A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2.

BACKGROUND AND PURPOSE: Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. METHODS: The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS>2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. RESULTS: An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS>2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%-53%), and 10/34 patients allocated to coiling (29%; 17%-46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%-94%), and 18/27 patients allocated to coiling (67%; 47%-81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%-60%]) than EVT (9/48 [19%; 10%-31%]). CONCLUSION: Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

Group versus traditional prenatal care in low-risk women delivering at term: a retrospective cohort study.

OBJECTIVE: Group prenatal care (GC) models are receiving increasing attention as a means of preventing preterm birth; yet, there are limited data on whether group care improves perinatal outcomes in women who deliver at term. The purpose of this study was to evaluate our institutional experience with GC over the past decade and test the hypothesis that GC, compared with traditional individual care (TC), improves perinatal outcomes in women who deliver at term. STUDY DESIGN: We performed a retrospective cohort study of women delivering at term who participated in GC compared with TC. A group of 207 GC patients who delivered at term from 2004 to 2014 were matched in a 1:2 ratio to 414 patients with term singleton pregnancies who delivered at our institution during the same period by delivery year, maternal age, race and insurance status. The primary outcome was low birth weight (<2500 g). Secondary outcomes included early term birth (37.0 to 38 6/7 weeks), 5 min APGAR score <7, special care nursery admission, neonatal intensive care unit (NICU) admission, neonatal demise, cesarean section and number of prenatal visits. Outcomes were compared between the two groups using univariable statistics. RESULTS: Baseline characteristics were similar between the two matched groups. GC was associated with a significant reduction in low birth weight infants compared with TC (11.1% vs 19.6%; relative risk (RR) 0.57; 95% confidence interval (CI) 0.37 to 0.87). Patients in GC were significantly less likely than controls to require cesarean delivery, have low 5 min APGAR scores and need higher-level neonatal care (NICU: 1.5% vs 6.5%; RR 0.22; 95% CI 0.07 to 0.72). There were no significant differences in rates of early term birth and neonatal demise. CONCLUSIONS: Low-risk women participating in GC and delivering at term had a lower risk of low birth weight and other adverse perinatal outcomes compared with women in TC. This suggests GC is a promising alternative to individual prenatal care to improve perinatal outcomes in addition to preterm birth.

[Aneurysmal subarachnoid hemorrhage: group of study of cerebrovascular pathology of the Spanish society of neurosurgery management guideline]. / Hemorragia subaracnoidea aneurismática: guía de tratamiento del grupo de patología vascular de la sociedad Española de neurocirugía.

An actualized revision of the most important aspects of aneurismal subarachnoid hemorrhage is presented from the guidelines previously published by the group of study of cerebrovascular pathology of the Spanish Society of Neurosurgery. The proposed recommendations should be considered as a general guide for the management of this pathological condition. However, they can be modified, even in a significant manner according to the circumstances relating each clinical case and the variations in the therapeutic and diagnostic procedures available in the center attending each patient.

Hemorragia subaracnoidea aneurismática: guía de tratamiento del Grupo de Patología Vascularde la Sociedad Española de Neurocirugía / Aneurysmal subarachnoid hemorrhage: group of study of Cerebrovascular Pathology of the Spanish Society of Neurosurgery management guideline

Se realiza una actualización sobre los aspectos másimportantes de la hemorragia subaracnoidea aneurismáticarespecto a las guías previamente publicadaspor el grupo de trabajo de la SENEC. Las recomendacionespropuestas deben considerarse como una guíageneral de manejo de esta patología. Sin embargo,pueden ser modificadas, incluso de manera significativapor las circunstancias propias de cada casoclínico, o las variaciones en los recursos diagnósticosy terapéuticos del centro hospitalario que reciba alpaciente (AU)

