Severe lightning pain after subarachnoid block in a patient with neuropathic pain of central origin: which drug is best to treat the pain?

OBJECTIVE: There have been many reports that spinal anesthesia induces severe lightning pain in the lower limbs of patients with phantom limb pain, tabes dorsalis, or causalgia. We report on a patient with neuropathic pain of central origin who showed newly developed severe lightning pain after therapeutic subarachnoid block (SAB). We performed SAB 16 times in this patient, and he complained of severe pain each time. We investigated which drug was best for treating such induced pain by administering various drugs to the patient. SETTING: The patient was hospitalized for treatment and observation. PATIENT: The patient was a 48-year-old man with neuropathic pain secondary to an incomplete spinal cord injury at the cervical segment. INTERVENTIONS: Various drugs were administered for relieving the newly developed severe pain, and the effectiveness of these agents was compared. RESULTS AND CONCLUSIONS: Intravenous thiopental, fentanyl, butorphanol, ketamine, midazolam, droperidol, and sevoflurane-oxygen anesthesia were quite effective. Intramuscular butorphanol was not effective. Intravenous physiologic saline and atropine sulfate as a placebo, intrathecal morphine hydrochloride, intravenous mexiletine, and lidocaine were ineffective. Intravenous thiopental (approximately 1 mg/kg) was thought to obtain the best pain relief because it stopped the pain quickly, the dose needed was subanesthetic, and there was no adverse effect.

Six months of maintenance chemotherapy after intensified treatment for acute lymphoblastic leukemia of childhood.

PURPOSE: We postulated that intensification of chemotherapy immediately after remission induction might reduce the leukemic cell burden sufficiently to allow an abbreviated period of antimetabolite therapy. PATIENTS AND METHODS: Three hundred forty-seven children (ages 1 to 15 years) with previously untreated acute lymphoblastic leukemia (ALL) were enrolled onto the Tokyo L92-13 study, which excluded patients with mature B-cell ALL and patients less than 1 year old. One hundred twenty-four patients were classified as standard risk, 122 as high risk, and 101 as extremely high risk, according to age, peripheral-blood leukocyte count, selected genetic abnormalities, and immunophenotype. All subjects received four drugs for remission induction, followed by a risk-directed multidrug intensification phase and therapy for presymptomatic leukemia in the CNS. Maintenance chemotherapy with oral mercaptopurine and methotrexate was administered for 6 months, with all treatment stopped by 1 year after diagnosis. RESULTS: The mean (+/- SD) event-free survival (EFS) and overall survival rates for all patients were 59.5% +/- 3.4% and 81.5% +/- 2.2%, respectively, at 5. 5 years after diagnosis. EFS rates by risk category were similar (60. 2% +/- 6.0% for standard risk, 57.7% +/- 5.6% for high risk, and 62. 5% +/- 5.7% for extremely high risk), whereas overall survival rates differed significantly (91.2% +/- 2.7%, 80.0% +/- 4.1%, and 72.1% +/- 4.5%, respectively, P <.0001 by the log-rank test). There were 107 relapses. Eighty-five (79.4%) of these 107 patients achieved second complete remissions, with subsequent EFS rates of 61.5% +/- 7. 9% (standard risk), 42.6% +/- 8.1% (high risk), and 9.6% +/- 6.4% (extremely high risk). Of the five risk factors analyzed, only the response to prednisolone monotherapy among extremely high-risk patients proved important. CONCLUSION: Early treatment intensification did not compensate for a truncated phase of maintenance chemotherapy in children with standard- or high-risk ALL. However, 6 months of antimetabolite treatment seemed adequate for extremely high-risk patients who were good responders to prednisolone and received intensified chemotherapy that included high-dose cytarabine early in the clinical course.

The effect of previous administration of nizatidine on the neuromuscular effects of vecuronium and the effect of nizatidine on gastric secretion.

