Comparison of endoscopic ultrasound and computed tomography for detecting and staging malignant pancreatic masses

Introduction: Endoscopic ultrasound [EUS] is now established as a valuable imaging test for diagnosing and staging pancreatic cancer. But, with significant recent improvements in spiral computed tomography [CT] scanners, particularly higher resolution and ability to reconstruct 3D images, spiral CT is now increasingly accepted as being better for pancreatic cancer staging. The debate continues, however, about the best diagnostic test or combination of tests in patients with suspected pancreatic cancer. Spiral CT is more readily available than endoscopic ultrasound guided fine needle aspiration [EUS-FNA], cheaper and, therefore, more frequently used In this study, we evaluated the use of EUS-FNA in comparison with spiral CT for detection and staging of malignant pancreatic massesMethods: This prospective study was carried in El-Ebrashi unit of Gastroenterology and Hepatology, Internal Medicine department, Cairo University over 3 years from 2011 to 2014. It included 68 patient with suspected pancreatic mass lesions based on abdominal ultrasound, CT or MRI and patients with obstructive jaundice due to common bile duct [CBD] stricture as proved by endoscopic retrograde cholangiopancreatography [ERCP] or Magnetic resonance cholangiopancreatography [MRCP]. The patients were subjected to dual phase pancreatic control multi-detector computed tomography [MDCT] to be followed by EUS-FNA, then cytopathological examination of the studied patients to determine the nature of pancreatic masses, normal and benign cases are followed up after 6 months by EUS for exclusion of malignancy

Results: The final diagnosis in this study was that, 61 patients were malignant and 7 benign cases. The sensitivity of CT was 75% compared to 100% for EUS. While the specificity for CT was 14% compared to 100% for EUS. The negative predictive value for CT was 6.25% compared to 100% for EUS. With an overall accuracy of MDCT was 69% compared to 100% for EUS for diagnosing pancreatic cancer. The sensitivity of CT for detection of small lesions

Conclusion: EUS is more accurate than CT for detection of pancreatic cancer especially in small tumors. EUS is more accurate than CT in staging of pancreatic cancer in early stages

Recommendation: Early diagnosis of pancreatic cancer is the most important step in the way of decreasing its mortality rate. For screening of patients with suspected pancreatic cancer, initially CT should be performed to be followed by EUS whether to exclude masses in negative CT patients or to confirm the mass and to provide a tool for sample/or cytopathological diagnosis in patients with positive CT We recommend a future study to correlate the accuracy of staging by EUS and CT with post-operative histopathological staging

new validated HPTLC method for quantitative determination of 1, 5-dicaffeoylquinic acid in Inula crithmoides roots

1, 5-Dicaffeoylquinic acid [1, 5-DCQA], a potent HIV-1 integrase inhibitor, is currently undergoing an evaluation as a promising novel HIV therapeutic agent. This work aims at developing an accurate, rapid, repeatable and robust HPTLC method for the determination of 1, 5-DCQA in its natural sources. 1, 5-DCQA is the major component of the n-butanol fraction, the most biologically active hepatoprotective fraction, of Inula crithmoides roots extract. Thus, it will be of interest to evaluate the plant roots as a potential source of 1, 5-DCQA using a fully validated HPTLC method. The percentage of 1, 5-DCQA in the studied plant [0.035% w/w] was found to be approximately similar to those previously determined in other antioxidant herbal drugs, in which 1, 5-DCQA is the main phenolic constituent. The results obtained showed that the described HPTLC method is suitable for routine use in quality control of herbal raw material, extracts and pharmaceutical preparations containing 1, 5-DCQA. No HPTLC method has been reported in literature for the determination of 1, 5-DCQA in medicinal plants

Study of the newborn feeding behaviors and fentanyl concentration in colostrums after an analgesic dose of epidural and intravenous fentanyl in caesarian section

To compare the effects of epidural and intravenous fentanyl on breast feeding behaviors and fentanyl concentration in colostrums after an analgesic dose. In Obstetric Department Kasr-El Aini Hospital-Cairo University. This study included 100 breast feeding mothers. All mothers were healthy multipara who gave birth. Prospective comparative study to full term healthy newborns by caesarian section using epidural anaesthesia or spinal anaesthesia with intravenous fentanyl. The studied patients were 100 multipara who had previous history of successful breastfeeding before. They were divided into 2 groups, group [1] included 50 patients who received epidural anaesthesia with fentanyl, and group [2] included 50 patients who received spinal anaesthesia with intravenous fentanyl, and both groups were observed for initial breast feeding behaviors of newborns and fentanyl concentration in colostrums at 45 minutes and 24 hours after birth. There were no statistically difference in breast feeding behaviors at birth or at 24 hours of age in both groups'. The levels of fentanyl concentration were greatest at 45 minutes of the initial sampling time reaching 0.40 +/- 0.059 ng/ml in the epidural group and, 0.19 +/- 0.019 ng/ml in intravenous fentanyl group. Although the levels of fentanyl concentration were greatest at 45 minutes of the initial sampling time it can be used safely as intravenous or epidural without affecting the initial breast feeding behaviors of the newborn

