Comparison of mometasone furoate administered by metered dose inhaler with beclomethasone dipropionate.

This study compared the efficacy and safety of mometasone furoate (MF) administered by metered dose inhaler (MDI) 56, 200 or 500 pg b.i.d., with beclomethasone dipropionate (BDP) 168 microg b.i.d. and placebo. Adult patients (n=395), with moderate persistent asthma (FEV1 50-90% of predicted normal), previously maintained on inhaled corticosteroids, were enrolled at 16 centres in a four-week, randomised, double-blind, double-dummy, multicentre, dose-ranging trial. At endpoint, FEV1 was significantly improved (p<0.01) with MF-MDI 56, 200 and 500 microg b.i.d., as well as with BDP (6%, 13%, 14% and 4%, respectively), compared with placebo (-12%). Mean change in FVC, FEF2575%, and a.m. and p.m. peak expiratory flow rate (PEFR) were also significantly improved for all active treatment groups at endpoint compared with placebo. Asthma symptoms and quality of life (SF-36) related to physical functioning improved with active treatments relative to placebo. All doses of MF-MDI were well tolerated. Treatment with MF-MDI 200 pg b.i.d. was superior to BDP MDI 168 microg b.i.d. or MF-MDI 56 microg b.i.d., with no additional benefit derived from a higher MF-MDI 500 microg b.i.d. dose. MF-MDI was well tolerated, with superior efficacy compared with BDP MDI in these patients with moderate persistent asthma.

Post-operative pain management.

For many years pediatric procedural and postoperative pain has been undertreated or not treated. In some areas this practice still exists and is a likely reflection of persistence of myths related to the infant's ability to perceive pain. Such myths include the lack of ability to perceive pain or remember painful experiences. New literature exists showing that these former beliefs do not hold true. The appropriate management of postoperative pain is contingent on a cooperative effort from pediatric surgeons, pediatric anesthesiologists, pediatricians, and parents. There are many ways to treat postoperative pain. The method of postoperative analgesia depends on the patient, underlying medical conditions, the type of surgery, the patient's disposition following surgery (inpatient vs. outpatient), and the physician's comfort level with a particular analgesic regimen. Many pediatric anesthesiologists and surgeons have excellent success with the utilization of regional anesthetic techniques as treatment for postoperative pain. Caudal epidural blocks, ilioinguinal/iliohypogastric nerve blocks, and penile nerve blocks are some of the commonly used blocks. These blocks not only provide excellent postoperative analgesia, but are great adjuncts to general anesthesia, thus, reducing the amount of general anesthesia required. Additionally, the use of epidural opioids is extremely useful in patients following major abdominal, thoracic, and orthopedic surgery. Traditional medications such as oral and parenteral narcotics, non-steroidal anti-inflammatory drugs, and acetaminophen (paracetamol), are much more commonly used to treat postoperative pain. Regardless of the analgesic regimen chosen, we must assure our pediatric patients the least painful perioperative experience possible.

Changes in cerebral blood flow velocity in children during sevoflurane and halothane anesthesia.

The purpose of this study was to evaluate arterial blood pressure and middle cerebral artery blood flow velocity in children during induction of anesthesia with sevoflurane. These measures were compared to findings in a control group anesthetized with halothane. Each child received mask induction of sevoflurane (n = 9) or halothane (n = 9) with 70% nitrous oxide in oxygen. Blood pressure was measured noninvasively by an oscillometric technique using a Dinamap. Blood flow velocity was measured using a transcranial Doppler with a 2-MHz probe. End-tidal CO2, nitrous oxide, and anesthetic concentrations were measured by a Datex Ultima Capnomac. Both sevoflurane (2.4%) and halothane (1.3%) combined with 70% nitrous oxide decreased blood pressure and increased cerebral blood flow velocity. Intubation increased blood pressure and further increased cerebral blood flow velocity with both anesthetic treatments. These results indicate that sevoflurane and halothane combined with nitrous oxide decrease blood pressure and increase cerebral blood flow velocity and suggest that sevoflurane produces cerebrovascular effects similar to those of halothane during anesthetic induction.

Craniomaxillofacial surgery in the Jehovah's Witness patient.

The reconstruction of severe craniofacial anomalies in patients who will not accept blood transfusions presents a considerable challenge to the craniofacial team. Traditionally, these patients have been refused major reconstructions, receiving no treatment or a highly compromised substitute. A management protocol was developed utilizing preoperative erythropoietin and ferrous sulfate therapy, intraoperative in-line normovolemic hemodilution, and meticulous intraoperative hemostasis which allows us to perform major craniomaxillofacial reconstructions in Jehovah's Witness patients without the use of homologous or predonated autologous blood transfusions.

Airway management and sedation for pediatric transport.