Nizatidine, a new H2-receptor antagonist, has been reported to inhibit acetylcholinesterase activity. This could lead to an interaction with neuromuscular blocking drugs. This study examined the effects of nizatidine on the actions of vecuronium. Oral nizatidine has been reported to be an effective protective agent against acid aspiration syndrome, and we reevaluated this effect. The control group (n = 10) received a placebo with water 50 ml and the nizatidine group (n = 10) received nizatidine 300 mg with water 50 ml two hours before arrival in the operating room. Gastric contents were aspirated and the volume and pH measured before induction of anaesthesia. Anaesthesia was induced in all patients with thiopentone 5 mg/kg and 1.5% isoflurane in 98.5% oxygen followed by vecuronium 0.1 mg/kg. Vecuronium onset time and duration time 25 (time from injection until recovery of 25% of vaseline twitch amplitude) were obtained using electromyography. There were no significant differences between the two groups in vecuronium onset time or duration time 25. Gastric fluid volume was greater and gastric pH was lower in the control group than in the nizatidine group. 70% of the control group and none of the nizatidine group (P < 0.005) had a gastric content pH < 2.5 or volume > 25 ml.

A case of well-differentiated, fetal-type hepatoblastoma with very low serum alpha-fetoprotein.

Serum alpha-fetoprotein (AFP) is elevated in 96.6% of infants and children with hepatoblastoma and hepatocarcinoma. Serum AFP was of normal level in only one case of immature-type hepatoblastoma, and very low in only one case of fetal-type hepatoblastoma among 43 cases reviewed in 1986. Recently, a case of hepatoblastoma with very low serum AFP was encountered in the authors' surgical department. In October 1998, a 55-month-old girl was admitted. Her birth weight was 717 g. A large space-occupying lesion (SOL) located in the left lobe of the liver was seen by magnetic resonance imaging (MRI), and her serum AFP level was 322 ng/mL with a subfractionation pattern of the "benign liver disease" type based on reactivity with lens culnaris hemagglutinin and concanavalin A. The patient underwent successful left lobectomy, and histological examination showed that the tumor, weighing 268 g, was hepatoblastoma of the well-differentiated, fetal type. Immunohistochemistry findings for AFP were negative. A hepatic mass in infants and children with low serum AFP level indicates the presence of either well-differentiated or immature hepatoblastoma, or fibrolamellar hepatocellular carcinoma. Subfractionation of AFP may contribute to the differential diagnosis of these subtypes.

What kind of patients are suitable for evaluating the therapeutic effect of sudden deafness?

OBJECTIVE: This study aimed to find out appropriate patients to evaluate the therapeutic effect of sudden deafness. STUDY DESIGN: The study design was a retrospective case review. SETTING: The study was performed at a university hospital. PATIENTS: A series of 443 patients with idiopathic sudden sensorineural hearing loss who visited the authors within 1 week from the onset participated. INTERVENTIONS: Relationship between interval from the onset and treatment prognosis was investigated. RESULTS: The significant difference in prognosis related to the days from the onset to the initial visit was noted only in the patients with the initial hearing level from 50-65 dB. The prognosis of the patients who visited the authors on the next day from the onset was excellent. Whereas, in the patients with initial hearing level worse than 70 dB, no significant difference in prognosis was noted among the days of visit. CONCLUSIONS: The patients with the initial hearing level worse than 70 dB and who visited the authors within 8 days from the onset were appropriate for candidates in evaluating the therapeutic effect of sudden deafness.

Public awareness and knowledge of prostate cancer in Japan: results of a survey at short-stay examination facilities.