Cystatine C biochemical marker for renal dysfunction in coronary artery bypass randomized double blinded comparison between the effects of sevoflurane and isoflurane

Volatile anesthetics exert significant protection against myocardial ischemia and excitotoxic cardiomyocyte death. One of the mechanisms by which volatile anesthetics induce protection in myocytes is pharmacological preconditioning, the activation of a potent endogenous protective mechanism in cardiac tissue against a variety of important stressors. Laboratory investigations further stress the concept that volatile anesthetics may protect endothelial and smooth muscle cells, implying that anesthetic protection might beneficially affect a much wider variety of tissues including the brain, spinal cord, liver, and kidneys. After written informed consents were obtained from all patients, 40 patients scheduled for elective CABG, they were divided into 2 groups, 20 patients each group, group I [isoflurane group], group II [sevoflurane group]. All patients received midazolam for premedication. Anesthesia was induced in all patients with propofol, fentanyl and the muscle relaxant vecuronium. Blood samples were obtained preoperatively, at arrival in the intensive care unit, and 24, 48, and 72h after surgery; they were stored at -20°C until analysis. Creatinine level and Cystatine C [CysC] assays were used as markers for renal dysfunction. Sevoflurane-treated patients required significantly more phenylephrine than did isoflurane-treated patients to maintain blood pressure above 50mmHg. However, there was no difference in mean arterial blood pressure between both groups. CysC concentrations significantly increased immediately postoperatively and peaked at 48 h after surgery for both groups [time effect, p<0.001]. Cystatine C concentrations were markedly higher for isoflurane-treated patients than for sevoflurane-treated patients. Plasma creatinine concentrations were slightly, but not significantly, increased in isoflurane-treated patients. The study concluded that, sevoflurane could be administered safely during CABG without affecting renal function. Because this study only evaluated immediate perioperativc effects of sevoflurane, we can only speculate on potential beneficial long-term effects of this treatment. Future studies should address this important issue

Randomized double blind comparison between sciatic-femoral nerve block, epidural anaesthesia, and spinal anaesthesia in out-patient knee arthroscopy

