alone. The effects were synergic but side effects were not.

Will epidural with light general anesthesia increase the incidence of awareness with recall or dream postoperatively

BACKGROUND

The incidence of awareness with recall during general combined with epidural anesthesia has not been previously reported. The purpose of this study was to quantify the incidence.

MATERIALS & METHODS

One hundred patients were divided into two groups. Group 1 (N = 50) received general anesthesia (GA), Group 2 (N = 50) received GA and epidural anesthesia (EA) intraoperatively. No premedication was given. These patients were induced with thiopentol (5 mg/kg) or propofol (2.0 mg/kg) and anectine (1.2 mg/kg) for smooth tracheal intubation and maintained with N2O:O2 = 1.5:1.5, and isoflurane and muscle relaxant of either pavulon or atracurium. No sedatives was given. Before anesthesia, we introduced an epidural catheter into the group 2 patients. After induction, headphones with soft music were given to the patients, in both groups, throughout the operation. 20-36 hours after operation or when the patients were fully awake, we asked the patients if they had heard anything or dreamed intraoperatively.

RESULTS

We found that not one of the one hundred patients heard anything or dreamed intraoperatively.

Electrodeposited Defect Chemistry Superlattices

Nanometer-scale layered structures based on thallium(III) oxide were electrodeposited in a beaker at room temperature by pulsing the applied potential during deposition. The conducting metal oxide samples were superlattices, with layers as thin as 6.7 nanometers. The defect chemistry was a function of the applied overpotential: High overpotentials favored oxygen vacancies, whereas low overpotentials favored cation interstitials. The transition from one defect chemistry to another in this nonequilibrium process occurred in the same potential range (100 to 120 millivolts) in which the rate of the back electron transfer reaction became significant. The epitaxial structures have the high carrier density and low electronic dimensionality of high transition temperature superconductors.

Scanning Tunneling Microscopy of Electrodeposited Ceramic Superlattices

Cleaved cross sections of nanometer-scale ceramic superlattices fabricated from materials of the lead-thallium-oxygen system were imaged in the scanning tunneling microscope (STM). The apparent height differences between the layers were attributed to composition-dependent variations in local electrical properties. For a typical superlattice, the measured modulation wavelength was 10.6 nanometers by STM and 10.8 nanometers by x-ray diffraction. The apparent height profile for potentiostatically deposited superlattices was more square than that for galvanostatically deposited samples. These results suggest that the composition follows the applied potential more closely than it follows the applied current. The x-ray diffraction pattern of a superlattice produced under potential control had satellites out to the fourth order around the (420) Bragg reflection.

[Etiologies of unilateral block of epidural anesthesia: a case report]

We would like to present a patient, who was a 60 years old man, 160 cm tall, weighing 55 kg, which received debridement for his pressure sores under epidural anesthesia. While inserting the Touhy needle, there was obvious loss of resistance at the level of 9 cm below the skin. When the test dose was injected, the compliance was good. Later, the anesthesia behaved as unilateral block. After the operation, the computerized tomography revealed the epidural catheter was between the facia of right psoas major muscle. Form this case, there were some lesions: (1) The distance from the skin to the lumbar dura mater is seldom longer than 7 cm. (2) The obvious loss-of-resistance and good compliance of test dose are not the guarantee of epidural anesthesia. (3) The psoas block may be another cause of unilateral block of lumbar epidural anesthesia.