The systemic score may identify life-threatening evolution in Still's disease: data from the GIRRCS AOSD-study group and the AIDA Network Still's Disease Registry

OBJECTIVES

To evaluate the clinical usefulness of the systemic score in the prediction of life-threatening evolution in Still's disease. To assess the clinical relevance of each component of the systemic score in predicting life-threatening evolution and to derive patient subsets accordingly.

METHODS

A multicenter, observational, prospective study was designed including patients included in the GIRRCS (Gruppo Italiano Di Ricerca in Reumatologia Clinica e Sperimentale) AOSD-study group and AIDA (AutoInflammatory Disease Alliance) Network Still's Disease Registry. Patients were assessed if variables to derive the systemic score were available. The life-threatening evolution was defined as mortality, whichever the clinical course, and/or macrophage activation syndrome (MAS), a secondary hemophagocytic lymphohistiocytosis associated with a poor prognosis.

RESULTS

Totally 597 patients with Still's disease were assessed (age 36.6±17.3 years; male 44.4%). The systemic score, assessed as continuous variable, significantly predicted the life-threatening evolution (OR: 1.24, 95%CI:1.07-1.42; p=0.004). A systemic score ≥7 also significantly predicted the likelihood of a patient experiencing life-threatening evolution (OR: 3.36, 95%CI:1.81-6.25; p<0.001). Assessing the clinical relevance of each component of the systemic score, liver involvement (OR: 1.68, 95%CI:1.48-2.67; p=0.031) and lung disease (OR: 2.12, 95%CI:1.14-4.49; p=0.042) both significantly predicted life-threatening evolution. The clinical characteristics of patients with liver involvement and lung disease were derived, highlighting their relevance in multiorgan disease manifestations.

CONCLUSION

The clinical utility of the systemic score was shown in identifying Still's disease at higher risk of life-threatening evolution in a large cohort. Furthermore, the clinical relevance of liver involvement and lung disease was highlighted.

Clinical and laboratory features associated with macrophage activation syndrome in Still's disease: data from the international AIDA Network Still's Disease Registry

To characterize clinical and laboratory signs of patients with Still's disease experiencing macrophage activation syndrome (MAS) and identify factors associated with MAS development. Patients with Still's disease classified according to internationally accepted criteria were enrolled in the AutoInflammatory Disease Alliance (AIDA) Still's Disease Registry. Clinical and laboratory features observed during the inflammatory attack complicated by MAS were included in univariate and multivariate logistic regression analysis to identify factors associated to MAS development. A total of 414 patients with Still's disease were included; 39 (9.4%) of them developed MAS during clinical history. At univariate analyses, the following variables were significantly associated with MAS: classification of arthritis based on the number of joints involved (p = 0.003), liver involvement (p = 0.04), hepatomegaly (p = 0.02), hepatic failure (p = 0.01), axillary lymphadenopathy (p = 0.04), pneumonia (p = 0.03), acute respiratory distress syndrome (p < 0.001), platelet abnormalities (p < 0.001), high serum ferritin levels (p = 0.009), abnormal liver function tests (p = 0.009), hypoalbuminemia (p = 0.002), increased LDH (p = 0.001), and LDH serum levels (p < 0.001). At multivariate analysis, hepatomegaly (OR 8.7, 95% CI 1.9-52.6, p = 0.007) and monoarthritis (OR 15.8, 95% CI 2.9-97.1, p = 0.001), were directly associated with MAS, while the decade of life at Still's disease onset (OR 0.6, 95% CI 0.4-0.9, p = 0.045), a normal platelet count (OR 0.1, 95% CI 0.01-0.8, p = 0.034) or thrombocytosis (OR 0.01, 95% CI 0.0-0.2, p = 0.008) resulted to be protective. Clinical and laboratory factors associated with MAS development have been identified in a large cohort of patients based on real-life data.

Separation, reserve estimation and radioactivity responsibility of the economic heavy minerals of East El- Arish black sand, North Sinai, Egypt

Multi-heavy mineral separation techniques like density, magnetic, and electromagnetic techniques are followed by picking, grain counting, and mineralogical examinations conducted with an environmental scanning electron microscope (ESEM). These techniques have been applied to several drill hole (well) composite samples representing beach sand and dunes of East El-Arish area, North Sinai, Egypt. The results explain the remarkable enrichment in total heavy minerals (THM) of beach sand (4.4%) compared to sand dunes (2.6%): this is due to the natural concentration of the currents of the Mediterranean Sea. After characterizing the heavy minerals in terms of the abundance of each mineral species, the mean values of content relative to total economic heavy minerals (TEHM) were determined as 70.03% ilmenite, 3.81% leucoxene, 3.03% magnetite, 8.7% garnet, 10.6% zircon, 3.13% rutile, 0.37% monazite, and 0.31% titanite in the sand dune samples. The total economic heavy minerals in the beach samples were 64.08% ilmenite, 1.6% leucoxene, 2.84% magnetite, 18.16% garnet, 10.4% zircon, 2.18% rutile, 0.61% monazite, and 0.13% titanite. Monazite, thorite, zircon, and apatite are the main radioactive minerals in the study area. The combination of two specific characteristics of the studied monazite (relatively high Th-U content and high frequency) makes monazite the main contributor to radioactivity of the study area.

