Effective awake thoracic epidural anesthetic for major abdominal surgery in two high-risk patients with severe pulmonary disease. A case report

Awake thoracic epidural anaesthesia as the sole anaesthetic technique was successfully employed for two high risk surgical patients with chronic obstructive pulmonary disease undergoing abdominal surgery. The procedure was tolerated well and the anaesthetic technique which has been shown to reduce intra-operative and post-operative cardiac, respiratory and gastrointestinal complications, may have significantly contributed to the prompt, complication free recovery experienced by both patients. We report two cases of awake major abdominal surgery in two high-risk surgical patients with severe pulmonary disease, performed effectively under thoracic epidural anaesthesia as a sole technique. The first case was an elective open sigmoid colectomy in a sixty one year old cancerous patient with chronic obstructive pulmonary disease [COPD] and recent thoracotomy for a wedge resection of a bronchial adenocarcinoma [pT1NoMx]. The second case was an emergency open cholecystectomy in an adult patient with end-stage COPD. Reviewing the literature, no similar cases were reported recently

comparative study between the analgesic effects of epidural diamorphine and levobupivacaine on established post-amputation stump pain

Pain is-necessary for survival but chronic pain is disabling and causes significant health and economic problems. Chronic stump pain [pain localized in the stump for >3 months] after amputation is a significant problem among amputees [5-10%]. The mechanism of this phenomenon is not very clean yet. In this study we attempted to better understand the role of peripheral and central mechanisms in this condition. 12 patients with established lower limb post-amputation stump pain were given lumbar epidural diamonhpine 5 mg in 20 ml normal saline [NS] and levobupivacaine 0.5% [20 ml] I week apart. Baseline pain, then onset, duration and side effects of analgesia were measured. Epidural diamorphine was found to relive the pain of all patients. Its onset was relatively rapid, median = 5.5min [5-9 min] and took 30 mm for complete analgesia to be achieved and continued for a median duration of 20.5 h [18-24 h]. Pruritis in 6 patients was the only side effect due to epidural diamorphine. Levobupivacaine usually relieved the discomfort but failed to do so in 3 patients only despite adequate neural blockade. Its onset of action was slower, median=11 min [10-20 min] and duration of effect was shorter, median=12 h [8-18 h] than diamorphine. The effects of levobupivacaine were inferior to diamorphine due to the associated sensory and motor paralyses as well as absence of euphoria. Epidural diamonphine provided profound analgesia with normalization of stump sensations and euphoria, probably due to absorption into the spinal cord causing segmental action. While peripheral mechanisms played a role, central mechanisms involving the spinal cord were more important in the modulation of established stump pain in the evaluated patients

Pre malignant skin conditions

Certain changes in the epidermis are important because they may, if left untreated, go on to become malignant tumours [NMSC]; namely BCC and SCC. Some, such as solar keratosis and leukoplakia of mucosal surfaces, may show little evidence of cellular unrest for much of their natural history. Others, like Bowen's disease or erythroplasia of Queyrat, may have the microscopical feature of intra-epidermal carcinoma from the beginning. Skin damaged by ionizing radiation, radiant heat or exposure to tar and other carcinogenic compounds and the keratoses that follow ingestion of inorgarsenic compounds, are also potentially malignant. Occasionally, long standing scars, sinuses and ulcers may be the site of cancer. Rarely, a burn or other injury may be followed almost immediately by a squamous cell carcinoma. The cumulative effect of UV radiation is to act directly on the epidermis and indirectly through the dermal changes. Also xerodermia pigmentosa, epidermolysis bullosa, condyloma accuminata, epidermodysplasia verruciformos, chronic discoid lupus erytheromatous and cutaneous horns may be complicated by malignant changes. The aim of the work was to identify various precancerous skin diseases in those attending outpatient clinic or admitted and treated in the inpatient clinic of dermatology department, Alexandria Faculty of Medicine [1990-1995], to quantify their relative frequencies and describe their age and sex distribution and compare and interpret the findings