BACKGROUND: This study was undertaken to determine public awareness and knowledge of prostate cancer, which has not been adequately studied in Japan. METHODS: Assessment was made of public awareness and perception of prostate cancer in Japan, based on health examination data for participants in a short-stay physical examination program ("human dry dock"). A multiple-choice, thirty-point questionnaire survey was conducted at 3 "human dry dock" medical facilities situated in urban areas. RESULTS: Many Japanese adults appeared to be inadequately aware of prostate cancer and of the means available for its early detection. One third of the participants were unfamiliar with this malignancy. Logistic regression analysis indicated smoking to be the only covariate associated with lack of knowledge of prostate cancer (P< 0.05). Seventy-one percent of the subjects had heard of digital rectal examination, but only 16% and 8%, respectively, were familiar with the terms transrectal ultrasonography and PSA testing. Japanese people may possibly be less informed about prostate cancer than African-American males. Both "human dry dock" facilities and subject gender were significantly associated with knowledge of digital rectal examination (P< 0.05). Knowledge of transrectal ultrasonography was found to depend on participation in "human dry dock" programs and level of education (P< 0.05). Smoking, participation in "human dry dock" programs under employer direction, and health status were all identified as determinants for knowledge of PSA testing (P< 0.05). CONCLUSION: Educational programs should be established and put into effect to instill adequate awareness of prostate cancer in Japan. In a better-informed society, more effort would be directed toward prevention and thus early stage prostate cancer would be detected more often.

Zonal biopsy in the detection of prostate cancer in Japanese men.

To reduce sampling error as much as possible in the detection of prostate cancer, extensive transition zone sampling, in addition to the standard sextant random systematic biopsies, has been proposed. Improved biopsy techniques should make possible earlier and more effective detection of prostate cancer in a population where the incidence is low. Evaluation of such biopsies for elderly Japanese males is thus required. A total of 344 Japanese patients participated in this study. They underwent two transition zone biopsies in addition to systematic biopsy. Fifty-five of the 344 patients (16.0%) had cancer. Both biopsies were positive in 33 patients (60.0%), the standard systematic sextant biopsy alone demonstrated cancer in further 20 (36.4%) and the transition zone biopsy alone was positive in two others (3.6%). The two patients with cancer only in the transition zone biopsy cores had palpable abnormality and elevated prostate specific antigen. None of those with palpably benign glands or those with prior negative biopsies had cancer in the transition zone. Two additional cores from the transition zone led to no increase in morbidity of biopsy. Transition zone biopsy would not significantly contribute to the detection of prostate cancer in the present Japanese elderly male population. Though possibly of some value for certain patients, this biopsy does not warrant routine use.

Analgesia after upper abdominal surgery with extradural buprenorphine with lidocaine.

PURPOSE: To determine whether the continuous low thoracic extradural administration of the same dose of lidocaine at low concentration with a high infusion rate or at high concentration with a low infusion rate in combination with a fixed dose of buprenorphine (0.4 mg.day-1) modifies postoperative pain relief. METHODS: Twenty-eight patients undergoing elective upper abdominal surgery were randomly allocated to one of two groups to receive lidocaine 2%--buprenorphine at a rate of 6.3 ml.hr-1 (2% group, n = 13) or lidocaine 6%-buprenorphine at a rate of 2.1 ml.hr-1 (6% group, n = 15). During suture of the peritoneum, mepivacaine 2% (8 ml) with 0.1 mg (0.5 ml) buprenorphine was infused extradurally. After extubation, the continuous extradural infusion was initiated. Patients were assessed for the level of analgesia with the 10 cm VAS score at rest and with the Prince Henry Pain Scale (PHPS) at 3, 6, 9, 12, 18, and 24 hr postoperatively. RESULTS: The visual analogue scale (VAS) scores at rest did not differ between the two groups except at 18 hr after surgery. The Prince Henry Pain Scale (PHPS) scores were not different between the two groups postoperatively. CONCLUSION: There was no difference in analgesia produced by the continuous extradural infusion of lidocaine 2%-buprenorphine at a rate of 6.3 ml.hr-1 and that of lidocaine 6%-buprenorphine at a rate of 2.1 ml.hr-1 following upper abdominal surgery.

Analgesia after upper abdominal surgery using extradural administration of a fixed dose of buprenorphine in combination with lignocaine given at two infusion rates: a comparative study.