Radioactive risk assessment of beach sand along the coastline of Mediterranean Sea at El-Arish area, North Sinai, Egypt

Beach sand includes various levels of natural radioactivity, which can cause health effects. The natural radioactivity was measured in the beach sand along the coastline of the Mediterranean Sea at the east of the El-Arish area, Egypt. Using the HPGe spectrometer, the contribution of radionuclides ²²⁶Ra, ²³²Th and ⁴⁰K in the gamma emitted radiation illustrated that the ²²⁶Ra, ²³²Th and ⁴⁰K activity concentrations are 8.8 ± 3.9, 30.8 ± 12.2 and 106.9 ± 46.8 Bq kg^-1, respectively, which is lower than the reported worldwide limit 33, 45 and 412 Bq kg^-1. The radioactive hazards associated with the beach sand along the coastline of the Mediterranean Sea at the east of the El-Arish area were investigated. The obtained results among the radiological hazard parameters, the radium equivalent content (Ra_eq), the absorbed dose rate (D_air), annual effective dose (AED), external (H_ex) and internal (H_in) hazard indices were estimated. Moreover, the excess lifetime cancer risk (ELCR) and the annual gonadal dose equivalent (AGDE) were also computed and illustrated their values less than the recommended levels. Multivariate statistical approaches like Pearson correlation, the principal component analysis (PCA) and the hierarchical cluster analysis (HCA) were applied to investigate the correlation between the radionuclides and the corresponding radiological hazard variables. Based on the statistical analysis, the ²²⁶Ra and ²³²Th mainly contribute to the radioactive risk of beach sand. Finally, no significant risk of the public associated with utilizing beach sand in building materials.

Biological control of Phlebotomus papatasi larvae by using entomopathogenic nematodes and its symbiotic bacterial toxins

The sand fly Phlebotomus papatasi is an important disease-bearing vector. Five entomopathogenic nematodes (EPNs) - Steinernema carpocapsae DD136, Steinernema sp. (SII), S. carpocapsae all, S. abbasi, and Heterorhabditis bacteriophora HP88 - were applied as biocontrol agents against the late third instar larvae of P. papatasi. In addition, the effect of toxin complexes (TCs) of Xenorhabdus nematophila and Photorhabdus luminescens laumondii bacteria was evaluated. Results revealed that S. carpocapsae DD136 was the most virulent species followed by Steinernema sp. (SII) and S. carpocapsae all where LC₅₀ were 472, 565, 962 IJs/ml, respectively. Also, the crude TCs were slightly more active and toxic than their fractionated protein. Histopathological examination of infected larvae with H. bacteriophora HP88 showed negative effect on their midgut cells. In conclusion, EPNs with their symbiotic bacteria are more effective as biocontrol agents than the crude or fractionated TCs against sand fly larvae.

Nodular fasciitis of the infraorbital rim in an adult patient

STATEMENT OF THE PROBLEM

Nodular fasciitis is a fibroblastic proliferation in which nodules develop rapidly. It most commonly affects the extremities followed by the trunk and occasionally the head and neck.

MATERIALS & METHODS

Case report.

RESULTS

A 32-year-old male was seen with a 4-month history of a painless infraorbital mass. On examination, a swelling was palpable anterior to the left infraorbital rim. There was some depression of the left corner of his mouth. Computerized tomography showed soft tissue swelling anterior to the left maxillary antrum which, also, appeared to be diseased. The mass was thought to be malignant owing to the short history, associated facial asymmetry and maxillary sinus opacity. Excisional biopsy was performed. Histology proved it to be nodular fasciitis.

CONCLUSIONS

The importance of otolaryngologists being aware of this entity is stressed. Simple excision, as tissue sparing as possible, is the treatment of choice.

Myofibroblastoma of breast: evidence favoring smooth-muscle rather than myofibroblastic differentiation

A histopathological study of two cases of the tumor known in the literature as myofibroblastoma of the breast is presented. The tumors occurred in Caucasian males aged 57 and 62 years. Histologically, these were moderately cellular, lobulated spindle-cell lesions, each with a reasonably well-delineated edge with surrounding fatty connective tissue. No breast ducts or lobules were present. Tumor cell nuclei were bland, with small nucleoli and some nuclear grooving. Nuclear atypia and mitoses were absent. Immunostaining revealed positivity for a-smooth-muscle actin, desmin, and CD34. Tumor cells contained rough endoplasmic reticulum, bundles of myofilaments with focal densities, intermediate filaments, attachment plaques alternating with plasmalemmal caveolae, and focal lamina. Ultrastructural findings pointed to true smooth-muscle differentiation, and the cell-surface in particular lacked surface features of myofibroblasts (fibronectin fibrils [microtendons] and fibronexus junctions). These and published data suggest that at least some of the lesions referred to in the literature as myofibroblastoma may not be myofibroblastic and may be better designated as myogenic stromal tumors or as variants of leiomyoma.