An actualized revision of the most important aspectsof aneurismal subarachnoid hemorrhage is presentedfrom the guidelines previously published by the groupof study of cerebrovascular pathology of the SpanishSociety of Neurosurgery. The proposed recommendationsshould be considered as a general guide for themanagement of this pathological condition. However,they can be modified, even in a significant manneraccording to the circumstances relating each clinicalcase and the variations in the therapeutic and diagnosticprocedures available in the center attending eachpatient (AU)

Bloqueo paravertebral torácico. Resultados a corto plazo en relación con la recidiva del cáncer de mama después de la cirugía / No disponible

Objetivo: Existen estudios en animales con cáncer de mama y estudios retrospectivos en humanos que sugieren una reducción de riesgo de metástasis tras realizar una anestesia regional en la cirugía de mama. Hemos estudiado si la realización de bloqueo paravertebral torácico (BPVT) asociado a una anestesia general comparado con una anestesia general sin BPVT reduce la incidencia de metástasis a corto plazo en las pacientes sometidas a cirugía oncológica de mama. Métodos: Se recogieron retrospectivamente 138 pacientes sometidas a cirugía de mama (bien cirugía conservadora, o bien mastectomía, en ambos casos con o sin linfadenectomía) en el periodo entre enero de 2008 hasta junio de 2009. Se consideraron las siguientes variables: edad, peso, antecedentes personales, tipo de tumor, grado histológico, TNM, índice de Nottingham, si recibió o no terapia sistémica, tipo de cirugía, tipo de anestesia, metástasis a 6 meses y a 12 meses, y la supervivencia libre de enfermedad. Resultados: En 40 pacientes se practicó un BPVT más anestesia general, y en 98 anestesia general solamente. En cuanto al grado histológico, clasificación TNM, índice de Nottingham y terapia sistémica no presentaban diferencias entre los dos grupos. La aparición de metástasis a 6 meses fue de 2,5% en el grupo de anestesia con BPVT y de un 6,1% en el grupo de anestesia general (p = 0,673), y a 12 meses, un 2,5% en el grupo de anestesia general con BPVT, y un 9,2% en el de anestesia general (p = 0,281). El consumo intraoperatorio de fentanilo y remifentanilo y de analgesia postoperatoria fue mayor en el grupo con anestesia general. Conclusiones: En este estudio retrospectivo el porcentaje de metástasis fue menor tanto a 6 como a 12 meses en las pacientes en las que se realizó un bloqueo paravertebral con respecto a las que se realizó anestesia general exclusivamente, sin que la diferencia fuera estadísticamente significativa(AU)

Objectives: A reduction in risk of metastasis after performing regional anesthesia in breast surgery has been suggested in both animal studies and retrospectives human studies with breast cancer. We studied whether thoracic paravertebral block (TPVB) associated with general anesthesia compared with general anesthesia reduces the metastases incidence in short term in patients undergoing breast cancer surgery. Methods: 138 patients undergoing breast surgery (either conservative breast surgery or mastectomy, both of them with or without lymphadenectomy) were retrospectively examined between January 2008 and June 2009. The following variables were recorded: age, weight, medical history, type of tumor, histological grade, TNM, Nottingham Index, adjuvant therapy, type of surgery, type of anesthesia, metastasis at 6 and 12 months and disease-free survival. Results: In 40 patients a TPVB combined with general anesthesia were performed, and 98 patients had general anesthesia alone. There were no differences in histological grade, TNM classification, Nottingham index and adjuvant therapy between the two groups. Metastasis at 6 months was 2.5% in the group of anesthesia combined with TPVB and 6.1% in the General Anesthesia group (p = 0.673). At 12 months was 2.5% and 9.2%, respectively (p = 0.281). The intraoperative consumption of fentanyl and remifentanil and postoperative analgesia requirements were higher in the group with general anesthesia. Conclusions: In this retrospective study, the rate of metastasis was lower at both 6 and 12 months in patients who underwent the paravertebral block combined with general anesthesia compared to general anesthesia. However, differences between both groups were not found to be significant(AU)

Idiopathic subarachnoid hemorrhage: a multicentre series of 220 patients.

