Eficacia analgésica del EMLA en procedimientos transcutáneos. Revisión sistemática / Analgesic efficacy of EMLA in transcutaneous procedures. Systematic review

Los parches de EMLA son frecuentemente utilizados como anestésicos locales durante la realización en procedimientos invasivos. Con el fin de valorar su eficacia y compararla con la de otros analgésicos y anestésicos disponibles, se realizó una revisión sistemática de todos los estudios realizados que cumplieran criterios de inclusión entre los años 1990 y 2019. Población y métodos: la búsqueda bibliográfica de la evidencia disponible fue realizada en las bases de datos de Cochrane Medline y Lilacs. Se incluyeron todos los ECA y revisiones sistemáticas en pacientes menores de 16 años entre los años 1990 y 2019. Resultados: Fueron hallados 31 artículos de los cuales 21 cumplían con los criterios de inclusión. De dichos 21, solamente 8 estudios resultaron de muy buena y excelente calidad metodológica (JADAD). Conclusiones: El EMLA demostró mayor eficacia como analgésico en el 100% de los estudios donde se comparaba respecto del placebo. Sin embargo, no se encontraron diferencias significativas respecto de otros analgésicos farmacológicos y no farmacológicos.(AU)

EMLA patches are commonly used as local anesthetics in minor invasive procedures. To assess efficacy and compare the patches with other available analgesics and anesthetics, a systematic review was conducted evaluated all studies that met the inclusion criteria published between 1990 and 2019. Population and methods: A literature search of the available evidence was conducted in the Cochrane, Medline, and Lilacs databases. All RCTs and systematic reviews in patients younger than 16 years published between 1990 and 2019 were included. Results: 31 articles were identified of which 21 met the inclusion criteria. Of these 21, of only 8 studies the methodology was of very good and excellent quality (JADAD). Conclusions: EMLA better efficacy as an analgesic in 100% of the studies comparing EMLA patches with placebo. However, no significant differences were found when comparing the patches with other pharmacological and non-pharmacological analgesics.(AU)

Endovascular treatment of acute haemoptysis secondary to aortobronchial fistula.

INTRODUCTION: Aortobronchial fistula is a rare but potentially fatal condition. We report our experience in the endovascular treatment of acute haemoptysis in high risk patients with aortobronchial fistula. REPORT: Between May 2002 and December 2004 five patients presenting with acute haemoptysys due to aortobronchial fistula were treated by endovascular stent grafting of the descending thoracic aorta. We did not observe intraoperative or perioperative mortality, stent-graft infection or paraplegia. In one case endoleak occurred. CONCLUSION: Endovascular stent-grafting represents an effective therapeutic option for the management of aortobronchial fistula. Careful follow up of the patients is mandatory.

Aortic graft infections: treatment with arterial allograft.

Since its reintroduction by Kieffer in 1991, many authors have used arterial allografts for surgical management of vascular prosthetic graft infection. During a decade, 25 patients with aortic graft infection were treated using in situ revascularization with arterial allograft. There were 23 male and 2 female patients of mean age of 65.7 +/- 8.8 years (range, 43-78). Antibiotic therapy was administered for a mean time of 26 +/- 5 days (range, 21-45) in the postoperative period. The mean follow-up time was 2.3 +/- 3 years (range, 22 days-8.7 years). The mean in-hospital postoperative stay was 29.6 +/- 14 days (range, 9-68). An aorto-enteric fistula (AEF) was present in 11 patients (44%), producing gastrointestinal bleeding. The overall mortality rate was 13 of 23 (56.5%) patients. The allograft-related mortality rate was 5 of 23 (22%). The overall allograft-complicated patient rate was 15 of 23 (65%); we observed 18 allograft ruptures in 12 patients and 8 allograft thromboses in 6 patients. The overall amputation rate was 8.7% (2 of 23). Age of the recipient older than 69 years (P = .02), positive preoperative marked-leukocyte scanning (P = .04), and persistent postoperative leukocytosis (P = .03) were significant variables associated with an increased risk of allograft-related complications. The use of arterial allografts for aortic graft infections represents an interesting alternative for the treatment of graft infection. Nevertheless, there are some problems related to the durability of this type of graft, which can still be considered as a "bridge transplant."

Spontaneous perforation of an oesophageal diverticulum in achalasia.