A comparison of the intubation conditions between mivacurium and rocuronium during balanced anesthesia

BACKGROUND

Comparisons of the intubation conditions with mivacurium and rocuronium from previous reports are confounded by the use of varied induction regimens. The authors compared intubation conditions of mivacurium, rocuronium, and a placebo at 90 s and their recovery profiles during anesthesia with nitrous oxide, oxygen, and propofol.

METHODS

After induction with midazolam, fentanyl, and propofol in a randomized blinded study, 100 patients received one of the following treatments: 0.25 mg/kg mivacurium in divided doses (0.15 mg/kg followed by 0.1 mg/kg 30 s later); 0.45, 0.6, 0.9, or 1.2 mg/kg rocuronium; or placebo. Evoked thumb adduction was measured throughout. Intubation was attempted 90 s after the initial dose of mivacurium and other treatment doses by a "blinded" physician. Intubating conditions were graded as excellent, good, poor, or not possible. Spontaneous recovery was studied until a 25% initial twitch height was reached. Mean arterial blood pressure and heart rate changes between groups were determined before induction through 6 min after administration of the study drugs.

RESULTS

There were no important changes or intergroup differences in mean arterial blood pressure and heart rate. Intubation conditions were good or excellent for both mivacurium and rocuronium at the 0.9 mg/kg dose (93%) and at the 1.2 mg/kg dose (100%). Rocuronium at the 0.6 mg/kg dose was excellent in 27% of patients, whereas rocuronium at the 0.45 mg/kg dose had the least number of excellent conditions and the most poor or not possible assessments. Patients given placebo could not be intubated. Times to maximum blockade for 0.9 and 1.2 mg/kg rocuronium were the shortest. The times to 25% recovery for 0.6 mg/kg rocuronium (mean +/- SD = 27 +/- 8.6 min), 0.9 mg/kg (43.1 +/- 10.8), and 1.2 mg/kg (62.3 +/- 17.4 min) were significantly longer than were those for mivacurium (17.4 +/- 6.2 min).

CONCLUSIONS

Mivacurium in a 0.25 mg/kg divided dose and rocuronium at 0.9 mg/kg and 1.2 mg/kg provide good or excellent intubation conditions at 90 s in most patients. Rocuronium was faster in onset at the higher doses (0.9 and 1.2 mg/kg) but had more prolonged recovery times to 25% single twitch height.

Efficacy and safety of divided dose administration of mivacurium for a 90-second tracheal intubation

STUDY OBJECTIVE

To compare the safety and effectiveness of 0.25 mg divided doses of mivacurium chloride to succinylcholine for a 90-second tracheal intubation.

DESIGN

Randomized, double-blind, multicenter study in two groups.

SETTING

Operating rooms at four university medical centers.

PATIENTS

200 healthy ASA status I and II adult patients scheduled for elective surgery with general anesthesia and endotracheal intubation.

INTERVENTIONS

Patients were premedicated with 1 to 2 mg midazolam and 2 micrograms/kg fentanyl. Anesthesia was induced with 2 mg/kg propofol. Group A received 0.25 mg/kg mivacurium given as a divided dose (0.15 mg/kg followed in 30 seconds with 0.1 mg/kg). Group B (control) received 1.5 mg/kg succinylcholine (SCh) preceded two minutes earlier by 50 micrograms/kg d-tubocurarine (dtc).

MEASUREMENTS AND MAIN RESULTS

Tracheal intubation grading, train-of-four response of the adductor pollicis, heart rate (HR), and mean arterial blood pressure (MAP) were measured and evaluated. Chi-square analysis was performed for comparison between Group A and Group B with respect to the frequency distribution of intubation using the scores excellent, good, and poor and not possible (combined). Group B had a significantly higher excellent score of intubation than Group A, 84% versus 56% (p < 0.0001). No significant difference was found between the two groups when the scores excellent and good were combined (Fisher's Exact test, p = 0.28). The changes in MAP and HR were similar for the two groups.

CONCLUSIONS

When Sch is not desirable, mivacurium 0.25 mg/kg given as a divided dose provides good to excellent intubation conditions 90 seconds after the initial dose without significant changes in MAP or HR. It can be an appropriate alternative for short surgical procedures. It must be emphasized that this conclusion does not apply to rapid-sequence induction-intubation.