BACKGROUND. The Spanish neurosurgical society created a multicentre data base on spontaneous SAH to analyze the real problematic of this disease in our country. This paper focuses on the group of patients with idiopathic SAH (ISAH). METHODS. 16 participant hospitals collect their spontaneous SAH cases in a common data base shared in the internet through a secured web page, considering clinical, radiological, evolution and outcome variables. The 220 ISAH cases collected from November 2004 to November 2007 were statistically analyzed as a whole and divided into 3 subgroups depending on the CT blood pattern (aneurysmal, perimesencephalic, or normal). RESULTS. The 220 ISAH patients constitute 19% of all 1149 spontaneous SAH collected in the study period. In 46,8% of ISAH the blood CT pattern was aneurysmal, which was related to older age, worse clinical condition, higher Fisher grade, more hydrocephalus and worse outcome, compared to perimesencephalic (42.7%) or normal CT (10.4%) pattern. Once surpassed the acute phase, outcome of ISAH patients is similarly good in all 3 ISAH subgroups, significantly better as a whole compared to aneurysmal SAH patients. The only variable related to outcome in ISAH after a logistic regression analysis was the admission clinical grade. CONCLUSIONS. ISAH percentage of spontaneous SAH is diminishing in Spain. Classification of ISAH cases depending on the blood CT pattern is important to differentiate higher risk groups although complications are not negligible in any of the ISAH subgroups. Neurological status on admission is the single most valuable prognostic factor for outcome in ISAH patients.

Idiopathic subarachnoid hemorrhage: a multicentre series of 220 patients

Background. The Spanish neurosurgical society created a multicentre data base on spontaneous SAH to analyze the real problematic of this disease in our country. This paper focuses on the group of patients with idiopathic SAH (ISAH).Methods. 16 participant hospitals collect their spontaneous SAH cases in a common data base shared in the internet through a secured web page, considering clinical, radiological, evolution and outcome variables. The 220 ISAH cases collected from November 2004 to November 2007 were statistically analyzed as a whole and divided into 3 subgroups depending on the CT bloodpattern (aneurysmal, perimesencephalic, or normal).Results. The 220 ISAH patients constitute 19% of all 1149 spontaneous SAH collected in the study period. In 46,8% of ISAH the blood CT pattern was aneurysmal, which was related to older age, worse clinical condition, higher Fisher grade, more hydrocephalus and worse outcome, compared to perimesencephalic (42,7%) or normal CT (10,4%) pattern. Once surpassed the acute phase, outcome of ISAH patients is similarly good in all 3 ISAH subgroups, significantly better as a whole compared to aneurysmal SAH patients. The only variable related to outcome in ISAH after a logistic regression analysis was the admission clinical grade. Conclusions. ISAH percentage of spontaneous SAHis diminishing in Spain. Classification of ISAH cases depending on the blood CT pattern is important to differentiate higher risk groups although complications are not negligible in any of the ISAH subgroups. Neurological status on admission is the single most valuable prognostic factor for outcome in ISAH patients (AU)

