[A woman with hypoxia after shoulder arthroscopy]. / Een vrouw met hypoxie na artroscopie van de schouder.

A 58-year-old female with a history of obesity, smoking and hypertension underwent shoulder arthroscopy. Prior to the arthroscopy, patient received an interscalene brachial plexus block. After the arthroscopy, patient had an oxygen saturation of 85%, caused by an unilateral diaphragm paralysis due to a phrenic nerve block.

Duloxetine in patients with central neuropathic pain caused by spinal cord injury or stroke: a randomized, double-blind, placebo-controlled trial.

The mechanisms underlying central neuropathic pain are poorly understood. Pain inhibitory mechanisms including sertononergic and norepinephrine systems may be dysfunctional. In this randomized, double-blinded, placebo-controlled trial we evaluated the effects of duloxetine on pain relief (spontaneous pain and evoked pain), tolerability, health status, and quality of life in patients with central pain related to cerebrovascular lesions or spinal cord lesions. At baseline and eight weeks following start of treatment subjects were evaluated with standard measures of efficacy: pain intensity (primary efficacy variable), quantitative sensory testing, health status and quality of life (secondary efficacy variables). Forty-eight patients received escalating doses of either duloxetine (60 and 120mg/day) or matching placebo capsules. In both groups, patients started with 1 capsule per day. If pain relief was insufficient, patients were titrated to a higher dose. A trend towards a decrease in mean pain score after eight weeks was observed for duloxetine treatment (p=0.056). Duloxetine alleviated dynamic (p=0.035) and cold allodynia (p<0.001) significantly better than placebo. Tactile pain and pressure pain thresholds did not improve significantly. The duloxetine group showed a significant improvement for the bodily pain domain of the SF36 (p=0.035). No significant differences were observed in the other domains of the SF36, the Pain Disability Index, and the EQ-5D. While this trial showed no significant effect on pain intensity, duloxetine revealed a biologic effect. It would be worthwhile to suspend our judgement and to perform more studies to evaluate the role of duloxetine in modulation of the symptoms of central neuropathic pain.

Pregabalin in patients with central neuropathic pain: a randomized, double-blind, placebo-controlled trial of a flexible-dose regimen.

The effective treatment of patients suffering from central neuropathic pain remains a clinical challenge, despite a standard pharmacological approach in combination with anticonvulsants and antidepressants. A randomized, double-blinded, placebo-controlled trial evaluated the effects of pregabalin on pain relief, tolerability, health status, and quality of life in patients with central neuropathic pain caused by brain or spinal cord injuries. At baseline and 4 weeks after the start of treatment subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analog scale, health status (Pain Disability Index and EQ-5D) and quality of life (SF-36). Forty patients received escalating doses of either pregabalin (150, 300, and 600mg/day) or matching placebo capsules. In both groups, patients started with 1 capsule per day (either 150mg of pregabalin or placebo). If pain relief was insufficient, patients were titrated to a higher dose. There was a statistically significant decrease in mean pain score at endpoint for pregabalin treatment, compared with placebo (P=0.016). Follow-up observation showed no significant difference in Pain Disability Index scores between the two groups. The pregabalin group, however, showed a statistically significant improvement for the EQ-5D. Pregabalin treatment led to a significant improvement in the bodily pain domain of the SF36. In the other domains, more favorable scores were reported without reaching statistical significance. Pregabalin, in a flexible-dose regime, produced clinically significant reductions in pain, as well as improvements in health status in patients suffering from severe central neuropathic pain.

[Psychiatric and neuropsychological characterization of a group of adults referred to a university outpatient clinic for ADHD]. / Psychiatrische en neuropsychologische kenmerken van een groep volwassenen verwezen naar een academische polikliniek voor ADHD.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) has always been classified as a psychiatric disorder of childhood. Very little research has been done into the nature of adult ADHD. AIM: To obtain insight into the clinical profile of a group of adults referred to an outpatient clinic for diagnostic assessment of ADHD. METHOD: A group of 225 adults diagnosed with ADHD were studied and compared with 101 adults who had been referred to the same outpatient clinic but had been given a different diagnosis. All referred patients were diagnosed according to dsm-iv criteria for ADHD and underwent neuropsychological tests. RESULTS: The diagnosis of ADHD was confirmed in 69% of the patients. In the ADHD group 72% were male and the average age was 32. Half of these patients had a co-morbid disorder. The 2 groups did not differ in psychopathology but the ADHD group used nicotine and alcohol more frequently. Neuropsychological tests revealed more signs of subjective distractibility in the non-ADHD group, whereas in the objective tests it was the ADHD group who gave a poorer performance. CONCLUSION: This study describes the clinical profile of a group of adults referred to an outpatient clinic for ADHD. The ADHD group differed from the non-ADHD group in a number of demographical, psychiatric and neuropsychological parameters.