Malignant peripheral nerve sheath tumour with vascular differentiation: a report of four cases

Four cases of malignant peripheral nerve sheath tumour showing vascular differentiation are described. One case was associated with neurofibromatosis 1 and contained angiosarcomatous, cartilaginous and rhabdomyoblastic elements. The other cases occurred in patients without neurofibromatosis and showed a spectrum of vascular lesions ranging from lobulated, haemangioma-like structures to angiosarcoma. These are the first recorded examples of this phenomenon not associated with neurofibromatosis. Immunohistochemical examination demonstrated the endothelial nature of the lesions in all cases and revealed cells positive for alpha-smooth muscle actin, probably pericytes, closely apposed to the endothelium.

Intra-arterial chemotherapy in patients with breast cancer: a feasibility study

The aim of this study was to assess the practicality of treating patients with various stages of breast cancer by means of regional (intra-arterial) chemotherapy. Three groups of patients received a median of four (range 2-4) cycles of combination chemotherapy: group I operable primary (n = 10); group II, locally advanced disease (n = 20); group III, recurrent locoregional disease (n = 22). The response rates (complete response, partial response and mixed response) in these groups of patients were 100% in groups I and II and 86% in group III. Morbidity included drug streaming and dysaesthesia in the hand. Patients in groups I and II had their tumours downstaged, allowing surgery to be performed. Local control was also achieved in group III when other treatment modalities had failed.

Assessment of patient position for fiberoptic intubation using videolaryngoscopy

STUDY OBJECTIVE

To compare laryngoscopic appearance obtained during flexible fiberoptic laryngoscopy with the patient's atlanto-occipital joint in the neutral and extended positions.

DESIGN

Controlled clinical trial with each patient (in the neutral position) acting as his or her own control.

SETTING

University teaching hospital.

PATIENTS

20 adult ASA physical status I and II patients, without anatomical airway abnormalities, undergoing elective surgical procedures.

INTERVENTIONS

Fiberoptic laryngoscopy was performed on each patient with his or her atlanto-occipital joint in the neutral and extended positions.

MEASUREMENTS AND MAIN RESULTS

Photographs of the laryngoscopic appearances were graded on a scale of 1 to 4 by a blinded observer according to the proportion of the laryngeal inlet visible. Atlanto-occipital extension improved laryngoscopic appearance in 14 cases and produced no change in the remaining 6.

CONCLUSION

Atlanto-occipital extension is a useful maneuver during attempted fiberoptic intubation.

Histamine release following atracurium in the elderly

A study was performed to evaluate histamine release, as well as potential cardiovascular and cutaneous sequelae, following bolus administration of atracurium in elderly patients. In 15 patients, using a radioenzymatic technique, plasma histamine concentrations were measured in venous blood samples obtained before and after induction of anaesthesia with thiopentone and at 2 and 5 min after administration of atracurium (0.6 mg.kg-1) over 30 s. Blood pressure and pulse rate were measured noninvasively and cutaneous changes sought and compared with those seen in 12 similar patients who received vecuronium (0.1 mg.kg-1). Our findings indicate that the histamine releasing property of atracurium in elderly patients is greater than that in children, similar to that in adolescents and less than that in nonelderly adults. The decreases in blood pressure following atracurium and vecuronium in elderly patients are similar.

Using the bubble inclinometer to measure laryngeal tilt and predict difficulty of laryngoscopy

STUDY OBJECTIVE

To evaluate a simple device, the bubble inclinometer, to measure degrees of laryngeal tilt (LT) for predicting difficulty of direct laryngoscopy using a Macintosh #3 laryngoscope.

DESIGN

Randomized, double-blind study.

SETTING

Inpatient surgery center at a university medical center.

PATIENTS

50 renal lithotripter patients.

INTERVENTIONS

Patients were measured with the bubble inclinometer and the laryngeal indices caliper. A sleep dose of thiopental sodium (4 mg/kg) and a muscle-relaxing dose of succinylcholine (1 mg/kg) were then given to each patient.

MEASUREMENTS AND MAIN RESULTS

LT was measured by both methods (directly and indirectly). Difficulty of laryngoscopy was graded as follows: Grade 1 = all of vocal cords seen; Grade 2 = part of vocal cords seen; Grade 3 = no part of vocal cords seen.

CONCLUSIONS

The bubble inclinometer accurately and reproducibly measures relative LT, and the anterior tilt of the larynx directly correlates with the ability to see the laryngeal opening during direct laryngoscopy with a Macintosh #3 laryngoscope.

Using the laryngeal indices caliper to predict difficulty of laryngoscopy with a Macintosh #3 laryngoscope

STUDY OBJECTIVE

(1) To evaluate a device of the authors' design, the laryngeal indices caliper, which quantitates the position of the anterior edges of the larynx relative to the upper teeth and the external auditory canals; (2) to determine how relative laryngeal position affects ease of direct laryngoscopy with a Macintosh #3 laryngoscope.