BACKGROUND: Extradural administration of combinations of local anaesthetics and opioids are frequently employed for postoperative pain relief. There is a scarcity of data on the analgesic effects of variations of the dose of local anaesthetic drug admixed to a fixed dose of opioid. METHODS: Twenty-four patients were investigated after elective upper abdominal surgery. During closure of the abdomen, 2% mepivacaine (8 ml) with buprenorphine 0.1 mg (0.5 ml) was given extradurally. After extubation, patients were randomly allocated to receive continuous extradural infusion of a fixed dose of buprenorphine (0.017 mg/h) in combination with 2% lignocaine at either 2.1 ml/h (low rate group, n = 14) or 6.3 ml/h (high rate group, n = 10). Postoperative pain at rest was assessed using visual analogue scale (VAS) scores and pain at movement by Prince Henry Pain Scale (PHPS) scores. Venous plasma lignocaine concentrations were measured. RESULTS: VAS scores at rest were similar in the two groups at 3 h postoperatively, whereas at 6-24 h postoperatively, VAS scores were higher in the low rate group than in the high rate group. PHPS scores were similar in the two groups at 3 h and at 18 h postoperatively, whereas at 6, 9, 12 and 24 h postoperatively, PHPS scores were higher in the low rate group than in the high rate group. Plasma lignocaine concentrations were higher at 23 h postoperatively in the high rate group than at 16 h in both groups, and at 23 h in the low rate group. At 3 h postoperatively, both the systolic and diastolic arterial pressures were higher in the low rate group than control values obtained on admission. Side effects were observed in one patient in the low rate group who complained of dizziness, and in one patient in the high rate group who complained of nausea. CONCLUSIONS: When added to a fixed dose of buprenorphine, continuous extradural infusion of 2% lignocaine at high rate provides better postoperative analgesia than when given at low rate without producing significant side effects.

Evaluation of activated eosinophil infiltration for the assessment of the effect of chemosurgical treatment for allergic rhinitis using trichloroacetic acid.

An immunohistochemical study was made on the degree of activated eosinophil (EG2) infiltration in the inferior turbinate of 20 cases of perennial allergic rhinitis who underwent septal reconstruction and bilateral inferior turbinectomy approximately 5 months after the unilateral application of trichloroacetic acid (TCA). The distribution of EG2 was also evaluated in nasal smears obtained from the same subjects, and a comparison was made between TCA-applied and nonapplied sides. It was found that the number of EG2 was significantly decreased in the TCA-applied side. It was assumed that TCA application successfully suppressed reagin-dependent allergic reaction in the tissues.

Continuous brachial plexus infusion of butorphanol-mepivacaine mixtures for analgesia after upper extremity surgery.

We have recently reported that continuous administration of butorphanol into the brachial plexus neurovascular sheath provided superior analgesia compared with that obtained with continuous i.v. administration. Furthermore, we found that analgesia was most pronounced when a mixture of mepivacaine and butorphanol was given and that butorphanol alone ranked next. In this study, we increased the dose of butorphanol, compared with that used in our previous reports, and an initial bolus dose of butorphanol was administered into the brachial plexus neurovascular sheath just after surgery had ended. Thereafter, postoperative pain relief was estimated. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, group A received a bolus of 1 ml of physiological saline with 1.5% mepivacaine, 10 ml into the brachial plexus sheath followed by a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/ 72 h. Group B was given a bolus of butorphanol 1 mg (1 ml) with 1.5% mepivacaine, 10 ml into the brachial plexus sheath and a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/72 h. After operation, VAS scores did not differ between the two groups. The time to first use of supplementary analgesia did not differ significantly between the two groups and there were no significant differences in the number of patients who required supplementary analgesia. These results indicate that continuous butorphanol 2 mg day-1 with 0.5% mepivacaine provided sufficient postoperative analgesia after upper limb surgery.

Suppression of the human carcinoma phenotype by an antioncogene ribozyme.