Propósito. El grupo de trabajo de Patología Vascular de la SENEC desarrolló y mantiene abierta una base de datos multicéntrica que recoge los casos de hemorragia subaracnoidea espontánea. Con esta base se pretende analizar la problemática real que representa esta patología en nuestro medio. Este trabajo se centra en el estudio del grupo de pacientes de la base que presentaron HSA idiopática o de origen no aclarado (HSAI).Materiales y métodos. La base de datos recoge los casos de HSA espontánea de 16 hospitales españoles a través de una página Web compartida en Internet de forma segura. Se consideran variables epidemiológicas ,clínicas y radiológicas, así como la aparición de complicaciones y la evolución de los pacientes. Entre Noviembre de 2004 y Noviembre de 2007 se recogieron 220 pacientes con HSA idiopática. Este grupo se ha analizado estadísticamente de forma global y subdividido en 3 grupos de acuerdo con el patrón TC de sangrado inicial (de tipo aneurismático, perimesencefálico o TCnormal). Resultados. Los 220 pacientes con HSAI representan el 19% del total de 1.149 pacientes con HSA recogidos en la base de datos en el mismo periodo. El 46,8% de los casos de HSAI presentaron patrón de sangrado aneurismático en TC, hecho que se correlacionó con mayor edad, peor condición clínica al ingreso, mayor grado Fisher de sangrado, más frecuencia de hidrocefalia y peor evolución, comparados con los casos de HSAI con sangrado en TC del tipo perimesencefálico (42,7%) o con TC normal (10,4%).Una vez superada la fase aguda, e independientemente del tipo de sangrado inicial, la evolución de los pacientes con HSAI es globalmente buena y significativamente mejor que la de los pacientes con HSA aneurismática. La única variable con valor pronóstico en los casos de HSAI, tras realizar un análisis de (..) (AU)

[Brachial plexus block for minimally invasive parathyroidectomy: report of 3 cases]. / Bloqueo del plexo cervical en paratiroidectomía mínimamente invasiva. A propósito de tres casos.

The brachial plexus block, either deep or superficial, is one of the anesthetic techniques used in parathyroidectomy. The block is easy to perform and has few hemodynamic side effects. Surgery can be carried out in an awake patient. We describe 3 cases of patients with primary hyperparathyroidism (parathyroid adenoma) who underwent unilateral minimally invasive parathyroidectomy under regional anesthesia and sedation with 2 mg of midazolam plus remifentanil at dosages ranging from 0.6 to 0.1 microg kg(-1) min(-1). To provide a deep cervical block, we administered 15 mL of 0.75% ropivacaine. For a superficial block, 15 mL of 0.2% ropivacaine was used. The procedure could be completed in all 3 patients under regional anesthesia. The latency time for the block ranged from 21 to 30 minutes, and remifentanil dosages from 0.05 to 0.09 microg kg(-1) min(-1) were administered for procedures that lasted 30 to 45 minutes. No patient required postoperative opioids or antiemetics, although a local anesthetic had to be used at the moment of incision for 1 patient. All 3 patients were discharged the same day. We wish to underline the utility of the brachial plexus block for parathyroid surgery. The technique is easy to perform, safe, and effective; as a result, surgery can be carried out on an outpatient basis.

[Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: presentation, inclusion criteria and development of an internet-based registry]. / Base de datos multicéntrica de hemorragia subaracnoidea espontánea del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía: presentación, criterios de inclusión y desarrollo de una base de datos en internet.

INTRODUCTION: Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease. MATERIALS AND METHODS: In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page. RESULTS: During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS = 5). CONCLUSIONS: Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH.

Base de datos multicéntrica de hemorragia subaracnoidea espontánea del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía: presentación, criterios de inclusión y desarrollo de una base de datos en internet / Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: Presentation, inclusion criteria and development of an internet-based registry

