Regional anaesthesia for major orthopaedic trauma surgery in patients with conservatively managed pneumothoraces.

The anaesthetic management of multiple traumatic injuries poses numerous challenges. In this report, we present the cases of two patients with polytrauma including pneumothoraces and multiple rib fractures. The first patient, a 39-year-old man, presented with multiple left upper limb fractures, multiple bilateral rib fractures, bilateral pneumothoraces and fractures of multiple facial and cranial bones. The second patient, a 39-year-old woman, presented with right-sided radial and ulnar fractures, a right-sided pelvic fracture, and multiple right-sided rib fractures with an associated pneumothorax. We used ultrasound-guided superficial cervical plexus, interscalene and supraclavicular blocks in the first case and a combined spinal and epidural after ultrasound-guided fascia iliaca and supraclavicular blocks in the second case. In both cases, the use of multiple regional techniques allowed us to avoid the risks of general anaesthesia in patients with conservatively managed pneumothoraces.

Displaced Supracondylar Humerus Fractures in Children - Are They All Identical?

Introduction: This study aims to ascertain if there are any differences in supracondylar fractures between children under seven years of age and those above 7 years of age. Materials and Methods: All cases of displaced humerus supracondylar fractures that required surgical stabilization were identified and retrospectively reviewed. Demographic data, mode of injury, associated neurovascular injuries and details of surgery performed were obtained from clinical records. The Gartland classification and the extent of comminution of fractures were also documented from review of radiographs. Results: One hundred and twelve children were included in this study, of whom 61 (54.46%) were younger than seven years of age while 51 (45.5%) were aged seven years or older. Children aged seven or older had a greater incidence of associated neurological deficit at presentation (p=0.046). Of the six patients with nerve injury in the older age group, one patient (16.7%) had a radial nerve injury, two patients (33.3%) had ulnar nerve injuries while another two patients (33.3%) had median nerve injuries. There was one patient (16.7%) with both median and ulnar nerve injuries. Comminuted fractures were also more common in the older children (p=0.004). No significant differences were demonstrated between the groups with regard to age, gender and mechanism of injury, laterality, incidence of open fracture, vascular injuries and operative time. Conclusion: Children aged seven years or older who sustain supracondylar humeral fractures tend to get more comminuted fractures. There is also a higher incidence of associated neurological injury. These cases must be carefully examined for at presentation and parents need to be appropriately counselled about them.

Phenotypical and functional characteristics of mesenchymal stem cells derived from equine umbilical cord blood.

Mesenchymal stem cells (MSCs) offer promise as therapeutic aid in the repair of tendon and ligament injuries in race horses. Fetal adnexa is considered as an ideal source of MSCs due to many advantages, including non-invasive nature of isolation procedures and availability of large tissue mass for harvesting the cells. However, MSCs isolated from equine fetal adnexa have not been fully characterized due to lack of species-specific markers. Therefore, this study was carried out to isolate MSCs from equine umbilical cord blood (UCB) and characterize them using cross-reactive markers. The plastic-adherent cells could be isolated from 13 out of 20 (65 %) UCB samples. The UCB derived cells proliferated till passage 20 with average cell doubling time of 46.40 ± 2.86 h. These cells expressed mesenchymal surface markers but did not express haematopoietic/leucocytic markers by RT-PCR and immunocytochemistry. The phenotypic expression of CD29, CD44, CD73 and CD90 was shown by 96.36 ± 1.28, 93.40 ± 0.70, 73.23 ± 1.29 and 46.75 ± 3.95 % cells, respectively in flow cytometry, whereas, reactivity against the haematopoietic antigens CD34 and CD45 was observed only in 2.4 ± 0.20 and 0.1 ± 0.0 % of cells, respectively. Osteogenic and chondrogenic differentiation could be achieved using established methods, whereas the optimum adipogenic differentiation was achieved after supplementing media with 15 % rabbit serum and 20 ng/ml of recombinant human insulin. In this study, we optimized methodology for isolation, cultural characterization, differentiation and immunophenotyping of MSCs from equine UCB. Protocols and markers used in this study can be employed for unequivocal characterization of equine MSCs.