DESIGN

Randomized, double-blind study.

SETTING

Inpatient surgery center at a university medical center.

PATIENTS

101 renal lithotripter patients.

INTERVENTIONS

Patients were measured with the laryngeal indices caliper prior to induction of general endotracheal anesthesia. They were then given a sleep dose of thiopental sodium (4 mg/kg) and paralyzed with a bolus dose of succinylcholine (1 mg/kg).

MEASUREMENTS AND MAIN RESULTS

Of the measurements taken or calculated, only laryngeal tilt (LT) showed a significant correlation with grade of difficulty of laryngoscopy. When the anterior surface of the thyroid cartilage was tilted more than 20 degrees anteriorly to a line perpendicular to the laryngeal indices line, the vocal cords could not be seen in 83% of the patients.

CONCLUSIONS

(1) Laryngeal tilt is a good predictor of difficulty of laryngoscopy with a Macintosh #3 laryngoscope; (2) the laryngeal indices caliper is a simple pocket device to measure LT indirectly.

Neostigmine and edrophonium antagonism of moderate neuromuscular block induced by pancuronium or tubocurarine

Edrophonium and neostigmine are anticholinesterase drugs used commonly to antagonize competitive neuromuscular block. Although it has a faster onset of action than neostigmine, edrophonium is unreliable when used to antagonize deep neuromuscular block. We have compared the antagonist characteristics of these two drugs when used to antagonize a moderate degree of pancuronium- or tubocurarine-induced neuromuscular block. Forty ASA I or II patients undergoing surgical procedures were allocated randomly to receive either pancuronium 70 micrograms kg-1 or tubocurarine 0.5 mg kg-1, and to receive either edrophonium 0.5 mg kg-1 or neostigmine 0.05 mg kg-1. Antagonism was attempted when the first response to train-of-four (TOF) stimulation recovered spontaneously to 25% of the control height. Neuromuscular function was monitored using the evoked integrated electromyogram of the first dorsal interosseous muscle of the hand. Adequate recovery was defined as the achievement of a TOF ratio of 0.70 or greater. Only seven of 20 patients who received edrophonium demonstrated adequate recovery 30 min after antagonism. Under the conditions described in this study, edrophonium 0.5 mg kg-1 was less effective as an antagonist than neostigmine 0.05 mg kg-1.

The Lambert-Eaton myasthenic syndrome: a cause of delayed recovery from general anesthesia

A 70-year-old man required prolonged ventilation after surgery to remove a rectal neoplasm. The cause of the slow recovery from the effects of neuromuscular blocking agents used during his anesthetic was the Lambert-Eaton myasthenic syndrome (LEMS). Before surgery, he had no neuromuscular symptoms, even in retrospect. LEMS should be considered in the diagnosis of prolonged recovery from neuromuscular blockade, even in previously asymptomatic patients.

Spontaneous rupture of liver due to cholangitis

Spontaneous rupture of the liver is rare in the Western world and most cases are associated with primary or metastatic tumours. Spontaneous rupture of the intrahepatic biliary tree is not well documented and only two reports have been found in the literature. The authors describe a further case due to ascending cholangitis but presenting with biliary peritonitis. The literature is reviewed and the diagnostic problems discussed.

Pharmacokinetics and pharmacodynamics of doxacurium in young and elderly patients during isoflurane anesthesia

Preliminary disposition studies of the investigational, long-acting muscle relaxant doxacurium chloride (Nuromax) have demonstrated dual elimination by renal and hepatobiliary pathways, as well as slow hydrolysis by plasma cholinesterase. The present study compares the kinetics and dynamics of doxacurium in eight ASA physical status I or II elderly patients (67-72 yr of age) and eight ASA I or II young patients (22-49 yr of age). After institutionally approved written informed consent, kinetic and dynamic measurements were made after a 25-micrograms/kg bolus injection of doxacurium during 1.25 MAC nitrous oxide/oxygen/isoflurane anesthesia. Maximum twitch depression was similar in older patients (96.4% +/- 1.3%) to that in the young patients (96.6% +/- 1.8%). The time to achieve this level of block was significantly longer in the elderly than in the young (11.2 +/- 1.1 min versus 7.7 +/- 1.0 min, respectively). Recovery times to twitch heights of 5% and 25% of control tended to be prolonged and were more variable in the elderly (82.6 +/- 17.2 and 97.1 +/- 20.1 min, respectively) than in the young (54.8 +/- 9 and 67.5 +/- 8.2 min, respectively). Elimination half-life (96 +/- 20 min) and clearance (2.47 +/- 0.69 mL.kg-1.min-1) in the elderly patients were not statistically different from values found in the younger group. Volume of distribution at steady state in the elderly (220 +/- 80.2 mL/kg) was significantly larger than in the young (150 +/- 40.0 mL/kg).(ABSTRACT TRUNCATED AT 250 WORDS)