Appropriate airway management is essential for the successful transport of sick children. Airway management begins with a thorough history and physical examination and may proceed to invasive therapeutic interventions. Successful care of the pediatric airway can be achieved only with a thorough knowledge of airway management technique and equipment. In addition, familiarity and understanding of the pharmacologic adjuvants to airway management and sedation will help to achieve the primary objective of any transport team, namely a safe and smooth transport of the critically ill child.

Herpesvirus infection of cornea allografts.

This report describes three patients who have in common an occurrence of ocular epithelial herpes infection following a penetrating keratoplasty for a corneal opacity unrelated to herpesvirus infection. It may be that patients undergoing episodes of graft rejection are at increased risk for the reactivation of herpesvirus latent in the trigeminal ganglia, and corticosteroids should be used with this in mind. Because virtually all adults have been exposed to herpes and therefore harbor latent virus, a viral etiology should be considered for lesions in post-penetrating keratoplasty patients. Although the occurrence of this possibly rejection-related reactivation of herpes simplex virus is undoubtedly rare, management of potential cases of this nature should take this possibility into account.

Aqueous hyposecretion after penetrating keratoplasty.

Following penetrating keratoplasty, aqueous hyposecretion results in marked thickening of the cornea identical to that seen when the donor endothelium is unsatisfactory. The lack of secretion is accompanied by hypotony, and the persistence of fluorescein in the anterior chamber can be measured by fluorophotometry or observed clinically 24 hours after the instillation of topical fluorescein. An eye with aqueous hyposecretion will usually recover in seven to ten days, and additional surgery is not only unnecessary, but harmful to an already damaged eye. However, poor donor tissue can often be replaced promptly and successfully with repeated penetrating keratoplasty. Therefore, clinical differentiation of these conditions is important in management decisions.

Corneal sensitivity after epikeratophakia.

Corneal sensitivity was tested in 60 eyes of 30 patients who underwent unilateral epikeratophakia for the correction of aphakia (20 patients) or keratoconus (10 patients). Postoperative recovery time ranged from 2 months to 21 months (mean: 10 months). Our results indicate a relative hypesthesia of the epikeratophakia lenticule when compared with the peripheral host cornea and contralateral control cornea. However, corneal sensitivity tested in 11 patients with more than 1 year follow-up was increased compared with the sensitivity of 19 patients whose postoperative recovery was less than 1 year. Histopathologic findings in two lenticules from a nonhuman primate demonstrated sparse epithelial axon terminals. Host corneal nerves appear to innervate the lenticules by intraepithelial extension and by penetration of the superficial keratectomy scar.

Endothelial cell counts after epikeratophakia surgery.

We used specular microscopy to study the corneal endothelium of eight aphakic patients who had undergone epikeratophakia. The average post-operative period was 16 months with a range of 12 to 18 months. Corneal thickness increased from 0.52 mm +/- 0.01 mm to 0.88 mm +/- 0.04 mm with the addition of the onlay graft. The average pre-operative endothelial cell count was low (1,450 per mm2 +/- 218) and did not differ significantly (p greater than .9) from the average postoperative cell count (1,438 per mm2 +/- 218). Despite the increase in corneal thickness and low endothelial cell counts, we saw no corneal edema. We conclude that epikeratophakia is well tolerated by the cornea and can be performed safely on eyes that have already undergone substantial trauma to the endothelium.

Regenerative effects of epidermal growth factor after penetrating keratoplasty in primates.

Epidermal growth factor (EGF) was injected into the anterior chambers of 12 rhesus monkeys after the denudation of the central corneal endothelium during autograft transplantation. The animals were treated both at the time of surgery and three weeks after surgery. Clinical appearance and corneal thickness were monitored until the corneas were removed by penetrating keratoplasty ten weeks after the initial treatment. Flat preparations of the corneas showed significantly more endothelial cells in the central corneas of the EGF-treated eyes compared with the control eyes. These findings indicate that EGF is effective in replenishing the corneal endothelium after injury.

Prolapse of the globe into the maxillary sinus after orbital floor fracture.

A 24-year-old woman sustained a blow-out fracture of the orbital floor with prolapse of the globe into the maxillary sinus. This was treated by replacing the globe in the orbit surgically and reconstructing the orbital floor. Postoperatively, the eye retained normal visual acuity.

Intravitreal cephalothin in experimental staphylococcal endophthalmitis.

Intravitreal cephalothin was used to treat experimentally induced bacterial endophthalmitis in rabbit eyes. A dose of 2 mg and less was apparently nontoxic to all intraocular structures. Thirty-two hours after injection of a 2 mg dose, the level remaining in the vitreous was above the minimal inhibitory concentration for most susceptible organisms. Treatment of experimentally induced staphylococcal infections of the vitreous was successful with early intravitreal injection. When therapy was delayed, vitreous bands and posterior lens cataracts developed. Eyes of control animals receiving intramuscular and subconjunctival injections of cephalothin all progressed to phthisis bulbi.