Evaluation of intubating conditions in children after sevoflurane induction using propofol or rocuronium bromide--a randomised, prospective, double blind study.

BACKGROUND: The use of sevoflurane without muscle relaxant for tracheal intubation has been widely investigated in children. Non-depolarizing neuromuscular blockers have long duration of action and do not provide rapid return of spontaneous ventilation. Use of suc-cinylcholine has been found to be associated with various side-effects especially in children. Therefore, we aim to evaluate the effect of propofol 1.5 mg/kg without muscle relaxant, on intubating conditions in children 2-8 yrs of age and we compare them with those achieved with rocuronium 0.6 mg/kg, at moderate sevoflurane concentration. METHODS: Fifty children between 2-8 yrs, ASA I or II scheduled for elective surgery were randomly allocated to either Group P (propofol) or group R (rocuronium). After premedication with oral midazolam 0.5 mg/kg 30 min before surgery, anaesthesia was induced with 8% sevoflurane in oxygen. Intravenous fentanyl 1 µg/kg was administered after securing intravenous access and dial concentration of sevoflurane was reduced to 4%. At one minute with regards to time T0, the patients received the drug which was either intravenous rocuronium 0.6 mg/kg or an equal volume of 0.9% saline (D) and at three minutes (two minutes after D1), second drug (D2) was given, which was either propofol 1.5 mg/kg or an equal volume of 0.9% saline according to the group allocated. At four minutes, laryngoscopy was done and intubation performed with appropriate sized uncuffed endotracheal tube. Incidence of acceptable and excellent intubating conditions, time to intubation and hemodynamic parameters were recorded. RESULTS: Incidence of acceptable or excellent intubating conditions was similar in both groups (p = 1.00). The difference in time to intubation was statistically not significant (25.03 ± 6.05s in Group P and 24.38 ?5.58s in Group R, p = 0.694), at similar end-tidal concentration of sevoflurane (3.2 ± 0.20% in Group P and 3.1 ± 0.20% in Group R, p = 0.12). CONCLUSION: Propofol (1.5 mg/kg) and rocuronium (0.6 mg/kg) produced similar intubating conditions in children induced with sevoflurane.

An indigenously developed method for sweat collection and estimation of chloride for diagnosis of cystic fibrosis.

An indigenously developed method for sweat collection and titration method for estimation of chloride was validated. The mean difference in estimated chloride value from the known strength of saline in 50 samples was -1.04 +/- 4.13 mEq/L (95% CI: -0.07 to 2.28). The mean difference in the estimated chloride values between two observers when the test was performed on known strengths of saline solution was -2.5 +/- 4.24 mEq/L (95% CI: -3.67 to 1.33). The inter observer variability between two observers when the test was performed on sweat samples obtained from 50 individuals was -1.12 +/- 4.34 mEq/L (95% CI: -2.23 to 0.8 ). Sweat weight of more than 100 mg could be collected in first attempt in 602 of 757 (80%) patient with an average sweat weight of 230 mg. This inexpensive method of sweat collection and chloride estimation has acceptable accuracy and repeatability and can be used in resource poor setting for making a diagnosis of cystic fibrosis.

Congenital myotonic dystrophy.

Myotonic muscular dystrophy is the most frequent autosomal muscular dystrophy affecting adults and children. It affects multiple organ systems and is probably the best example of variable expressivity in a human disease. This article presents a patient with congenital myotonic dystrophy who had facial dysmorphism, hypotonia, talipes, feeding and respiratory difficulties in the neonatal period and later presented to us with developmental delay and had percussion myotonia. His mother had clinical and electrophysiological features of myotonia. Expansion of unstable CTG trinucleotide repeat in the myotonic protein kinase gene was demonstrated in both. The identification of this molecular defect allows its specific diagnosis in relation to other neuromuscular disorders as well as accurate prenatal diagnosis.

