Intravenous Methadone for Severe Cancer Pain: A Presentation of 10 Cases.

Purpose. Methadone, a synthetic opioid agonist, is an effective alternative to strong opioids (morphine, hydromorphone, oxycodone, and buprenorphine) and is widely available as an oral formulation. Few data have been published so far on the use of intravenous (i.v.) methadone for the management of severe or refractory cancer pain. Methods. We followed 10 consecutives cancer patients with severe pain, treated with IV methadone. All had advanced disease and had already received strong opioids, some in association with ketamine. Pain was assessed at T0, T24 hours, and at the end of the treatment. Results. All patients benefited from the switch to IV methadone with a reduction of pain on VAS after 24 hours (median: 4/10; range 0-5) until the end of the treatment (all cases <3/10). The median starting dose was 100 mg/day (range 20-400) and the final dose remained stable with a median of 100 mg/day (range 27-700). The median duration of IV methadone was 11 days (range 2-59). No cardiac toxicity had been observed. Conclusions. IV methadone is an effective pain relieving alternative for the treatment of severe cancer pain, especially in refractory pain syndrome. Moreover, we did not observe any toxicity (neurological or cardiac) or any other major side effects and the treatment was overall well tolerated. More extensive comparative studies should be planned.

A prospective evaluation of the incidence of bacteremia associated with EUS-guided fine-needle aspiration.

BACKGROUND: Endoscopic ultrasound (EUS)--guided fine-needle aspiration (FNA) is frequently performed for diagnostic evaluation of lesions in or near the gastrointestinal (GI) tract. Little data exist concerning possible infectious complications associated with EUS-guided FNA. This prospective evaluation was undertaken to determine the frequency of bacteremia and infectious complications associated with EUS-guided FNA. METHODS: All patients undergoing EUS-guided FNA for any indication were enrolled in this study. Patients who required antibiotic prophylaxis as per the American Heart Association or American Society for Gastrointestinal Endoscopy guidelines were excluded from the study as were patients with cystic lesions, patients with advanced liver disease/ascites and those with human immunodeficiency virus/acquired immune deficiency syndrome. Blood cultures were obtained 30 and 60 minutes after the EUS-FNA. Patients were monitored for evidence of infection after procedure including telephone follow-up of each subject 1 week after procedure. RESULTS: One hundred patients underwent EUS-FNA of 108 lesions. All blood cultures were negative except in 6 patients in whom 1 of 2 bottles were positive for coagulase negative Staphylococcus, which was considered a contaminant. There were no complications of acute febrile illness, abscess or other infections. CONCLUSION: EUS-guided FNA was not associated with bacteremia or infectious complications.

Clinical course, microbiologic profile, and diagnosis of periannular complications in prosthetic valve endocarditis.

Whether periannular extension of prosthetic valve endocarditis (abscesses, pseudoaneurysms, fistulas) is related to the etiologic agent, the clinical course and the prognosis is still unknown. Likewise, transesophageal echocardiographic accuracy in detecting periannular complications in prosthetic recipients remains unsettled. We retrospectively analyzed data from 87 patients with anatomically proven prosthetic valve endocarditis who underwent a transesophageal echocardiographic examination. Periannular complications (30 abscesses, 18 pseudoaneurysms, 8 fistulas; 8 with >1) were found in 46 patients; results were compared with the remaining 41 without complications. Transesophageal echocardiography correctly identified 27 abscesses (90%) and all pseudoaneurysms and fistulas. One diagnosis of pseudoaneurysm by echocardiography was not found at surgery. No statistical differences were found regarding age, sex, type of prosthesis (mechanical vs biologic), and etiologic agent. Periannular complications were more frequent in aortic location (70% vs 20% in mitral position; p <0.001) and in early (within 6 months after surgery) endocarditis (63% vs 38% in late endocarditis; p = 0.04). The same percentage of patients from both groups underwent surgery (98% with and 90% without complications). At discharge, 62% and 67% of patients were alive, respectively. Thus, periannular complications in prosthetic valve endocarditis are more frequent in aortic location and within 6 months after surgery. Neither the type of prosthesis nor the etiologic agent are related to the presence of periannular complications. Short-term prognosis in patients who underwent surgery is not affected by the presence of periannular complications.

Papillary roof incision using the Erlangen-type pre-cut papillotome to achieve selective bile duct cannulation.