Strategy for patients undergoing knee surgery would have the potential to reduce the number of days of restricted activity and lost work. Knee surgery can generate significant postoperative pain. Pain is one of the most common symptoms requiring hospital admissions after outpatient surgery. The aim of this study is to compare between sciatic-femoral nerve block, epidural anaesthesia, and spinal anaesthesia in out-patient knee arthroscopy study to evaluate discharge time as the time from admission to PACU until the patient met all discharge criteria from Phase II. These included mental alertness stable vital signs, ability to ambulate, and voiding. Side effects measured were the incidence of hypotension or bradycardia requiring treatment in either the operating room or in the PACU, nausea or vomiting, pain severe enough to require IV narcotics in the PACU, or pruritus requiring treatment and patient's satisfaction. The study included 60 patients in Kaser EI-Aini Hospital, the patients were divided into three groups [epidural anaesthesia, n=20], [spinal anaesthesia group II, n=20], and, a combined sciatic-femoral nerve block [peripheral nerve block PNB group III, n=20], all patients were requested sedation were given an intraoperative infusion of propofol [25-50ug/kg/min]. All patients received 15-30mg IV ketorolac. The surgeon injected 50mL of 0.25% bupivacaine into the knee joint at the completion of the procedure. In group I, Epidural anaesthesia was performed in a standard fashion at the L2-3 or L3-4 interspaces with the operative knee in the dependent position. Skin infiltration was performed with 1% lidocaine, and a test dose of 3mL of 1.5% lidocaine with 15 micro g epinephrine was injected. If there was no evidence of IV or sub-arachnoid injection, 15mL of bupivacaine 0.5% was injected in 5mL increments, with an additional 5mL added after 10min, if the block height was below T-10 [level needed to provide anesthesia for thigh tourniquet discomfort]. In group II spinal anaesthesia was received using 2-3ml of bupivacaine 0.5%. In the PNB group [group III], patients received a sciatic-femoral nerve block with ropivacaine 25mL 0.75% mg using a multiple injection technique aided by a nerve stimulator] and a short, bevelled, Teflon[R] -coated stimulating needle [stimulation frequency 2Hz, stimulation intensity 1mA, which was gradually decreased to 0.5mA]. When the surgical procedure was performed by the same surgeon sequentially in the same operating room, turnover time was measured. This was defined as the time interval from the departure of the previous patient from the operating room until the completion of anesthesia preparation. All patients were transferred by to the Phase I post anesthesia care unit [PACU]. When vital signs were stable for two measurements and block level [for spinal and epidural block patients] was below T-8, they were transferred to the Phase II area. Discharge time was recorded as the time from admission to PACU until the patient met all discharge criteria from Phase II. These included mental alertness stable vital signs, ability to ambulate, and voiding, Side effects measured were the incidence of hypotension [systolic blood pressure <100mmHg requiring treatment with ephedrine or bradycardia [heart rate <60 beat per minute requiring treatment with atropine at the discretion of the anesthesiologist] in either the operating room or in the PACU, nausea or vomiting, pain severe enough to require IV narcotics in the PACU, or pruritus requiring treatment. Patient satisfaction [rated on a verbal scale of 5 = Very satisfied, 4 = Satisfied, 3 = Neutral, 2 = dissatisfied, 1 = Very dissatisfied]. Antipruritics were given to 8 patients, all in the spinal group [p<0.001]. Voiding was required for discharge after regional anesthesia. Time from injection to voiding was shorter in the PNB group versus the spinal and epidural groups [50 +/- 10, 80 +/- 16, 135 +/- 51, p = 0.0013]. The time in the PACU was also significantly shorter for PNB and epidural as compared with spinal [PNB, 50 +/- 30min; epidural, 90 +/- 18min; spinal, 145 +/- 50min; p<0.0003. Back/leg pain were 4, 5, 8 patients Satisfaction scores were [15, 18, 8] [PNB, epidural. spinal groups]. In conclusion, this prospective randomized study suggests that in patients undergoing out-patient arthroscopy, a combined sciatic-femoral nerve block [using a small volume of ropivacaine 0.75% mg] compared with epidural anaesthesia or spinal anaesthesia techniques may provide similar intraoperative analgesic efficacy, a shorter length of stay in the post operative care unit [PACU] and an increased likelihood of bypassing the first phase of postoperative recovery. The advantages of sciatic-femoral blockade as a sole anesthetic technique include avoidance of general anesthesia, avoidance of neuroaxial blockade, minimization of haemodynamic effects, and provision of long-lasting postoperative analgesia, and the cost should studied in the future

S [+] Ketamine suppresses TNF-alpha, IL-6 and IL-8 production in blood in major abominal surgery under combined epidural general anestesia

Cytokines are essential for hematopoiesis and immune responses, and they play a key role in the defense against infection. It has been demonstrated that proinflammatory cytokines such as [TNF-alpha], interleukin [IL] 6 and IL-8 increase in patients with trauma, surgical trauma, sepsis burns. 40 patients scheduled for major abdominal surgery under combined epidural general anaesthesia in Kasr, EI-Aini Hospital were included in this study. Patients age was ranged between 18-50 years, patients were ASA I and II. The patients were divided into 2 groups each group 20 patients, group I was received S [+] Ketamine as a single preincision dose, while in II S [+] Ketamine was received preincision and as a repeated doses, S [+] ketamine was injected as a single IV dose 0.5 mg/kg before incision in both groups, and repeated 0.2 mg/kg doses at 20 minutes interval until 30 minutes before the end of the operation [In group II, 20 patients only]. This study reported that S [+] ketamine suppressed TNF-alpha production IL-6, IL-8. The study also reported that a single S [+] ketamine preincision dose decreased IL-6 to 550 +/- 20 at 30 minutes before end of operation while the repeated 20 minutes doses decreased IL-6 to 440 +/- 20 minutes. IL-8 when single dose of S [+] ketamine was given decreased to 850 +/- 50 at 30 minutes before end of the operation, while after repeated S [+] ketamine it was 600'40 at 30 minutes before operation, about TNF-a. It decreased to reach 1110 +/- 180 in a single dose ofS [+] ketamine while it decreased to 1000 +/- 120 in repeated dose of S [+] ketamine. The total dose of S [+] ketamine was 35+30 in single dose group, while it was 80 +/- 40 in repeated dose group, the dose ofropivacaine given epidurally was 148 +/- 20 in single group while it was 130 +/- 15 in repeated group. This mean the anesthetics required in repeated doses of S [+] group was lower, indicated that S [+] ketamine decreased the anesthetics requirement. The conclusion of the study was S [+] ketamine directly suppresses proinflammatory cytokines production when given in repeated doses, it also decreased the ropivacaine dose needed more in repeated doses of S [+] ketamine. A larger study is also needed to assess whether the favorable postoperative effect of S [+] ketamine make differ

Thermoregulatory effects of perioperative intravenous amino acid infusion in patients undergoing TURP under spinal anesthesia