[Coeliac plexus block in patients with pancreatic tumour pain]. / Blokkade van de plexus coeliacus bij patiënten met pijn door een pancreastumor.

Pancreatic cancer tends to be diagnosed at a relatively late stage of the disease when curative resection is precluded. In view of the poor prognosis and the severe pain, palliative care should be aimed at providing adequate pain relief and optimal quality of life. Pancreatic cancer pain is primarily treated by the combination of NSAIDs, adjuvant analgesic drugs, and oral or transdermal opioids. The neurolytic coeliac plexus block is recommended as adjuvant therapy for the palliative treatment of pancreatic cancer pain. In addition quality of life, especially functional and physical aspects, is significantly improved in patients following a coeliac plexus block. The most common approach to the coeliac plexus is the percutaneous posterior technique. Serious complications that may follow application of this technique include sensory disorders, muscle weakness and paraparesis. More recently, new techniques such as thoracoscopic splanchnicectomy and endoscopic ultrasound-guided coeliac plexus block have emerged as efficient alternatives in terms of pain relief and quality-of-life improvement. The neurolytic coeliac plexus block has become a well-developed method of pain relief in patients with pain resulting from malignancies of the pancreas. To define the role of these new techniques in the palliative treatment of pancreatic cancer pain, comparative studies regarding efficacy, side effects, and complications have to be performed.

Iontophoretic administration of S(+)-ketamine in patients with intractable central pain: a placebo-controlled trial.

The efficacy of 50 and 75 mg S(+)-ketamine administered daily by an iontophoresis-assisted transdermal drug delivery system was tested against placebo in a randomized, double-blind design in 33 patients with central neuropathic pain. At baseline and 1 week after the start of treatment subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analog scale (VAS), health status (Pain Disability Index and EQ-5D) and quality of life (SF-36). Safety assessment included incidence and intensity of adverse events. No significant differences in pain scores (VAS) were observed between the ketamine groups and placebo during the course of the trial. Corrected for baseline levels, daily 50 mg S(+)-ketamine did not improve patient's health status or quality of life compared with placebo treatment. However, daily 75 mg S(+)-ketamine showed significant improvements on the Pain Disability Index, on the EQ-5D, and on the SF-36 except for the role-physical functioning and general health perception. Iontophoretic administration of S(+)-ketamine was well tolerated with a low incidence of adverse events (mild and transient in nature, resolving spontaneously). Iontophoretic administration of S(+)-ketamine was not more effective than placebo treatment in reducing pain scores in patients with severe central neuropathic pain. However, iontophoretic administration of 75 mg S(+)-ketamine improved the health status and the quality of life in these patients.

Neuropathological findings after continuous intrathecal administration of S(+)-ketamine for the management of neuropathic cancer pain.

Questions have been raised about the potential neurotoxicity of the neuraxial use of ketamine although ketamine and its active enantiomer S(+)-ketamine have been used intrathecally and epidurally (caudally) for the management of perioperative pain and in a variety of chronic pain syndromes. Clinical experience following neuraxial administration of S(+)-ketamine has been documented without reference to local central nervous system toxicity following this approach. In addition, there are no preclinical safety data regarding stability, compatibility, and neurotoxicity on intrathecal use of single S(+)-ketamine or combinations of S(+)-ketamine, morphine, bupivacaine, and clonidine. In the present case, the continuous intrathecal administration of S(+)-ketamine, in combination with morphine, bupivacaine, and clonidine resulted in adequate pain relief in a patient suffering from intractable neuropathic cancer pain. However, postmortem observation of the spinal cord and nerve roots revealed severe histological abnormalities including central chromatolysis, nerve cell shrinkage, neuronophagia, microglial upregulation, and gliosis. Based on our results, neuraxial administration of S (+)-ketamine cannot be recommended for clinical practise before a systematic study of toxicology of neuraxial S(+)-ketamine in animals or humans has been performed.

Plasma concentrations of meperidine and normeperidine following continuous intrathecal meperidine in patients with neuropathic cancer pain.

BACKGROUND: Intrathecal administration of meperidine, an opioid with local anesthetic activity, can induce analgesia in patients with intractable cancer pain. However, continuous intrathecal administration may result in the accumulation of normeperidine, responsible for central nervous system toxicity. METHODS: Ten patients with neuropathic cancer pain, not responding to conventional opioid therapy, were treated with continuous intrathecal administration of meperidine. In all patients, plasma concentrations of meperidine and normeperidine were measured the first days after the start of treatment. Visual analog scale scores were recorded to evaluate pain relief. Quality of life was assessed before and 3 weeks following the start of intrathecal treatment. RESULTS: In three patients the plasma concentrations of meperidine and normeperidine increased rapidly. In one patient the plasma normeperidine concentration was higher than the meperidine concentration. One patient demonstrated transient symptoms suggestive for central nervous system excitation. Three weeks following the start of treatment, seven patients were available for evaluation of their quality of life. Pain relief and overall quality of life improved during the intrathecal treatment. CONCLUSION: We conclude that continuous intrathecal administration of meperidine alone, or in combination with clonidine, can provide significant pain relief in patients with poor pain control despite pharmacological treatment. However, accumulation of meperidine and normeperidine resulting in central nervous system toxicity may occur during this treatment.