Introducción: La hemorragia subaracnoidea (HSA) continúa siendo una de las enfermedades de interés neuroquirúrgico de más alta morbilidad y mortalidad. Su estudio es clave a la hora de mejorar la atención de estos enfermos en nuestro medio. Con este fin el Grupo de Trabajo de Patología Vascular de la SENEC decidió la creación de una base de datos multicéntrica para su estudio. Material y métodos: Se incluyen en esta base de datos todos los casos de hemorragia subaracnoidea espontánea ingresados en los centros participantes de forma prospectiva desde Noviembre del año 2004 hasta Noviembre del 2007. Se decidieron de forma consensuada los campos a recoger incluyendo edad, antecedentes personales, características clínicas, características radiológicas y del aneurisma, tipo de tratamiento y complicaciones de la enfermedad, evolución según la escala de evolución de Glasgow (GOS) al alta y a los seis meses así como el resultado angiográfico del tratamiento. Todos los campos se recogieron en un formulario rellenable a través de una página web segura. Resultados: En los tres años en los que ha estado activa la base se han recogido un total de 1149 casos de HSA espontánea recogidos por 14 centros participantes. Se ha estimado que es necesario aproximadamente un tiempo de 3.4 minutos para rellenar cada caso.En cuanto a sus características generales la serie es similar a otras series hospitalarias no seleccionadas. La edad media de los enfermos incluidos es de unos 55 años y la relación mujer:hombre 4:3. En cuanto a la gravedad del sagrado inicial un 32% de los enfermos se encontraba en mal grado clínico (WFNS = 4 ó 5). El 5% de los pacientes fallecieron antes de realizarse una angiografía que confirmara el origen aneurismático del sangrado. Se confirmó el origen aneurismático en el 76% de los pacientes mientras que en el 19% no se encontró ninguna lesión vascular responsable del sangrado, siendo clasificados como HSA idiopática. En los pacientes en los que se detectó un aneurisma su tratamiento fue endovascular en el 47% de los casos, quirúrgico en el 39, mixto en el 3% y no recibieron tratamiento de su aneurisma el 11% de los pacientes por fallecimiento precoz. En cuanto a su evolución, la mortalidad global de la serie se sitúa en el 22%. Sólo el 40% de los enfermos con HSA aneurismática presentaron una buena evolución (GOS=5). Conclusiones: La HSA espontánea continúa siendo una enfermedad con alta morbilidad y mortalidad. Esta base de datos puede ser un instrumento para conocer mejor sus características en nuestro medio y mejorar sus resultados, ya que se trata de una serie multicéntrica hospitalaria no seleccionada. Sería pues recomendable que esta base constituyera el germen de un registro nacional de HSA espontánea (AU)

Introduction: Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease. Materials and methods: In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page. Results:During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS=5). Conclusions: Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH (AU)

Bloqueo del plexo cervical en paratiroidectomia minimamente invasiva. A proposito de tres casos / Brachial plexus block for minimally invasive parathyroidectomy: report of 3 cases

El bloqueo del plexo cervical profundo y superficial,es una de las tecnicas anestesicas para el manejo depacientes sometidos a cirugia de paratiroides. Es facil derealizar, con pocos efectos hemodinamicos, y permite llevara cabo la cirugia con el paciente despierto. Presentamostres casos clinicos, en pacientes con hiperparatiroidismo(HPT) primario (adenoma de paratiroides) en losque se les practica una paratiroidectomia unilateral minimamenteinvasiva. Para ello, se realiza una anestesiaregional mas sedacion con midazolam 2 mg y remifentaniloen un rango de 0,06-0,1 ug kg-1min-1. Para el bloqueocervical profundo se administra ropivacaina 0,75% untotal de 15 mL, y para el bloqueo cervical superficial ropivacaina0,2%15 mL. En los tres pacientes se pudo realizarla tecnica quirurgica mediante anestesia regional, conun tiempo de latencia del bloqueo que oscilo entre 21-30min, y unas dosis de remifentanilo 0,05-0,09 ug kg-1min-1durante el tiempo que duro la cirugia (30-45 min). Ningun paciente preciso opioides ni antiemeticos postoperatorios,aunque uno requirio en el momento de la incision la infiltracio nde la piel con anestesico local. Los tres pacientesfueron dados de alta en el dia. Con estos casos clinicos queremos mostrar la utilidad del bloqueo del plexo cervicalpara la cirugia de paratiroides, que ademss de su facil realizacion, es seguro y efectivo, lo que permite queeste tipo de cirugia sea ambulatoria (AU)