Monitoring of neuromuscular function

Clinical monitoring of neuromuscular function can be accomplished by either measuring the evoked mechanical or EMG response of a skeletal muscle via an accessible motor nerve. The pattern of motor nerve stimulation varies from supramaximal single repeated stimuli at a specified frequency to tetanic stimulation, posttetanic single stimuli at the pretetanic frequency, and train-of-four stimuli at 2 Hz. The response to relaxants is unpredictable in the population at large and more so in pathologic states. This makes monitoring of the muscle response to motor nerve stimulation extremely valuable and helpful. The train-of-four technique of measurement has proved to be valuable not only as a reliable clinical tool to measure the response to relaxants and monitoring recovery, but also as a research tool for studies of old and new neuromuscular blocking drugs. Evoked responses and clinical criteria for adequate recovery from muscle relaxants should complement each other. The more criteria fulfilled, the better and safer the conclusion that the patient has recovered from clinical neuromuscular blockade.

The cardiovascular effects of mivacurium chloride (BW B1090U) in patients receiving nitrous oxide-opiate-barbiturate anesthesia

The dose-effect relationship of mivacurium chloride on arterial blood pressure, heart rate, and plasma histamine was determined in 97 consenting ASA physical status I-II patients receiving nitrous oxide-oxygen-opiate-barbiturate anesthesia. In the absence of surgical stimulation during steady state anesthetic conditions with controlled ventilation, average maximum change in tachograph-counted heart rate was 7% or less after 10-15-s injection of mivacurium at all doses from 0.03 to 0.30 mg/kg. Average peak change in mean arterial pressure measured via radial arterial catheter was 7% or less after all doses from 0.03 to 0.15 mg/kg. Transient (0.2-4.5 min) decreases in arterial blood pressure were noted after 10-15-s injection in some patients at 0.20, 0.25, and 0.30 mg/kg. When they occurred, these changes were usually accompanied by facial erythema lasting 2-5 min and were correlated with increases in plasma histamine level (P less than 0.001). Facial erythema, decrease in blood pressure, and elevation of histamine level were all accentuated by increasing the dose of mivacurium and by more rapid injection of the drug. For example, mean blood pressure decreased an average of 13% after injection of mivacurium 0.25 mg/kg over 10-15 s. In contrast, during administration over 30 and 60 s of this dose, arterial pressure decreased 7.6 and 1.5%, respectively (P less than 0.001, 10-15 s vs. 60-s injection). Average peak histamine level, which increased to 132% of control after administration of 0.25 mg/kg over 10-15 s, did not change after injection over 60 s.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaesthetic management of a patient with facioscapulohumeral muscular dystrophy

We describe the anaesthetic management of a patient with a rare form of muscular dystrophy (Facioscapulohumeral or Landouzy-Dejerine type). Anaesthesia and controlled ventilation using alfentanil-nitrous oxide and atracurium was satisfactory. In this patient, sensitivity to atracurium was found to be similar to that of the normal population, but more rapid recovery was observed.

Clinical pharmacology of mivacurium chloride (BW B1090U) infusion: comparison with vecuronium and atracurium

Mivacurium chloride (BW B1090U) is a new, short-acting non-depolarizing neuromuscular blocking agent. It is a synthetic bis-benzylisoquinolinium diester, which is hydrolysed rapidly by plasma cholinesterase. This study compares mivacurium, atracurium and vecuronium by continuous i.v. infusion. The duration of mivacurium infusion ranged from 29.5 to 286 min. The steady state infusion rates necessary to maintain 95 (SEM 4)% twitch suppression were: mivacurium 8.3 (0.7) micrograms kg-1 min-1; atracurium 7.9 (0.4) micrograms kg-1 min-1; vecuronium 1.2 (0.3) micrograms kg-1 min-1. Following infusions of mivacurium, various recovery times (for example: 25-75%, 6.9 (0.3) min; 25-95%, 11.0 (0.4) min; 5-95% 14.5 (0.4) min) did not differ significantly from those following single bolus doses. Recovery times following cessation of mivacarium infusions were approximately 50% of those for equivalent durations of infusion of atracurium (10.9 (0.3) min for 25-75% recovery and 26.6 (0.4) min for 5-95% recovery). For vecuronium, corresponding recovery times were 13.8 (0.9) and 32.0 (1.2) min, respectively. Comparative recovery times for mivacurium were 40-50% of those for vecuronium. There was a significant correlation between the infusion rate of mivacurium required to maintain 95% twitch depression and the plasma cholinesterase activity of individual subjects.