Treatment of neuropathic cancer pain with continuous intrathecal administration of S +-ketamine.

The effective treatment of patients suffering from neuropathic cancer pain remains a clinical challenge. When patients experience either insufficient analgesia or problematic side-effects after opioid administration, intrathecal administration of morphine and other medications such as bupivacaine and clonidine may offer significant advantages. Additionally, ketamine, a non-competitive N-methyl-D-Aspartate-receptor antagonist is able to alter pain perception at the spinal level. Because of the potential neurotoxicity after neuraxial use of racemic ketamine, intrathecal administration of the preservative-free active compound, S (+)-ketamine may be a valuable alternative. In this paper, we present a patient with severe neuropathic cancer pain successfully treated by continuous intrathecal infusion of morphine, bupivacaine, clonidine and S (+)-ketamine. Moreover, quality of life measurements before and 3 weeks after the start of spinal treatment revealed an improvement in pain relief and a higher overall quality of life. No clinical signs of neurologic deficit were observed during spinal treatment with S (+)-ketamine. However, the continuous intrathecal administration of S (+)-ketamine should be considered as the last resort because there are no preclinical safety data with relevant concentrations on intrathecal use of S (+)-ketamine.

Continuous brachial plexus block at the cervical level using a posterior approach in the management of neuropathic cancer pain.

BACKGROUND AND OBJECTIVES: Neuropathic cancer pain due to tumor growth near the brachial plexus is often treated with a combination of nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, and oral or transdermal opioids. We propose placement of a catheter along the brachial plexus using a posterior approach for patients not responding to the above-mentioned treatment. CASE REPORT: We describe 2 patients with neuropathic cancer pain in the arm and shoulder despite treatment with dexamethasone, amitriptyline, gabapentin, opioids, and, in 1 patient, oral ketamine. An increase in daily opioid dosage did not relieve the pain but caused unacceptable side effects of nausea, vomiting, and sedation. Continuous administration of local anesthetics via a brachial plexus catheter inserted at the cervical level using a posterior approach resulted in a markedly improved analgesia and decreased opioid requirement. CONCLUSION: Continuous brachial plexus block should be considered in patients with severe neuropathic cancer pain in the arm and shoulder. To achieve sufficient pain relief for prolonged periods of time, a catheter was inserted to block the brachial plexus using a posterior approach. This technique may be a valuable alternative to the interscalene approach because of the improved fixation of the catheter in the muscle sheet of the trapezius, splenius cervicus, and levator scapulae muscles, and the decreased likelihood of catheter dislodgment during neck movements.

An evaluation of a modified Macintosh laryngoscope in a manikin.

PURPOSE: In this manikin study a modified Macintosh blade was prospectively compared with its original focussing on the forces exerted on the maxillary incisor teeth and intubation success. The modified blade, a standard Macintosh blade with a reduced proximal flange, was intended to reduce the forces exerted on the maxillary incisors. METHODS: A manikin equipped with two sensors, to measure forces applied to the maxillary incisors in the axial and the transverse direction, was used. Fourteen staff anaesthetists and 16 residents each performed two laryngoscopies with both blades. RESULTS: All laryngoscopies resulted in successful tracheal intubation. The maximal and mean forces exerted on the teeth in the axial direction were 12 N and 5.8 N smaller (P < 0.0005 and P < 0.0005, respectively) when the modified blade was used. CONCLUSION: The use of the modified blade resulted in a reduction of the forces on the maxillary incisors whereas the intubation success rate was the same as with the original. Studies in manikins can be useful in comparative laryngoscope testing.

Reshaping the Macintosh blade using biomechanical modelling. A prospective comparative study in patients.

It has been demonstrated that during routine use of the Macintosh blade, great forces are exerted on the maxillary incisors. The aim of this study was, by using biomechanical modelling, to modify a standard Macintosh blade in order to reduce these forces. This resulted in a Macintosh blade with a reduced proximal flange. Five anaesthetists performed tracheal intubation in 46 patients using the modified (n = 24) or the standard blade (n = 22). The mean (SD) maximal forces exerted on the maxillary incisors were 12.7 (8.8) N in patients in the modified Macintosh group compared to 25.5 (17.8) N in the standard Macintosh group (p = 0.008). These results demonstrate that reducing the proximal step of the Macintosh laryngoscope results in a reduction of the forces exerted on the teeth and suggest that laryngoscope blades with a high proximal step might be more traumatic than blades in which the proximal step is reduced.