Spontaneous perforation of the oesophagus is a rare occurrence that is usually due to vomiting and is seldom associated with an oesophageal lesion. We report a case of the spontaneous perforation of a large oesophageal diverticulum not preceded by any precipitating event in a 75-year-old male who was not known to have achalasia. The diverticulum was repaired by emergency surgery. Achalasia was later diagnosed and successfully treated with botulin toxin injection. Surgery decision-making and the treatment of achalasia are discussed.

Single doses of ritodrine delay orocaecal transit in patients with irritable bowel syndrome.

The lactulose hydrogen breath test was used to assess the effect of a single dose of the beta 2-adrenoceptor agonist ritodrine on orocaecal transit time in 11 patients (three men) with irritable bowel syndrome. Transit time (median values, range) was significantly longer (P less than 0.01) after ritodrine than after placebo (120, 50-200 vs 75, 40-100 min). Median heart rate was similar before treatments whereas the maximal increase in heart rate was significantly greater (P less than 0.01) after ritodrine than after placebo.

Orocecal transit delay in obese patients.

Orocecal transit time was assessed with lactulose hydrogen breath test in 12 obese patients during intravenous infusion of placebo or naloxone 40 micrograms/kg/hr given in randomized order and in double-blind conditions. Transit time was also evaluated in 22 healthy controls. Orocecal transit was significantly (P less than 0.01) longer in the obese patients, during placebo treatment (median 130, range 100-200 min) than in the healthy controls (median 75, range 40-170 min). Compared with placebo, transit time in the obese subjects was delayed (P less than 0.05) during naloxone treatment (median 150, range 100-230 min).

Intragastric and intraoesophageal pH monitoring in duodenal ulcerpatients: effect of the new histamine H2-receptor antagonist ramixotidine.

The effect of the new histamine H2-receptor antagonist ramixotidine 750 mg p.o., administered at 22.00 h, on intragastric and intraoesophageal pH monitored from 22.00 h to 08.00 h, was studied in a double-blind cross-over trial in 11 duodenal ulcer patients. Placebo and ramixotidine were given to each patient on 2 consecutive days in a randomized sequence. Three patients were excluded from the intragastric pH analysis as the records on the second study day were technically inadequate. No significant carry-over or sequence effect was noted. Intragastric hydrogen ion activity was significantly lower (p = 0.01) after ramixotidine than after placebo: median (range) 24 (9-100) vs 97 (27-188) mmol/l. The percentage of time with intraoesophageal pH less than 4 was less than 5% in all but three recordings, with a maximum value of 12%, and it was not significantly different after the two treatments.

Repeatability of lactulose hydrogen breath test in subjects with normal or prolonged orocecal transit.

The within-subject repeatability of orocecal transit assessed with lactulose hydrogen breath test was evaluated in 15 healthy volunteers and 16 constipated or obese patients. The test was repeated twice in each subject. Mean (SD) transit time was 105 (63) and 103 (60) min in the first and second series of tests, respectively, showing that the first measurement did not affect the second. The within-subject repeatability of the test was related to the length of transit, the scatter of the differences between the first and second test being greater with the increase of the mean gastrointestinal transit time. The 95% coefficient of repeatability was 84 min for all measurements and 30 and 118 min, respectively, for transit times under and over 100 min. The lowest reproducibility of the test was found in constipated patients with prolonged orocecal transit.

Oral naloxone antagonizes loperamide-induced delay of orocecal transit.

Orocecal transit time was determined by the lactulose hydrogen breath test in nine healthy volunteers after administration of placebo, loperamide (16 mg per os), and loperamide (16 mg per os) followed by oral naloxone at doses of 16 and 32 mg. The four tests were performed in double-blind conditions and in random sequences. Transit time (mean, SD) after loperamide (128.8 min, 32.9) was significantly increased (P less than 0.05) compared with placebo (85.5 min, 35.7), loperamide followed by naloxone 16 mg (88.8 min, 46.2), and loperamide followed by naloxone 32 mg (84.4 min, 40.6). These results show that the peripheral opioid agonist loperamide delays orocecal transit in healthy subjects and that naloxone per os at adequate doses antagonizes this effect.

Lactose malabsorption and intolerance in Italians. Clinical implications.