Reversal of pancuronium. Neuromuscular and cardiovascular effects of a mixture of neostigmine and glycopyrronium

Moderate to deep (67-99% single twitch depression) pancuronium-induced neuromuscular blockade was antagonised with neostigmine (30 micrograms/kg, 60 micrograms/kg, or 80 micrograms/kg) in combination with glycopyrronium. Twenty-seven patients were reversed from 91%-99% twitch depression. Recovery of the first twitch of a train-of-four to 95% of control twitch took at least 20 minutes with neostigmine 30 micrograms/kg. The higher doses were significantly faster (60 micrograms/kg p less than 0.05, 80 micrograms/kg p less than 0.01) and took 15.8 and 14.8 minutes respectively. Reversal to a train of four ratio of 0.75 was not consistently achieved in under 30 minutes with any dose of neostigmine. Nineteen patients were antagonised from a 67%-80% depression of first twitch and in all but two recovery to 95% of control took under 10 minutes. To achieve a train of four ratio of 0.75 took less than 12.5 minutes except in three patients, two of whom, both given neostigmine 30 micrograms/kg, took longer than 20 minutes. Neostigmine 60 micrograms/kg produced as rapid a degree of antagonism as 80 micrograms/kg. Heart rates after reversal decreased gradually in all groups, although the decrease was initially greater in the low dose neostigmine (30 micrograms/kg) group. A fixed 5:1 ratio of neostigmine and glycopyrronium will usually antagonise a moderate (70%-80%) pancuronium block to a train of four of greater than 75% within 12.5 minutes if at least 60 micrograms/kg of neostigmine is administered. More than 30 minutes may be required for reversal whatever the dose of neostigmine, for antagonism from greater than 90% twitch depression.

Role of endothelial cell injury in the spectrum of azathioprine-induced liver disease after renal transplant: light microscopy and ultrastructural observations

Three cases of azathioprine-induced complex of liver diseases are described, and their light microscopy and ultrastructural findings are detailed. It was found that the drug produces a spectrum of pathological changes that include veno-occlusive disease, peliosis hepatis, perisinusoidal (Disse space) fibrosis, and nodular regenerative hyperplasia. It is suggested that the explanation for this spectrum is the variable degree of damage to the endothelial cells lining the sinusoids and the terminal hepatic venules. This spectrum is seen almost exclusively in male patients with renal transplant.

Monitoring of neuromuscular function

Monitoring neuromuscular transmission provides valuable information to the anesthesiologist. The acquisition of relevant data contributes to a more predictable and rational approach to the use of muscle relaxants and assures improved patient care during and in the immediate postoperative period. Clinical noninvasive criteria such as the presence or absence of diplopia and or ptosis, the ability to open the eyes widely, protrude the tongue or swallow, measurement of hand grip strength or head lift or assessment of the vital capacity are limited to awake and cooperative patients. Measurement of inspiratory force and tidal volume can be evaluated in anesthetized patients breathing spontaneously. Central depressant drugs tend to depress these respiratory parameters. Accordingly, the assumption that relaxants are responsible for respiratory depression at the end of an anesthetic can only be documented when impairment of neuromuscular transmission can be demonstrated. The most reliable method of measuring neuromuscular function is to stimulate an accessible peripheral motor nerve and measurement of the evoked response of the skeletal muscle or muscles innervated by the stimulated motor nerve. The evoked muscle response depends on the pattern of motor nerve stimulation: Single twitch stimuli at a defined frequency, tetanic stimulation, posttetanic single twitch stimulation or train-of-four stimulation. The response to these different modes of stimulation can be assessed either mechanically (evoked tension response) or electrically (evoked electromyography: EMG or integrated EMG). These response criteria can be employed either individually or combined to evaluate the response to muscle relaxants and to assess the adequacy of recovery from neuromuscular blockade.

Clinical pharmacology of atracurium given in high dose

The safety and efficacy of atracurium 0.8 mg kg-1 was determined in healthy patients with particular attention to the speed of onset of blockade, and to changes in haemodynamic variables. Atracurium 0.8 mg kg-1 had a shorter onset time than atracurium 0.5 mg kg-1, and satisfactory intubating conditions were achieved earlier. "Priming" produced no significant improvement in onset time or intubating conditions. Onset times were significantly shorter with nitrous oxide-opioid anaesthesia than following thiopentone alone. Although a 0.8-mg kg-1 bolus resulted in a significant reduction in mean arterial pressure to 75% of control and was associated with a significant increase in plasma histamine concentrations, this response could be prevented by injecting the drug over 75 s. "Priming" or a 30-s injection produced no haemodynamic protection. The protection achieved by pretreatment with anti-histamines was incomplete: mean arterial pressure decreased to 83% of control.

Pharmacokinetics and pharmacodynamics of atracurium during isoflurane anesthesia in normal and anephric patients

We compared the pharmacokinetics and pharmacodynamics of atracurium in eight normal and eight anephric patients during isoflurane anesthesia. Plasma concentrations were measured by high performance liquid chromatography after a single injection of 0.5 mg/kg, and neuromuscular effects were evaluated by the single twitch method. With regard to pharmacokinetic or pharmacodynamic parameters, we found no statistically significant differences between normal and anephric patients. We conclude that during isoflurane anesthesia, anephric patients distribute and eliminate atracurium much as normal patients do.

