Role of dipstick in detection of haeme pigment due to rhabdomyolysis in victims of Bam earthquake.

Avoiding life-threatening complications of rhabdomyolysis depends on early diagnosis and prompt management. The aim of this study was to evaluate the role of urinary dipstick test in the detection of haeme pigment in patients who were at risk of acute renal failure (ARF) due to rhabdomyolysis after suffering injury in the Bam earthquake. Serum creatine phosphokinase (CPK) level was used as the gold standard for prediction of ARF. ARF developed in 8 (10%) of 79 patients studied. We found no significant differences in the sensitivity, specificity and accuracy of dipstick urine and serum CPK tests for identifying patients who were at risk of ARF. However, dipstick urine test is an easy test that can be performed quickly at an earthquake site.

Effects of oral clonidine premedication on haemodynamic response to laryngoscopy and tracheal intubation: a clinical trial.

The objective of this study was to evaluate the efficacy of pre-anesthetic orally administration of clonidine on pulse rate and blood stress response to laryngoscopy and tracheal intubation. In a double-blinded, randomized study, 274 ASA I and II subjects with age of 18 to 45 years scheduled for elective surgery under general anesthesia were enrolled. They were randomly allocated to receive oral clonidine (0.2 mg) or placebo as premedication 90-120 min before surgery. All the patients received Succinylcholine (1.5 mg kg(-1)) after induction of anesthesia with Fentanyl (50 microg) and Thiopentone (5 mg kg(-1)). The anesthesia was maintained with halothane (1.5 Mac) in 50% mixture of N2O/O2. Heart rate and systolic blood pressure were recorded before, immediately after and then every 5 min after intubation until 20 min. The Clonidine group showed a significant superiority over placebo in the prevention of increase in systolic blood pressure as well as heart rate over the intubation. A significant difference was observed in both heart rate and systolic blood pressures were significantly higher in Control group at three subsequent measurements following intubation. The results of this study suggest that orally administered clonidine in preanesthetic period, provides more haemodynamic stability and attenuates the stress response to laryngoscopy and intubation.

Effects of combination of intrathecal lidocaine and two doses of intrathecal midazolam on post-operative pain in patients undergoing herniorrhaphy: a randomized controlled trial.

Assessment of the effect of combination of intrathecal midazolam and lidocaine on postoperative pain was the aim of this study. This randomized controlled trial was performed during 2007 in a teaching hospital of Arak University of Medical Sciences. Forty five male patients who were candidates for elective inguinal herniorrhaphy entered the study and randomly divided into three groups of control (lidocaine 5% plus normal saline), M 0.5 (lidocaine 5% and midazolam 0.5 mg) and M 1.0 (lidocaine 5% and midazolam 1 mg) according intrathecal solution injected for spinal anesthesia. Mean arterial blood pressure, heart rate, post-operative pain, narcotic requirements and complications (nausea, vomiting, pruritic, headache, hypotension and bradycardia) were recorded. The severity of post-operative pain was lowest in M 1.0 group in all postoperative measurements except at 2 h after operation. With regard of complications, only there was significant difference in vomiting between three groups which had the highest frequency in M 0.5 group. No severe hypotension was seen; though, bradycardia occurred in one patient in M 0.5 group which needed treatment. Present findings suggest that administration of intrathecal midazolam (especially 1 mg) together with lidocaine is effective in reducing post-operative pain in patients undergoing open inguinal herniorrhaphy and is not associated with adverse effect.

Effect of adding ketamine to pethidine on postoperative pain in patients undergoing major abdominal operations: a double blind randomized controlled trial.

To determine the effect of adding ketamine to pethidine in reducing post-operative pain in patients undergoing major abdominal operations, in a double blind randomized controlled trial, 100 patients aged 15-60 years who were candidate for elective major abdominal surgery allocated into two groups of pethidine + ketamine group (5 mg pethidine and 0.25 mg kg(-1) ketamine) or pethidine and placebo group (10 mg pethidine and NS) according to the regimen prescribed in postanesthesia care unit. Severity of pain (using visual analogue scale), prescribed dose of pethidine and side effects were recorded until 24 h after operation. Regarding post-operative pain, pethidine + ketamine group showed significant lower scores in all the times except 0 min, 2, 6 and 16 h. Nausea was significantly less frequent amongst pethidine + placebo group at times of 0, 15, 30 and 45 min (p < 0.05). Comparison of two groups did not show significant differences in prescribed pethedine dose in 0, 9, 12, 16, 20 and 24 h (p > 0.05). Yet, the mean dose of administered pethidine as rescue analgesic was significant lower in pethidine + ketamine group compared to pethidine + placebo group (112 +/- 31.5 mg vs. 133.5 +/- 24.5 mg, p < 0.001). In conclusion, our results showed that co-administration of ketamine and pethidine in postanesthesia care unit will improve postoperative pain and reduce narcotic consumption. It may, however, increase rate of postoperative nausea in the first hour after operation.