Hypothermia during anesthesia is associated with many postoperative complications. Therefore, many ways to avoid intraoperative hypothermia have been developed, usually by minimizing heat loss. Anesthetic agents suppress oxidative metabolism. Amino acids enhance thermogenesis by stimulating this metabolism. Forty-five adult patients were randomized into 3 groups each included 15 patients. Group A received intravenous amino acid infusion for 1 hour before spinal anesthesia and continuing throughout the first hour intraoperatively, Group B received intravenous amino acid infusion for 1 hour after the onset of spinal anesthesia and Group C received volumes of nutrient-free saline solution infused for 1 hour before and during first hour of anesthesia. Tympanic membrane core temperature and mean skin temperature were measured every 15 minutes during the 1[st] hour then after 120 minutes from the onset of spinal anesthesia. Plasma osmolality and serum lactate were measured in the 3 groups. Shivering, TUR Syndrome and total hospital stay were also assessed. Mean final core temperature, 120 minutes after induction of spinal anesthesia was 37.1 +/- 0.29°C in group A, 36.7 +/- 0.31°C in group B and 35.5 +/- 0.34°C in group C [P<0.05]. The increased level of oxygen consumption in the amino acid groups compared with the saline group was preserved even after the onset of anesthesia. The thermal vasoconstriction threshold, the tympanic membrane temperature that triggered a rapid increase a skin temperature gradient, was increased in group A [36.55 +/- 0.48°C] in comparison to group B [36.34 +/- 0.47°C] and group C [35.02 +/- 0.45°C]. Plasma osmolality was higher in groups A and B in comparison to group C [P<0.05]. Serum lactate was higher in group C in comparison to both A and B [P<0.05]. The incidence of shivering and the total hospital stay were higher in group C than in groups A and B [P<0.05]. Amino acid infusion in the preopferative period for anesthesia for TURP, prevents spinal anesthesia-induced hypothermia by increasing the metabolic rate and core temperature for peripheral thermal vasoconstriction

Ophthalmological findings in children with hypoxic-ischaemic insults

To evaluate ophthalmological abnormalities in children with brain injury due to prenatal hypoxic ischemic insult, and to correlate these abnormalities with the severity of brain affection. Thirty children below 3 years of age were include in the study. Full ophthalmological examination was done with interest to visual acuity measurement, ocular motility and ocular alignment examination. Neurological assessment was also done. Ophthalmological disorders including defective visual acuity, negative optokinetic nystagmus and strabismus were found in the studied children. An associated was detected between the incidence of these findings and the motor mental development of the children. Ophthalmological examination and follow up is mandatory for children who experienced perinatal hypoxic insults together with their medical and neurological car

Comparison of pharmacokinetics and pharmacodynamics of rocuronium infusion in adults and children

This study compared the pharmacokinetics and pharmacokinetic-dynamic relationship of rocuronium in children and adults, we studied 10 children [4-8 years] and 10 adults [20-40 years] ASA I and II underwent surgical operation in Kasr-El-Aini hospital. After induction with thiopentone [2-6 mg/kg], fentanyl 5-10 Hg/kg, infusion of rocuronium 0.09 mg/kg/min. in children group and 0.1 mg/kg/min. in the adults group. The infusion was given over +/- 5 minutes. The patients were monitored with the EMG of the adductor pollicis muscle. When neuromuscular block reached 85% endotracheal intubation, and then mechanical ventilation was started Maintenance of anesthesia with isoflurane 0.5- 1%, O[2]/NO[2] 50% in both groups. Arterial sample were obtained over 240 min./ Plasma concentrations were measured by HpLc. pharmacokinetic-dynamic variables were calculated using sheiner model, and the Hill equation. Statistical analysis was performed using the Mann-Whitney U test [p < 0.05]. The mean administered dose of rocuronium infusion was 0.65 +/- 0.09 mg/kg/hour in adults group and 0.35 +/- 0.1 mg/kg/hour in children group. Children differed from adults in plasma clearance 5.2 +/- 0.043 versus 7.65 +/- 1.05 ml/min./kg in adults group, distribution volume at steady state 220 +/- 20 ml/kg in children group and 168+50 ml/kg in adults group, mean residence time 50.5 +/- 9.0 [min.] in children group and 26 +/- 9.0 [min.] in adults group, concentration in effect compartment at 50% block 1.19 +/- 0.4 mg/liter in children group and 1.3 +/- 0.3 mg/liter in adults group, calculated mean ED[90] values were 0.345 +/- 0.077 in adults group, 0.25 +/- 0.067 in children group. The time course of neuromuscular block did not differ. The study concluded that infusion of rocuronium has different pharmacokinetic-dynamic in both adults and children, but it can be safely used in children especially when the infused dose adjusted by using the EMG