The brachial plexus block, either deep or superficial,is one of the anesthetic techniques used inparathyroidectomy. The block is easy to perform andhas few hemodynamic side effects. Surgery can becarried out in an awake patient. We describe 3 cases ofpatients with primary hyperparathyroidism(parathyroid adenoma) who underwent unilateralminimally invasive parathyroidectomy under regionalanesthesia and sedation with 2 mg of midazolam plusremifentanil at dosages ranging from 0.6 to 0.1 ¦Ìg kg-1min-1.To provide a deep cervical block, we administered 15mL of 0.75% ropivacaine. For a superficial block, 15 mLof 0.2% ropivacaine was used. The procedure could becompleted in all 3 patients under regional anesthesia.The latency time for the block ranged from 21 to 30minutes, and remifentanil dosages from 0.05 to 0.09¦Ìg kg-1min-1 were administered for procedures that lasted30 to 45 minutes. No patient required postoperativeopioids or antiemetics, although a local anesthetic had tobe used at the moment of incision for 1 patient. All 3patients were discharged the same day. We wish tounderline the utility of the brachial plexus block forparathyroid surgery. The technique is easy to perform,safe, and effective; as a result, surgery can be carriedout on an outpatient basis (AU)

Sublethal zinc exposure has a detrimental effect on reproductive performance but not on the cyst hatching success of Artemia parthenogenetica.

The sublethal zinc toxicity to Artemia parthenogenetica as regards the possibility of colonization of zinc polluted salterns by means of cysts has been assessed by a cyst hatching assay and a life table approach. Emergence and hatching at different times as well as the whole hatching profile were taken as end-points for evaluating success of development. Demographic and reproductive parameters calculated according to the Lotka equation were used as an indicator of the chronic toxicity of the population. No adverse effects of waterborne zinc were found on hatching and emergence of cysts of A. parthenogenetica at any of the concentrations tested (0.01 mg/l, 0.1 mg/l, 0.5 mg/l, 1 mg/l, 5 mg/l). Chronic zinc exposure at 0.08 mg/l had detrimental effects on A. parthenogenetica fecundity, as detected by a decrease in the percentage of fertile females, which in turn produces a decrease in r. Chronic toxicity of zinc may be a limiting step for A. parthenogenetica colonization and the establishing of permanent populations in zinc-polluted brine ponds.

Comparative toxicokinetics of cadmium in Artemia.

The toxicokinetics of cadmium was determined for five populations belonging to four species of Artemia (A. salina, A. parthenogenetica, A. franciscana, and A. persimilis) using a bicompartmental model. The effects of sublethal cadmium concentration on the kinetic parameters in A. parthenogenetica were determined. The BCF values are inversely related to the concentration, as is the uptake rate (ku), whilst the elimination rate (ke) constant seems to be directly related to the exposure concentration. Values corresponding to the rate of metal influx (I) remain relatively constant (0.2477 to 0.4455 microg/g.h) in the concentration range from 0.1 to 1 mg Cd/L, and are higher (1.098 microg/g.h) at an exposure to 10 mg Cd/L. The cadmium accumulation pattern seems well conserved in the genus and is characterized by a fast elimination of the metal with Ke ranging from 0.0050 to 0.0231 h(-1). A. persimilis displays a different model to that corresponding to the other studied species exposed to the same cadmium concentration, presenting a low uptake rate constant (1.0564 mL/g. h) and a low BCF (211.3 mL/g).

The influence of buffer species and strength on diltiazem HCl release from beads coated with the aqueous cationic polymer dispersions, Eudragit RS, RL 30D.