Atracurium: clinical strategies for preventing histamine release and attenuating the haemodynamic response

This study was designed to determine the effects of a rapid bolus dose of atracurium 0.6 mg kg-1 on arterial pressure, heart rate and plasma histamine concentration (n = 9), and to compare these values with those obtained by (a) giving the same dose of atracurium slowly (over 75 s) (n = 9), or (b) pre-treating with H1- and H2- antagonists (n = 9). The rapid (5-s) bolus dose of atracurium i.v. resulted in a significant increase in plasma histamine concentration (P less than 0.05) and was associated with a decrease in mean arterial pressure and an increase in heart rate. Administering the same dose of atracurium slowly (over 75 s) prevented the increase in plasma histamine concentration, and abolished the subsequent haemodynamic response. Pretreatment with cimetidine 4 mg kg-1 i.v. and chlorpheniramine 0.1 mg kg-1 i.v. abolished the haemodynamic response despite a moderate increase in histamine concentration (0.1 greater than P greater than 0.05).

Jaundice after open heart surgery: a prospective study

Images

The dose response effect of long-acting nondepolarizing neuromuscular blocking agents in children

Cumulative dose-response curves were constructed for pancuronium, metocurine, d-tubocurarine and gallamine in 56 children anaesthetized with thiopentone, N2O/O2 and narcotic. The dose response curves of the four relaxants did not deviate significantly from parallelism. The effective dose causing 95 per cent depression of the twitch at 0.1 Hz was: pancuronium 0.08 mg X kg-1, metocurine 0.34 mg X kg-1, d-tubocurarine 0.6 mg X kg-1, and gallamine 3.4 mg X kg-1. Thus, pancuronium is 40 times more potent than gallamine, while metocurine and d-tubocurarine are seven and four times more potent than gallamine. The recovery of twitch height from 5-25 per cent of control for pancuronium (15.6 +/- 1.7 min) was significantly faster (p less than 0.01) than metocurine (27.3 +/- 1.9 min), d-tubocurarine (32.2 +/- 4.8 min), or gallamine (30 +/- 3.3 min). Compared to studies in adults, the present data indicate that children have a tendency (statistically not significant) to require more relaxant and recover more quickly than adults.

Pneumatosis coli: a case report with ultrastructural study

A case of pneumatosis intestinalis studied by light and electron microscopy is presented. The cysts are dilated lymphatic vessels. Abundant fine fatty globules are found in the cysts and in the histiocytes and multinucleated giant cells which line the lymphatics and which are present in the interstitium. The giant cell formation and florid histiocytic reaction are most probably due to leakage of fatty material from the dilated lymphatics.

Necrotising granulomatous prostatitis after transurethral resection

Images

Micronodular adrenal disease: a light and electron microscopic study

A case of Cushing's syndrome due to micronodular adrenal disease in a 17-year-old girl is presented. The adrenals showed both black and yellow nodules. Histologically the cells contained lipofuschin and either had a clear cytoplasm or an eosinophilic cytoplasm with a prominent nucleus. Lymphocytes were a prominent feature. No cells of the zona reticularis were identified. The cell of origin of these nodules appeared to be from the inner layer of the zona fasciculata. We postulate that the disease is caused by an abnormality in the migration and ultimate destruction of cells from the zona fasciculata to the zona reticularis with a build up of cells at the interface zone.

Clinical pharmacology of atracurium besylate (BW 33A): a new non-depolarizing muscle relaxant

Atracurium, a new non-depolarizing neuromuscular blocking agent, was studied in 70 patients anesthetized with fentanyl, thiopental, and nitrous oxide-oxygen. The dose found to produce 95% twitch inhibition (ED95) was 0.2 mg/kg. The onset time from injection to maximum depression of twitch was 4.0 minutes at this dose; the duration to 95% recovery was 44.1 minutes. Twice the ED95 dose (0.4 mg/kg) had an onset time of 1.7 minutes and a duration of 63.5 minutes. No cardiovascular effects were observed in this dosage range. At higher doses (0.5 and 0.6 mg/kg) arterial pressure decreased 13% and 20% and heart rate increased 5% and 8%, respectively. Sixteen patients received at least four successive doses of atracurium. No clinically significant cumulative effect could be shown when recovery from 25% to 75% of control twitch height was compared for initial and final doses in the series. Atracurium spontaneously decomposes at physiologic pH via the Hofmann elimination reaction and may also undergo ester hydrolysis independent of plasma cholinesterase. These proposed pathways of inactivation may explain the lack of cumulative effect and the drug's intermediate duration of action. Based on the results of this study, atracurium offers several clinical advantages and should undergo more extensive clinical trials.