A spectrum of oncogenes have been identified and are thought to be associated with the progression of neoplasia. These oncogenes include the following: growth factors/receptors, kinases, nuclear proteins (i.e., Fos/Jun), and tumor suppressor genes. Perturbation of one or more of these genes can transform normal cells into invasive/metastatic cancer cells. Understanding the role of these oncogenes for specific types of cancer may lead to a more rational basis for tissue-specific targets in cancer gene therapy.

Dobutamine infusion modifies thermoregulation during general anesthesia.

A redistribution of body heat from core to peripheral tissues causes a rapid decrease in core temperature. The present study tested whether a dobutamine infusion would facilitate redistribution and induce a further decrease in core temperature. Volunteers were randomly assigned to the control group (n = 8) and the experimental group (n = 8). They were anesthetized with isoflurane at an end-tidal concentration of near 1.2% for 120 min. In the experimental group, dobutamine was infused at a rate of 4 micrograms.kg-1.min-1. Core temperature, skin temperature, tissue temperature, and laser-Doppler perfusion index were measured. Leg heat content was calculated by morphometric data and observed temperatures. The decrease in leg heat content was larger in the control group than in the experimental group 30 min after anesthetic induction (P < 0.05). In contrast, the core temperature decreased further in the dobutamine group than in the control group 40 min after induction (P < 0.05). Dobutamine induced further hypothermia, presumably by facilitating heat transfer and by increasing cutaneous heat loss. Hypothermia will be increased when using dobutamine for anesthesia.

[Linear polarized light irradiation around the stellate ganglion area increases skin temperature and blood flow].

We evaluated the effect of linear polarized light irradiation with a SUPER LIZER around the stellate ganglion area on skin temperature and blood flow in healthy adult volunteers. We carried out two experiments (study I and study II). In study I, we investigated one-sided irradiation around the stellate ganglion area or posterior neck on the skin temperature of the bilateral nasus externi and earlobes. In study II, we investigated one-sided irradiation around the stellate ganglion area or posterior neck on the skin temperatures of both hands and skin blood flow on the irradiated side. In study I, irradiation around the stellate ganglion area increased skin temperature on the irradiated sides of the nasus externi (wings of the nose), and in study II, skin temperature and blood flow were increased on the irradiated side of the hands. These results suggest that linear polarized light irradiation with a SUPER LIZER around the stellate ganglion area would be useful and beneficial in clinical therapy.

Hearing recovery and its process from the time of onset in sudden deafness.

A total of 547 patients with idiopathic sudden hearing loss were divided into eight groups according to the days (1-8 days) of their initial visit after onset, and initial hearing thresholds, hearing recovery and its process were investigated. There were no significant differences in initial hearing thresholds and hearing recovery among the eight groups. However, a difference was noticeable in the distribution of the thresholds at the initial visit and that on the 7th day between groups 1, 2 and 7. Many cases showed rapid recovery in groups 1, 2 and 7. We speculate that the treatment influenced the hearing recovery process in patients who showed relatively rapid recovery.

Idiopathic bilateral sensorineural hearing loss: its clinical study in cases with rapidly progressed deafness.

In a series of 127 patients with idiopathic bilateral sensorineural hearing loss (IBSH) at the Hearing Clinic in the Department of Otolaryngology, Kitasato University Hospital, 20 cases showed rapid progression of hearing impairment. These patients had been treated with the same therapeutic regimen used in sudden deafness (SD). Improvement of hearing loss after treatment was generally less effective in the cases with rapidly progressed IBSH than in the cases with SD. However, hearing improvement was achieved in some cases with rapidly progressed IBSH when the treatment had started in the early stages after the onset of rapidly progressive hearing loss.

Effectiveness of fibronectin in myringoplasty using temporal fascia.

A study of myringoplasty with temporal fascia homograft employing fibronectin was conducted in 14 ears in which the same myringoplasty procedure without fibronectin (1-5 times) had failed to afford closure of tympanic membrane perforation. Closure was obtained in eight ears. These results suggest that fibronectin is effective in myringoplasty using treated temporal fascia homograft.