Role of dipstick in detection of haeme pigment due to rhabdomyolysis in victims of Bam earthquake

Avoiding life-threatening complications of rhabdomyolysis depends on early diagnosis and prompt management. The aim of this study was to evaluate the role of urinary dipstick test in the detection of haeme pigment in patients who were at risk of acute renal failure [ARF] due to rhabdomyolysis after suffering injury in the Bam earthquake. Serum creatine phosphokinase [CPK] level was used as the gold standard for prediction of ARF. ARF developed in 8 [10%] of 79 patients studied. We found no significant differences in the sensitivity, specificity and accuracy of dipstick urine and serum CPK tests for identifying patients who were at risk of ARF. However, dipstick urine test is an easy test that can be performed quickly at an earthquake site

Entonox for labor pain: a randomized placebo controlled trial.

This study aims to investigate the effectiveness of nitrous oxide on pain of labor contractions and on maternal SaO2. The patients were randomized to receive either a pre-prepared mixture of 50% nitrous oxide and oxygen or 50% oxygen by a coin. Study drugs started as early as the onset of pain with each contraction. The patient herself administered gases via a facemask connected to the uni-directional valve which enables the patients to breathe fresh gas in each inspiration. The gas administration was continued to the end of contraction pain at which the patient breathed the room air. Variables such as SaO2, blood pressure, pain and side effects were recorded. 534 ASA I and II parturients, aged from 16 to 35 years, scheduled for elective labor from September 2004 to 2006 were evaluated. Four patients were lost from the study. The mean age of patients was 25.5+/-4.3 years. During the first three measurements, the SaO2 was significantly higher in control group. In addition, the mean arterial pressure was comparable between groups except two first measurements in which the control group was higher. All the Visual Analogue Scale (VAS) values were significantly lower in nitrous oxide group. There were no significant differences in 1st and 5th min apgar scores between groups. All of the side effects were significantly higher among patients in nitrous oxide. In conclusion, our data indicate that using nitrous oxide 50% provides significant pain relief. Nonetheless, it is associated with few side effects, nitrous oxide can be quickly implemented during advanced painful labor.

[Kidney involvement in rheumatoid arthritis]. / Coinvolgimento renale in corso di artrite reumatoide.

Rheumatoid Arthritis (RA) is a widespread disease and its renal involvement, relatively common, is clinically significant because worsens course and mortality of the primary disease. There is still no agreement on the prevalence of renal disorders in RA: data analysis originates from different sources, as death certificates, autopsies, clinical and laboratory findings and kidney biopsies, each with its limitations. Histoimmunological studies on bioptical specimens of patients with RA and kidney damage, led to clarify prevalent pathologies. In order of frequency: glomerulonephritis and amyloidosis (60-65% and 20-30% respectively), followed by acute or chronic interstitial nephritis. Kidney injury during RA includes secondary renal amyloidosis, nephrotoxic effects of antirheumatic drugs and nephropathies as extra-articular manifestations (rheumatoid nephropathy). Amyloidosis affects survival, increases morbidity and is the main cause of end stage renal disease in patients with RA and nephropathy. Strong association between RA activity and amyloidosis needs the use of immunosuppressive and combined therapies, to prevent this complication and reduce risk of dialysis. Long-lasting and combined RA pharmacotherapy involves various renal side effects. In this review we describe NSAIDs and DMARDs (Disease-Modifying Antirheumatic Drugs) nephrotoxicity, particularly by gold compounds, D-penicillamine, cyclosporine A and methotrexate. Rare cases of IgA glomerulonephritis during immunomodulating therapy with leflunomide and TNF blocking receptor (etanercept) are reported; real clinical significance of this drug-related nephropathy will be established by development of RA treatment. In RA nephropathies, mesangial glomerulonephritis is the most frequent histological lesion (35-60 % out of biopsies from patients with urinary abnormalities and/or kidney impairment), followed by minimal change glomerulopathy (3-14%) and p-ANCA positive necrotizing crescentic glomerulonephritis.

Inadequate diagnosis and therapy of arterial hypertension as causes of left ventricular hypertrophy in uremic dialysis patients.