Infantile-onset leukoencephalopathy with discrepant mild clinical course.

Four children characterised by megalencephaly and cerebral leukoencephalopathy with infantile onset, defined on the basis of clinical and neuroimaging findings are reported. The course of the disease is characterised by stabilization of the macrocephaly and slow clinical deterioration. The CT scan findings include supratentorial diffuse hypodensities in the white matter and swelling. The characteristic MRI findings include the discrepant severity in comparison with the clinical picture, diffuse supratentorial white matter abnormalities with subcortical cysts. The basic defect of the disease is unknown. Considering the high rate of consanguinity among the parents and the presence of two affected sibs in one family, an autosomal recessive inheritance is assumed. We report four unrelated cases of this entity.

Voltage- and calcium-dependent inactivation of calcium channels in Lymnaea neurons.

Ca(2+) channel inactivation in the neurons of the freshwater snail, Lymnaea stagnalis, was studied using patch-clamp techniques. In the presence of a high concentration of intracellular Ca(2+) buffer (5 mM EGTA), the inactivation of these Ca(2+) channels is entirely voltage dependent; it is not influenced by the identity of the permeant divalent ions or the amount of extracellular Ca(2+) influx, or reduced by higher levels of intracellular Ca(2+) buffering. Inactivation measured under these conditions, despite being independent of Ca(2+) influx, has a bell-shaped voltage dependence, which has often been considered a hallmark of Ca(2+)-dependent inactivation. Ca(2+)-dependent inactivation does occur in Lymnaea neurons, when the concentration of the intracellular Ca(2+) buffer is lowered to 0.1 mM EGTA. However, the magnitude of Ca(2+)-dependent inactivation does not increase linearly with Ca(2+) influx, but saturates for relatively small amounts of Ca(2+) influx. Recovery from inactivation at negative potentials is biexponential and has the same time constants in the presence of different intracellular concentrations of EGTA. However, the amplitude of the slow component is selectively enhanced by a decrease in intracellular EGTA, thus slowing the overall rate of recovery. The ability of 5 mM EGTA to completely suppress Ca(2+)-dependent inactivation suggests that the Ca(2+) binding site is at some distance from the channel protein itself. No evidence was found of a role for serine/threonine phosphorylation in Ca(2+) channel inactivation. Cytochalasin B, a microfilament disrupter, was found to greatly enhance the amount of Ca(2+) channel inactivation, but the involvement of actin filaments in this effect of cytochalasin B on Ca(2+) channel inactivation could not be verified using other pharmacological compounds. Thus, the mechanism of Ca(2+)-dependent inactivation in these neurons remains unknown, but appears to differ from those proposed for mammalian L-type Ca(2+) channels.

Measurement of calcium channel inactivation is dependent upon the test pulse potential.

We have developed two methods to measure Ca2+ channel inactivation in Lymnaea neurons-one method, based upon the conventional double-pulse protocol, uses currents during a moderately large depolarizing pulse, and the other uses tail currents after a very strong activating pulse. Both methods avoid contamination by proton currents and are unaffected by rundown of Ca2+ current. The magnitude of inactivation measured differs for the two methods; this difference arises because the measurement of inactivation is inherently dependent upon the test pulse voltage used to monitor the Ca2+ channel conductance. We discuss two models that can generate such test pulse dependence of inactivation measurements-a two-channel model and a two-open-state model. The first model accounts for this by assuming the existence of two types of Ca2+ channels, different proportions of which are activated by the different test pulses. The second model assumes only one Ca2+ channel type, with two closed and open states; in this model, the test pulse dependence is due to the differential activation of channels in the two closed states by the test pulses. Test pulse dependence of inactivation measurements of Ca2+ channels may be a general phenomenon that has been overlooked in previous studies.

Pharmacokinetics and pharmacodynamics of ramipril and piretanide administered alone and in combination.