BACKGROUND: Prior studies evaluating pre-cutting the major papilla to access the bile duct when standard cannulation falls have usually used the needle-knife papillotome. We conducted a prospective study to evaluate the efficacy and safety of an Erlangen-type pre-cut papillotome for pre-cutting. PATIENTS AND METHODS: Three hundred twenty-seven patients (114 men, mean age 67 years) who underwent first-time sphincterotomy at our institution were included. Pre-cutting was performed if free and wire-guided cannulation of the bile duct failed according to an algorithm. RESULTS: Pre-cutting was performed in 123 patients (38%) and selective cannulation was successful in all. Post-ERCP serum pancreatic enzyme levels were more frequently elevated in the pre-cut group (50%) than the non-pre-cut group (27%, p < 0.001); however, there was no difference in the incidence of post-ERCP pancreatitis (pre-cut = 2.7%, 95% CI: 0.66% to 7.6%; non-pre-cut = 1.6%, 95% CI: 0.3% to 4.7%). The incidence of bleeding was similar (pre-cut, 2.4%, non-pre-cut, 3.9%; p > 0.05). CONCLUSION: Pre-cutting the major papilla for biliary access using the Erlangen-type pre-cut papillotome is an effective and reasonably safe procedure when performed by endoscopists with extensive experience in pancreatobiliary endoscopy.

Smoking, acculturation, and pregnancy outcome among Mexican Americans.

The authors present an evaluation of the role of acculturation in smoking practices and pregnancy outcome (N = 767 births) in a national sample of Mexican American women. Data employed are from the 1982-1984 Hispanic Health and Nutrition Examination Survey. The prevalence rates of smoking during pregnancy, low birth weight (< or = 2500 g), and preterm delivery (> or = 3 weeks prior to the expected date) are higher among more acculturated women compared with less acculturated women. Among the more acculturated women, the prevalence of smoking and poor birth outcomes did not increase linearly with increasing American orientation. Rather, women in the third quartile of acculturation scores, i.e., those with a moderate American orientation, experienced significantly poorer birth outcomes than women with either a stronger American orientation or a Mexican orientation. Women at this moderate level of acculturation appear to have the greatest need for public health services rather than women with the lowest level of acculturation (non-English speaking, lowest income) as a means of improving their pregnancy outcomes.

Traumatic pancreatitis in a patient with pancreas divisum: clinical and radiographic features.

A previously healthy patient with chronic hyperamylasemia and epigastric pain following blunt abdominal trauma complicated by retroperitoneal hematoma is reported. Endoscopic retrograde cholangiopancreatographic and computerized tomographic examinations revealed pancreatographic characteristics of pancreas divisum with traumatic disruption of the duct of Santorini and adjacent pseudocyst formation. Distal pancreatectomy with cystjejunostomy resulted in total recovery. This represents the first documented case of traumatic pancreatitis in a patient with pancreas divisum.

Birth weight and smoking practices during pregnancy among Mexican-American women.

The smoking practices of a national sample of Mexican-American mothers and the resulting effects of those practices on birth weight were examined. Data were from the Hispanic Health and Nutrition Examination Survey conducted by the U.S. National Center for Health Statistics during 1983-1984. We found that 24% of the mothers had smoked during their pregnancy, with a mean of 11 cigarettes per day. Infants of these women weighed 101 g less at birth than did infants of nonsmoking mothers and had a low birth weight rate of 8.0% compared with the 5.1% low birth weight rate for the sample as a whole. Multiple regression results indicate a 7.4 g decrease in birth weight for each cigarette smoked per day during pregnancy. Cultural factors that promote a low birth weight rate for Mexican-Americans that is comparable to that of non-Hispanic whites despite increased rates of poverty and inadequate health care do not protect against the insidious effects of cigarette smoking.

[Pulmonary valvuloplasty in adolescents and adults: 2 year follow-up by continuous Doppler]. / Valvuloplastia pulmonar en el adolescente y el adulto: seguimiento a los 2 años mediante Doppler continuo.

The purpose of this study is the long term follow-up of the first pulmonary valvuloplasties performed by our group. From september 1984 to march 1988, 10 patients (4 men and 6 women) aged 8 to 58 (mean: 21) with severe or moderate pulmonary valve stenosis underwent pulmonary valvotomy. In all cases the balloon diameter was equal to or 1 mm smaller than the valvular annulus. The results were satisfactory with a significant mean gradient reduction of 51.7%. A follow-up gradient estimation by Doppler echocardiogram was obtained 10 to 37 months after valvuloplasty (mean: 23 months). The mean follow-up gradient by Doppler (31.3 +/- 9.9 mmHg) was not significantly different from the mean hemodynamic post-dilatation gradient (35.6 +/- 14.7 mmHg). A linear correlation was found between the post-dilatation hemodynamic mean gradient and the mean gradient by Doppler follow-up (r = 0.66, p less than 0.05, SEE = 4.1 mmHg). No restenosis were observed. These results suggest that the benefits of valvuloplasty are long lasting. Continuous Doppler is an excellent technique for the follow-up of these patients.