SELECTED ABSTRACTS FROM OTHER JOURNALS

Edited by: Dr. A. A. Gehani and Dr. M. Hammoudeh
Hamad Medical Corporation, Doha, Qatar

BRITISH JOURNAL OF ANESTHESIA

Double-Blind, Placebo-Controlled Analgesic Study of Ibuprofen or Rofecoxib in Combination With Paracetamol for Tonsillectomy in Children

Background:

The analgesics used for pediatric tonsillectomy may be associated with side-effects such as sedation, respiratory depression and vomiting (opiods) or increased bleeding [non-steroidal anti inflammatory drugs (NSAIDs)]. In our institution, we employ a combination of paracetamol, NSAID and opioid, although there is no published evidence of analgesic benefits from adding NSAIDs to paracetamol in children.

Methods:

This randomized, double-blinded clinical study examined the analgesic effectiveness of combining paracetamol (20 mg kg/1) with refecoxib (0.625mg kg/1), ibuprofen (5mg kg/1), or placebo as pre medication for (adeno) tonsillectomy (n=98) in children aged 3-15yr. Intravenous fantasy 11-2ugkg/1 was given intraoperatively. Regular oral paracetamol ( 15 mg kg/1, 4 hourly) was given after operation and could be supplemented on request from the child with oral ibuprofen 5mg kg/1 or oral codeine 1mg kg/1. The primary outcome variable was need for early supplementary analgesia (within 2 h after surgery).

Results:

The addition of ibuprofen to paracetamol reduced the need for early analgesia from 75% to 38% of children (difference 34%; 95% confidence interval 4-6%). The addition of refecoxib or paracetamol did not significantly alter the need for early analgesia (68 vs 72%). Pain scores were higher in those children who required early analgesia. There were no differences between the groups in operative blood loss or complications, total 24 h analgesic consumption, pain scores at 4 and 8 h, vomiting or antiemetic use.

Conclusion:

This study provides evidence to support the combination of ibuprofen (but not refecoxib) with paracetamol for perioperative analgesia in children. (AE Pickering et al; British Journal of Anesthesia: 2002; 88: 72-77)

EUROPEAN HEART JOURNAL

Right Ventricular Cardiomyopathy In B-Thalassaemia Major Aims: To evaluate right ventricular function in patients with B-thalassaemia major and congestive heart failure.

Background:

In patients with B–thalassaemia major a high incidence of cardiac involvement still exists despite improved prognosis with chelation therapy. Development of severe right heart failure is common and has been attributed to pulmonary hypertension secondary to lung homochromatosis, however, the possibility of direct right ventricular myocardial involvement in the absence of significant pulmonary hypertension has not been adequately investigated.

Methods:

Twenty-nine consecutively screened patients with B–thalassaemia major and congestive heart failure were investigated by Doppler echocardigraphy, right ventricular first-pass-radionuclide examination and cardiac catheterization. Haemodynamic data were obtained both before and after volume loading. A control group of 39 patients with B–thalassaemia major, free from cardiac disease, and matched for age, gender, body surface area and heart rate was used for comparison. A subset of the control thalassaemic group (n=15) underwent both radionuclide and haemodynamic assessment.

Result:

The majority of patients were in non-optimal chelation therapy. Only two of 29 patients were found to have cor pulmonale. One other patient suffered from constrictive pericarditis. A restrictive filling pattern in both ventricles and left ventricular systolic dys function were evidence in the other 26 patients. Pulmonary artery pressure (Systolic, 33+ 8 vs 27+ 5mm Hg, P,.05) and pulmonary vascular resistance (114 + 56 vs 65 + 29dynes. s. cm-5), P < .01) were only markedly elevated in the heart failure group. After volume challenge, cardiac output remained unchanged although the increments of ventricular filling pressures were significant (Ð right atrial: 4.8 + 2.2mm Hg, P<.05; Ðpulmonary capillary wedge; 5.6 + 2.6mm Hg, P < 05) and correlated with each other (r = 0.69; P<.001) in heart failure patients, suggesting pericardial constraint and ventricular interaction. In these patients compared with the control thalassaemic group, a lower right ventricular ejection fraction (29% + 9 vs 59% + 6 P<.0001) without correlation with pulmonary artery pressures was found. Haemodynamically significant right ventricular dysfuction defined as mean right atrial pressure > 10mmHg and ration of mean right atrial-to-capillary wedge pressure > 0.8 was evident in 15 of the 26 patients (58%), all with severe symptoms, representing three fourths of patients in functional calls II and IV. Simultaneous pressure recordings in six of these 15 patients showed equalization of ventricular end-diastolic pressure within 2mmHg.

Conclusion:

The majority of patients with B-thalassaemia major and severe congestive heart failure demonstrated a unique haemodynamic pattern similar to that described in predominant right ventricular infarction, indicating severe right ventricular cardiomyopathy in addition to left ventricular dysfunction. The incidence of cor pulmonale as a cause of right heart failure seems to be much lower than previously hypothesized.

(G Hahalis et al; European Heart Journal: 2002;23;147 147-156)

LANCET

Ambulatory Blood Pressure After Therapeutic and Subtherapeutic Nasal Continuous Positive Airways Pressure for Obstructive Sleep Apnoea: A Randomised Parallel Trial

Background:

Obstructive sleep apnoea is associated with raised blood pressure. If blood pressure can be reduced by nasal continuous positive airway pressure (nCPAP), such treatment could reduce risk of cardiovascular disease in patients with obstructive sleep apnoea. Our aim was to see whether nCPAP for sleep apnoea reduces blood pressure compared with the most robust control intervention subtherapeutic nCPAP.