The pharmacokinetics and pharmacodynamics of single oral doses of 5 mg ramipril and 6 mg piretanide administered separately and in combination were determined in a single blind, randomised, 3-period cross-over study in 24 healthy male volunteers. The peak plasma concentrations of ramipril and ramiprilat increased slightly (from 11.9 to 14.8 ng/ml, and from 6.39 to 8.96 ng/ml, respectively) as did the area under the plasma concentration-time curve of ramipril (0-4 h) and ramiprilat (0-24 h) (from 15.8 to 19.8 ng.ml-1.h, and from 63.4 to 74.6 ng.ml-1.h, respectively). The urinary excretion of ramiprilat also rose (from 6.82 to 7.73% of dose) following simultaneous treatment with piretanide. These effects were probably due to reduced first-pass metabolism of ramipril/ramiprilat to inactive metabolites. The blood pressure lowering effect, the time course of inhibition of ACE activity in plasma and the concentration-response relationship for the inhibition of plasma ACE activity were not affected by piretanide. The peak plasma concentration of piretanide was somewhat reduced (from 285 to 244 ng/ml) following simultaneous treatment with ramipril. No other pharmacokinetic parameter was affected. Piretanide increased urine flow, and sodium, chloride and potassium excretion, especially during the first 2 hours following administration. These pharmacodynamic parameters were not affected by ramipril. Thus, simultaneous administration of single oral doses of ramipril and piretanide caused modest changes in the peak and average plasma concentrations of both drugs, which did not lead to detectable alterations in the pharmacodynamic parameters measured in healthy volunteers.

Relevance of the hydrolysis and protein binding of melphalan to the treatment of multiple myeloma.

Experiments to determine the hydrolysis and protein binding of melphalan (L-phenylalanine mustard, L-PAM) were carried out in vitro for therapeutic concentration of the drug: the decrease in L-PAM concentration in plasma and whole blood during 24 h incubation at 37 degrees C was only 5% due to hydrolysis. Serum protein binding was about 90%, whereby 60% and 20% of this binding was due to interactions with albumin and acid alpha 1-glycoprotein, respectively. Immunoglobulins did not participate in the binding of L-PAM. The covalently bound part of L-PAM in serum was 30% in the concentration range of 1-30 micrograms/ml. The binding of dihydroxymelphalan (DOH) in serum did not exceed 20%. Glucocorticoids used in combination with L-PAM for treating multiple myeloma did not influence its protein binding. Our study with 35 sera from 15 patients with multiple myeloma shows that high levels of paraproteins do not increase but may decrease the binding of L-PAM, resulting in an elevated concentration of free drug.

Hepatic capillariasis.

The clinico-pathologic features of Capillaria hepatica infection in a 27-year-old Nigerian woman are discussed. This animal parasite has been encountered only rarely in humans. Less than 30 cases of human infection, mostly in children, having been recorded as far as the present authors are aware. This is the first case of hepatic capillariasis reported in West Africa. The pathologic features of this patient is marked by severe hepatic fibrosis, and this is correlated with disordered liver function. The possibility of histopathologic confusion with schistosomiasis mansoni is discussed.

Incidence of hypertension in Ahmadu Bello University Hospital Kaduna--Nigeria.

The incidence and pattern of hypertension in General Out Patient Department of Ahmadu Nello University Teaching Hospital, Kaduna have been described. Two thousand nine hundred and fifty adult patients with 1,636 males and 1,314 females, aged 20 to 70 years were examined in this study. One hundred and twelve patients (3.79%) with 47 males (2.87%) and 65 females (4.94%) were found to be suffering from hypertension. The incidence in females was significantly more than in males. The mode of presentation of 112 cases with hypertension has been discussed. Thirty four (30.35%) with 14 males and 20 females were asymptomatic. Sixteen (14.28%) with 7 males and 9 females presented with cardiac failure. Contrary to previous opinion this study has shown that hypertension is probably more common in Northern Nigeria than was previously realized. There appears to be ample justification for further and more detailed study of hypertension in the rural and urban communities in this area.