BACKGROUND: Left ventricular hypertrophy (LVH) is highly prevalent in the dialyzed population, possibly because of inadequate diagnosis and therapy of arterial hypertension. The purpose of this study was to ascertain the adequacy of our approach in correctly identifying and treating arterial hypertension in our dialysis center. METHODS: Fifty-five dialyzed uremics were studied by continuous ambulatory blood pressure (BP) monitoring, which started before a single hemodialysis (HD) session, continued for 24 hours after HD ended, and was repeated for 15 minutes before the beginning of the next HD. Clinical pre-HD and post-HD routine BP measurements taken the month preceding BP monitoring were retrieved, and echocardiography was performed. RESULTS: LVH was present in 46 out of 55 patients, and clinical pre-HD arterial hypertension was present in 36 out of 55. There were discrepancies between clinical and monitored BPs, mostly concerning diastolic pre-HD BP since BP readings were lower than monitored BP records (P < 0.0002). Although both clinical and monitored BPs bore strong direct correlations with the left ventricular mass (LVM), the closest correlations were those for monitored BP. Four groups of patients were identified by BP monitoring: group A (N = 14), with persistently normal BP, and group D (N = 13), with persistently supranormal BP levels. There were also two other groups (group B, N = 19; and group C, N = 9), whose BP values were high before HD, normalized after HD, and then increased again either soon after HD (group C) or later on following HD (group B). Monthly averaged clinical pre-HD mean BP values differed significantly among the four groups [91 +/- 10 (SD) mm Hg in group A, 101 +/- 7 in group B, 106 +/- 6 in group C, and 106 +/- 7 in group D; P < 0.0001, analysis of variance], as did their corresponding LVMs [132 +/- 27 g/m2 body surface area (BSA), 156 +/- 26, 201 +/- 51, and 200 +/- 36; P < 0.0001]. There were also differences in dialytic age, which was significantly longer in group A patients (109 +/- 54 months), who also tended to have higher, although not significantly higher, Kt/V(urea) values. No differences, however, were detected among the groups as far as type, dosages, and number of antihypertensive drugs given to each individual patient. CONCLUSIONS: The high prevalence of LVH in the dialysis population might be the result of inadequate diagnosis and therapy of arterial hypertension. Arterial hypertension, in fact, was insufficiently treated in our dialysis center, since patients with varying degrees of severity of both arterial hypertension and LVH were kept on antihypertensive therapy of similar strength. Undertreatment may have resulted from not having recognized and/or from having underestimated the severity of arterial hypertension since some clinical BPs were measured incorrectly. Reluctance to use more aggressive antihypertensive therapy might also result from the deceptive feeling of "normalized" BP that one has following volume unloading with dialysis. This causes both the BP to run out of control between dialyses and LVH to worsen.

Effects of recombinant human growth hormone on muscle protein turnover in malnourished hemodialysis patients.

To assess the effect of recombinant human growth hormone (rhGH) on muscle protein metabolism in uremic patients with malnutrition, forearm [3H]phenylalanine kinetics were evaluated in six chronically wasted (body weight 79% of ideal weight) hemodialysis (HD) patients in a self-controlled, crossover study. Forearm protein dynamics were evaluated before, after a 6-wk course of rhGH (5 mg thrice weekly) and after a 6-wk washout period. After rhGH: (a) forearm phenylalanine net balance--the difference between phenylalanine incorporation into and phenylalanine release from muscle proteins--decreased by 46% (-8+/-2 vs. -15+/-2 nmol/min x 100 ml at the baseline and -11+/-2 after washout, P < 0.02); (b) phenylalanine rate of disposal, an index of protein synthesis, increased by 25% (25+/-5 vs. 20+/-5 at the baseline and 20+/-4 after washout, P < 0.03); (c) phenylalanine rate of appearance, an index of protein degradation, was unchanged (33+/-5 vs. 35+/-5 at the baseline and 31+/-4 after washout); (d) forearm potassium release declined (0.24+/-0.13 vs. 0.60+/-0.15 microeq/min at the baseline, and 0.42+/-0.20 microeq/min after washout P < 0.03); (e) changes in the insulin-like growth factor binding protein (IGFBP)-1 levels and insulin-like growth factor-I (IGF-I)/IGFBP-3 ratios accounted for 15.1% and 47.1% of the percent variations in forearm net phenylalanine balance, respectively. Together, these two factors accounted for 62.2% of variations in forearm net phenylalanine balance during and after rhGH administration. These data indicate: (a) that rhGH administration in malnourished hemodialysis patients is followed by an increase in muscle protein synthesis and by a decrease in the negative muscle protein balance observed in the postabsorptive state; and (b) that the reduction in net protein catabolism obtained with rhGH can be accounted for by the associated changes in circulating free, but not total, IGF-I levels.