Methods:

We did a randomized parallel trial to compare change in blood pressure in 118 men with obstructive sleep apnoea (Epworth score > 9, and a > 4% oxygen desaturation index of > 10 per h) who were assigned to either therapeutic (n=59) or subtherapuetic (59) nCPAP (about I cm H2O pressure) for I month. The primary outcome was the change in 24-h mean blood pressure. Secondary outcome was the changes in systolic, diastolic, sleep, and wake blood pressure, and relations between blood pressure changes, baseline blood pressure, and severity of sleep apnoea.

Findings:

Therapeutic n nCPAP reduced mean arterial ambulatory blood pressure by 2.5mm Hg (SE 0.8) whereas subtherapuetic nCPAP increased blood pressure by 0.8 mm Hg (0.7) (difference - 3.3 [95% CI - 5.3 to 1.3]; P = .0013, unpaired t test). This benefit was seen in both systolic and diastolic blood pressure, and during both sleep and wake. The benefit was larger in patients with more severe sleep apnoea than those who had less severe apnoea, but was independent of the base line blood pressure. The benefit was especially large in patients taking drug treatment for blood pressure.

Interpretation:

In patients with most severe sleep apnoea nCPAP reduces blood pressure providing significant vascular risk benefits, and substantially improving excessive daytime sleepiness and quality of life.

(Justin C.T. Pepperell at al; LANCET: 2001; 359:204-210)

ARCHIVES OF SURGERY

Common Bile Duct Injury During Laparoscopic Cholecystectomy and the Use of Intraoperative Cholangiography: Adverse Outcome or Preventable Error?

Background:

Common bile duct (CBD) injury is a serious complication of laparoscopic cholecystectomy (LC). Predicators of this adverse outcome have not been well documented.

Hypotheses:

Surgeon experience and the use of intraoperative cholangiography (ICO) are associated with a decreased rate of major CBD injury during L.C.

Design:

A retrospective population-based cohort study. Setting: Washington State Hospital discharge database reports from 1991 through 1998.

Patients:

Discharge reports were searched for International Classification of Diseases, Ninth Revision, procedure codes consistent with LC and then evaluated for procedure codes for CBD repair and reconstruction within 90 days of LC.

Main Outcome Measure:

The rate of CBD injury in patients undergoing LC based on the surgeon’s experience IOC use.

Results:

In all, 30 630LCs and 76 major CBD injuries (2.5/1000 operations) were identified in this analysis. There were no significant differences between injured and noninjured in demographics, disease, payer status, or hospital variables. A CBD injury occurred in 3.2 of 1000 LCs in the early case order of surgeons compared with 1.7 per 1000 at later points (P=.01) (relative risk, 1.81; 95% confidence interval, 1.44-2.88). the rate of injury in LCs performed without IOC was 3.3 1000 compared with 2.0 per 1000 in LCs with IOC (P=.02) (relative risk, 1.7;95% confidence interval, 1.1-2.6) surgeon’s experience and IOC use were independent predictors of injury.

Conclusions:

The rate of CBD injury is significantly lower when IOC is used. This effect is magnified during the early experience of surgeons. Systematic use of IOC may significantly reduce the rate of CBD injury.

(David R. Flum et al; Archives of Surgery: 2001;136;1287-1292)

ARCHIVES OF OTOLARYNGOLOGY HEAD & NECK SURGERY

Analysis of Risk Factors Predictive of Distance Failure After Targeted Chemoradiation for Advanced Head and Neck Cancer

Background:

Distant metastasis (DM) is the most common mode of recurrence among patients with advanced head and neck carcinoma treated with intra arterial cisplatin and radiotherapy (RADPLAT).

Objective:

To identify which patients are at greatest risk for DM and would benefit the most from new strategies designed to treat occult metastases.

Methods:

Between 1993 and 1999, 250 patients with advanced head and neck cancer were treated by RADPLAT. Excluded from the analysis were 10 patients who either did not complete the protocol or were unavailable for follow –up and 39 patients with persistent disease or local recurrence. The incidence and the risk factors for DM in these patients were evaluated in a model that included the following factors; age, T and N classification, site of tumor, histologic grade number (0. 1, or > 1) and position (High vs low) of neck levels involved, and bilateral nodal disease. Multiple stepwise logistic regression was used for the analysis.

Results:

In a univariate analysis, the following variable correlated to DM: in classification (P = .02), site of tumor (P =.01), lower neck.

Nodes (P =.02), number of neck levels involved (P =.01), and bilateral nodal disease (P =.02). In a multivariate analysis, the most significant risk factors for DM were the number of neck levels involved and the site of the primary tumor (P <.001). The highest odds ratios for DM were among patients with multiple levels of nodal involvement (3.17) and patients with hypopharyngeal carcinoma (2.8).

Conclusions:

Patients with more than 1 level of clinical nodal involvement and patients with hypopharyngeal carcinoma have the highest risk of developing DM as the initial site of failure and would benefit most from treatment strategies that address occult distant disease.

(Ilana Doweck et al; Archives of Otolaryngology: 2001;127;1315-1318)