PURPOSE: Eudragit RL and RS 30D are pseudolatexes frequently used in the coating of solid dosage forms. They are based on cationic copolymers stabilized with quaternary ammonium groups (poly(ethylacrylate-methylmethacrylate-trimethylammonioethyl methacrylate chloride). A pH-independent drug release is expected because of the quaternary nature of the cationic groups. The objective was to explain a distinct "pH-dependent" drug release in various buffer media with coated diltiazem beads. METHODS: The diltiazem HCl release from and water uptake of Eudragit RS/RL-coated beads was determined in various buffers of different buffer species, pH or concentration. RESULTS: The drug release in the different buffer media was in the following order: pH 5.0 acetate > pH 3.5 formate > pH 7.4 phosphate buffer > 0.1M HCl). This "pH-dependent" drug release could be explained with an anion exchange process; the chloride counterions of the quaternary groups were exchanged with the anionic buffer species during the dissolution study. The water uptake of the coated beads correlated well with the drug release from the beads. Increasing the buffer strength (acetate buffer) first increased and then decreased the drug release, while increasing the ionic strength of different buffers with NaCl decreased the drug release and eliminated the observed buffer effects because of the excess of chloride ions. CONCLUSIONS: The anionic buffer species and not the pH had a significant effect on the hydration and hence on the drug release from beads coated with the cationic polymers, Eudragit RS and RL.

Changes in systemic blood pressure and cardiac rhythm induced by therapeutic compression of the trigeminal ganglion.

Percutaneous compression of the trigeminal ganglion, which is currently being used for the control of trigeminal neuralgia, induces marked intraoperative elevations of the systemic blood pressure and heart rate changes, which may increase the risk of cardiovascular complications. We have analyzed the characteristics of the arterial hypertensive response and the cardiac rhythm changes induced by percutaneous compression of the trigeminal ganglion in 42 consecutive, unselected patients undergoing operations for essential trigeminal neuralgia under three different regimens of anesthesia. The first 22 patients (Group 1) underwent operations under brief general anesthesia without endotracheal intubation. The following 10 patients (Group 2) had general anesthesia with intubation and mechanical ventilation and received larger doses of hypnotic and analgesic agents. Finally, 10 more patients (Group 3), who had general anesthesia with intubation, underwent local anesthetic blockade of Meckel's cave (injection of 1 ml of 1% lidocaine) before ganglion compression. Foramen ovale puncture elicited bradycardia in the majority of the patients of Groups 2 and 3, but only four patients (18%) of Group 1 showed bradycardia. Ganglion compression caused marked tachycardia in all patients of Groups 1 and 2; about one-third of the patients also had extrasystoles. By contrast, patients of Group 3, who had local anesthetic blockade of Meckel's cave before ganglion compression, did not develop tachycardia or extrasystoles. Foramen ovale puncture elicited marked elevations of the systemic blood pressure in all patients. Ganglion compression further increased blood pressure, except in patients of Group 3, who had local anesthetic blockade of Meckel's cave.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship of film properties to drug release from monolithic films containing adjuvants.

The rate of drug release from a polymeric matrix system was influenced by the physical and chemical properties of the monolithic films. The model drugs, salicylic acid and chlorpheniramine maleate, and two poly(methyl methacrylate) copolymers of different permeabilities (Eudragit RL and Eudragit RS), with and without additional adjuvants, were used to form monolithic matrix films for controlled drug release. Adjuvants, including polyethylene glycols (PEG 400 and PEG 8000) and poly(vinylpyrrolidones) (PVP-K15 and PVP-K90), were incorporated into films of Eudragit RL PM and Eudragit RS PM. The moisture permeation constant, glass transition temperature (Tg), tensile strength, and drug release profiles were determined for each acrylic resin slab to correlate the physicochemical and physicomechanical film properties to observed drug release. Faster rates of drug diffusion were observed with the addition of PEG 400 to the films, because of its plasticizing effect and the resultant increased moisture permeability of the matrix. An exception existed with the Eudragit RL PM film containing salicylic acid where drug-polymer interactions inhibited drug diffusion. The small changes in moisture permeability, Tg, and tensile strength observed with incorporation of the PVPs had an insignificant influence on the dissolution results for salicylic acid from Eudragit RS PM films. Increases in the tensile strength and Tg after addition of PVP to the Eudragit RS PM matrix support the observed decreased rate of diffusion for chlorpheniramine maleate. The pores formed by migration of the hydrophilic adjuvants from the films altered the diffusion kinetics of the matrix, compared with that of the nonporous polymer, when only the antihistamine was present.