Lactose malabsorption was assessed by the hydrogen breath test in 40 Italian patients with irritable bowel syndrome and 42 controls without abdominal disturbances. Sixty-five percent of patients were "low milk consumers" (0-250 ml milk per day) compared with 38% of controls (P less than 0.02). Lactose loads of 25 and 50 g caused malabsorption in 82.5 and 87.5% patients and in 55 and 62% controls, respectively (patients vs controls P less than 0.02). Malabsorption was more frequent in the "low milk consumers" group (P less than 0.05). During a four-month lactose-free diet as the only treatment 7.5% of patients became symptom-free (and remained so for a further eight-month diet), 52.5% improved, and 40% showed no change.

The effect of dietary guar on serum cholesterol, intestinal transit, and fecal output in man.

In six healthy subjects serum cholesterol was unchanged during a 2-wk period of controlled diet (2750 kcal) followed by a 2-wk period of free diet but showed a 16% decrease (p less than 0.05) during a further 2-wk period of controlled diet to which guar (5.7 g bid) was added. Stool weight, frequency and whole gut transit time did not differ in the diet periods with and without guar. Of guar ingested 82-95% was metabolized in the gut. Mouth to cecum transit of a meal measured by the hydrogen breath test in the same subjects was unaffected by the addition of 5.7 g of guar.

Effect of loperamide and naloxone on mouth-to-caecum transit time evaluated by lactulose hydrogen breath test.

The effect of loperamide and naloxone on mouth-to-caecum transit time was evaluated by the lactulose hydrogen breath test in four men and four women. Each subject underwent tests during the administration of placebo, loperamide (12-16 mg po), naloxone (40 micrograms/kg/h by a three-hour intravenous infusion), and loperamide plus naloxone, carried out at intervals of one or two weeks. The transit time was significantly longer after loperamide, and this effect was antagonised by the concomitant administration of naloxone whereas naloxone administered alone had no effect on mean transit time. No clinically important side effects were reported.

Gastrointestinal transit in hyperthyroid patients before and after propranolol treatment.

Mean mouth to cecum transit time determined by the hydrogen breath test after oral lactulose in a group of 10 hyperthyroid patients (nine with regular bowel habit and one with diarrhea) was significantly lower than that observed in 10 euthyroid controls [53 min (SD 15) versus 123 min (SD 12.2), p less than 0.01]. After 5 days of propranolol treatment the patients showed a significant reduction of the heart rate but no modification of transit time [51 min (SD 7.3)].

Secretin-induced gastrin response in the Zollinger-Ellison syndrome and chronic duodenal ulcer patients before and after cimetidine treatment.

A secretin provocative test was performed in 16 patients with chronic duodenal ulcer and in five patients with the Zollinger-Ellison syndrome. In four chronic duodenal ulcer patients a second secretin test was done during acute iv cimetidine administration. There were only slight variations of gastrin compared with the first test. A third test was done on the same four chronic duodenal ulcer patients after 1 month's po cimetidine treatment (1 g/day); gastrin at 0 time was significantly higher than in the previous two tests (p less than 0.01). Integrated gastrin response after secretin was significantly lower in the third test than in the first (p less than 0.05). In two Zollinger-Ellison syndrome patients treated with 1.0 and 1.4 g/day cimetidine for 3 months, gastrin at 0 time was not markedly increased, whereas compared with the first test gastrin levels were higher at each time after secretin. These data suggest that previous cimetidine treatment does not alter, and may even increase, the diagnostic sensitivity of the secretin test.

Respiratory excretion of hydrogen and methane in Italian subjects after ingestion of lactose and milk.

Lactose malabsorption, by the breath hydrogen test, and lactose intolerance (presence of symptoms) were studied in twenty healthy Italian subjects after intake of 12.5, 25 and 50 g lactose, whole milk and low-lactose milk. A rise in respiratory concentration of hydrogen (greater than 20 ppm) (malabsorption) was found in fifteen subjects after 50 g lactose, in thirteen after 25 g and in seven after 12.5 g. Symptoms generally occurred in subjects presenting a rise in respiratory hydrogen excretion, but such a rise was often observed without symptoms. Thirteen subjects presented symptoms after 50 g lactose, but only three after 25 g and one after 12.5 g. Whole milk (500 ml) gave a lower incidence of lactose malabsorption than 25 g lactose (7/20 versus 13/20, P less than 0.05) and more subjects developed symptoms (7/20 versus 3/20, NS). Low-lactose milk produced no malabsorbers and one intolerant. Breath methane was detected constantly in seven subjects and in three on some of the days of observation. Respiratory methane excretion generally appeared to be unrelated to lactose ingestion.