Children with stable asthma have reduced airway matrix metalloproteinase-9 and matrix metalloproteinase-9/tissue inhibitor of metalloproteinase-1 ratio.

BACKGROUND: Childhood asthma is characterized by inflammation of the airways. Structural changes of the airway wall may also be seen in some children early in the course of the disease. Matrix metalloproteinases (MMPs) are key mediators in the metabolism of the extracellular matrix (ECM). OBJECTIVE: To investigate the balance of MMP-8, MMP-9 and tissue inhibitor of metalloproteinases (TIMP)-1 in the airways of children with asthma. METHODS: One hundred and twenty-four children undergoing elective surgical procedures also underwent non-bronchoscopic bronchoalveolar lavage (BAL). MMP-8, MMP-9 and TIMP-1 were measured by ELISA. RESULTS: There was a significant reduction in MMP-9 in atopic asthmatic children (n=31) compared with normal children (n=30) [median difference: 0.57 ng/mL (95% confidence interval: 0.18-1.1 ng/mL)]. The ratio of MMP-9 to TIMP-1 was also reduced in asthmatic children. Levels of all three proteins were significantly correlated to each other and to the relative proportions of particular inflammatory cells in BAL fluid (BALF). Both MMP-8 and MMP-9 were moderately strongly correlated to the percentage neutrophil count (r=0.40 and 0.47, respectively, P<0.001). CONCLUSIONS: An imbalance of MMPs and their inhibitors occurs in children with well-controlled asthma, which may indicate early derangement of the metabolism of the ECM.

Respiratory failure in myasthenia gravis and negative pressure support.

A young female whose pyridostigmine treatment had recently been changed presented with myasthenia gravis, acute respiratory failure, and respiratory infection. She was supported with a noninvasive negative pressure cuirass device as an aid to optimizing medical therapies without the confounding factor of pharmacology-induced sedation and analgesia.

Postoperative epidural infusion of a mixture of bupivacaine 0.2% with fentanyl for upper abdominal surgery. A comparison of thoracic and lumbar routes.

Thirty-three patients who had undergone elective open cholecystectomy were studied in a prospective, randomised comparison of thoracic (n = 17) and lumbar (n = 16) epidural routes of administration of a mixture of bupivacaine 0.2% with fentanyl 10 micrograms.ml-1 for postoperative pain. Pain relief, cardiovascular stability, respiratory rate and side effects were assessed by a 'blinded' observer at specific times in the 24 h study period. The thoracic epidural route proved significantly more reliable than the lumbar and provided effective analgesia in all patients (p < 0.05). This was not accompanied by significant hypotension or respiratory depression. The incidence of side effects attributable to use of the lumbar epidural route was significantly higher than with the thoracic route (p < 0.05). This study supports the use of the thoracic epidural route for postoperative pain management after upper abdominal surgery.

Anticholinergic prophylaxis does not prevent emesis following strabismus surgery in children.

One hundred and twenty-one children were studied in this prospective, randomized double-blind, placebo-controlled comparison of the effectiveness of anticholinergic prophylaxis for the prevention of emetic symptoms following strabismus surgery. The children were allocated to three groups, to receive placebo (n = 40), glycopyrrolate (n = 40) or atropine (n = 41). The incidence of intraoperative oculocardiac reflex (OCR) and of postoperative emetic symptoms for 24 h was recorded. The incidence of OCR was 55% in the placebo group compared with 5% and 2% in the glycopyrrolate and atropine groups respectively (P < 0.05). Thirty percent (12/40) of patients in the placebo group, 25% (10/40) in the glycopyrrolate group, and 22% (9/41) in the atropine group experienced nausea and/or vomiting (difference not significant). It is concluded that prophylactic administration of anticholinergic agents during strabismus surgery in children despite being effective against the occurrence of the oculocardiac reflex, does not reduce the incidence of emetic symptoms.

Thoracic epidural analgesia compared with patient controlled intravenous morphine after upper abdominal surgery.

Twenty-one ASA I or II patients undergoing upper abdominal surgery were studied for 24 hours after operation. They were entered into a prospective, randomised study of patient-controlled intravenous morphine compared with continuous thoracic epidural fentanyl combined with 0.2% bupivacaine. Pain relief was superior in the bupivacaine series (P < 0.05) throughout the 24 hour study period and this was associated with significantly greater pulmonary ventilation compared with the PCA series. Forced expiratory parameters were reduced in both series after the operation but significantly less so in the epidural group. There was a reduced incidence of emetic symptoms in the epidural group (P < 0.05) but the incidence of other minor side effects did not differ significantly. Thoracic epidural fentanyl/bupivacaine results in significantly better analgesia than patient-controlled intravenous morphine.

Thoracic epidural infusion for postoperative pain relief following abdominal aortic surgery: bupivacaine, fentanyl or a mixture of both?

Thirty patients who had undergone elective abdominal aortic surgery were studied in a prospective, randomised double-blind comparison of thoracic epidural 0.2% bupivacaine alone, thoracic epidural fentanyl alone and thoracic epidural 0.2% bupivacaine combined with fentanyl. Pain relief, pulmonary function, cardiovascular stability and side effects were assessed. Pain relief was excellent in the combined bupivacaine-fentanyl series, being significantly better than the other groups (p less than 0.05) during the entire study period and was not accompanied by hypotension. Forced expiratory parameters were reduced in all groups throughout the study to 50-60% of the pre-operative values, but there were no significant differences between groups. The incidence of side effects attributable to either epidural bupivacaine or fentanyl was low. This study supports the increasing use of epidural infusion analgesia for postoperative pain management after abdominal surgery.

Continuous thoracic epidural fentanyl for post-thoracotomy pain relief: with or without bupivacaine?

Twenty-five ASA 1 or 2 patients undergoing thoracotomy were entered into a prospective, randomised, double-blind study comparing thoracic epidural fentanyl alone and thoracic epidural fentanyl combined with 0.2% bupivacaine. Pain relief, pulmonary function and cardiovascular stability were assessed. Pain relief was superior in the bupivacaine series (p less than 0.05) during the first day after operation and this was accompanied by better oxygenation (p less than 0.05); the difference did not persist into the second day. Forced expiratory variables were reduced in both series to 50-60% of the values before operation throughout the study (p less than 0.05) and differences did not occur between the groups. The incidence of side effects attributable to epidural fentanyl was high, but hypotension did not occur. Small doses of bupivacaine administered together with fentanyl into the thoracic epidural space improve analgesia without causing hypotension.

Audit in intensive care. The APACHE II classification of severity of disease.

The Acute Physiology and Chronic Health Evaluation System (APACHE II) was used in 451 patients admitted to the intensive care unit, Belfast City Hospital, in 1988 and 1989. Mortality in the patients studied was 15.5% which is slightly less than that predicted for patients with equal severity of disease (18.8%). Within the limitations discussed the APACHE II system has valuable potential both in terms of predictive power and as a means of audit.