An open study of triiodothyronine augmentation of tricyclic antidepressants in inpatients with refractory depression.

Several studies, mainly performed in outpatients, suggest that triiodothyronine (T3) addition may convert depressed patients who are nonresponders to tricyclic antidepressants (TCAs) into responders. This study is to our knowledge the first study of T3 augmentation performed in severely depressed inpatients. In our study no evidence for the efficacy of adjunctive T3 treatment was found in a sample of 14 inpatients. T3 augmentation was performed over a four-week period; during the last three weeks the daily dosage was 37.5 micrograms. The patients involved were suffering from refactory depression and previously had not responded to an adequate six-week course of treatment with a TCA (mainly nortriptyline). Many of the patients were suffering from depression with melancholic and/or psychotic features. During follow-up, eleven of the patients responded to further treatment with either an MAOI or electroconvulsive therapy.

Transverse forces exerted on the maxillary incisors during laryngoscopy.

PURPOSE: In this study the effect of level of experience of the intubator on the forces applied by the Macintosh laryngoscope on the maxillary incisors in both the axial and transverse direction were investigated. METHODS: Five groups of different levels of experience (15 per group), staff anaesthetists, residents, nurse anaesthetists, surgeons and students, performed one laryngoscopy and subsequent intubation on an intubation manikin equipped with sensors to measure these forces. RESULTS: Maximal transverse forces oriented toward the base of the skull (Fmtpmax) were between 0 and 10 N in 46 cases (61%), between 10 and 20 N in 21 (28%) and > or = 20 N (maximum 46.5 N) in eight cases (11%). The maximal values of the transverse forces oriented toward the intubator (Fmtnmax) were between 0 and 10 N in 69 cases (92%), between 10 and 20 N in 3 (4%) and > or = 20 N (maximum 36.4 N) in 3 (4%). Level of experience was related to Fmtpmax (Spearman: P = 0.04, r = 0.24). In addition, Fmtnmax was less in experienced intubators (anaesthetist and residents) than in inexperienced intubators (all other groups) (Student's t test: P = 0.04). CONCLUSION: In contrast to the effect on forces exerted in the axial direction, experience proved to have a beneficial effect on the forces in the transverse direction.

The use of thyroid hormone in the treatment of depression: a review.

The writers of this paper made an inventory of the studies on the use of thyroid hormone in the treatment of depression. Fifteen clinical trials (353 patients), published between 1969 and 1987. were found, that can be described, as to their design, in two seperate groups: One group (7 studies) administers thyroid hormone simultaneously with a tricyclic antidepressant to reach a faster effect of the antidepressant. The other group (8 studies) adds thyroid hormone to a tricyclic antidepressant in patients who fail to respond to this treatment, with the aim to convert therapeutic failure to success. After studying the literature we think we are able to conclude that it can be usefull to combine the antidepressant with thyroid hormone in view of the fact that, in a number of depressed patients, it shortens the duration of the illness. The augmentation of tricyclics by thyroid hormone needs further study.

Characterization of tumour cells in malignant fibrous histiocytomas and other soft tissue tumours in comparison with malignant histiocytes. I. Immunohistochemical study on paraffin sections.

We have studied the possible origin of histiocytic cells, present in fibrous histiocytomas (MFH) by using immunohistochemistry to demonstrate lysozyme, alpha 1-antitrypsin, alpha 1-antichymotrypsin and receptors for peanut and soy bean agglutinin in tumour cells of MFH compared with their presence in tumour cells of malignant histiocytosis (MH) ('true' histiocytic lymphoma, 'true' histiocytic sarcoma). We included in this study a number of other soft tissue tumours (STT). Lysozyme was detected in half of the cases of malignant histiocytosis (n = 16) but in only two out of 77 MFH. alpha 1-Antitrypsin and alpha 1-antichymotrypsin usually occurred together although the latter was seen in more cases. Both markers were present in majority of cases of MH whereas they were detected in a minority of cases of MFH. MFH cases of the storiform subtype were less frequently stained than the pleomorphic or giant cell subtypes. Receptors for peanut or soy bean agglutinin were detected in nearly all MH cases, whereas their presence was only detected in a small number of MFH. Lysozyme was not detectable in other STT. alpha 1-Antitrypsin and alpha 1-antichymotrypsin were uncommonly present in other STT, except in osteosarcoma and rhabdomyosarcoma. These markers therefore have a limited value as indicators of a possible histiocytic origin of MFH. Lectins showed weak affinity for other STT. In accordance with others, we therefore conclude that the progenitor cell of MFH has to be sought within the undifferentiated mesenchymal cells and that histiocytes themselves probably do not give rise to MFH.