Remifentanil for analgesia during retrobulbar nerve block placement.

BACKGROUND AND OBJECTIVES: Patients undergoing eye surgery under regional anaesthesia often require concomitant medication for analgesia and comfort. Remifentanil, with its ultra-short acting-profile, may be useful to reduce pain during retrobulbar nerve block for cataract surgery. METHODS: We performed a prospective, randomized, double-blind study to compare the efficacy of remifentanil for analgesia during retrobulbar nerve block placement. Ninety patients undergoing cataract surgery were randomly divided to receive either remifentanil 0.3 microg kg(-1) (n = 45) or an equivalent volume of saline (n = 45). The injection was administered within 30 s in both groups. Patients rated their amount of pain on a 10 cm visual analogue scale. Respiratory frequency, oxygen saturation, cardiac rhythm and postoperative nausea and vomiting (PONV) were recorded. RESULTS: The mean visual analogue score in the Remifentanil group was 2.56; it was 5.51 in the Saline group (P = 0.001, U-test). Three patients developed bradycardia and three had PONV in the Remifentanil group. Two patients developed tachycardia and one had PONV in the Saline group. No patient developed respiratory depression. CONCLUSION: In patients undergoing retrobulbar block placement for eye surgery, 0.3 microg kg(-1) remifentanil over 30 s significantly reduced their reported pain. In addition, remifentanil did not increase the risk of untoward side-effects.

Chronic infantile neurological cutaneous and articular/neonatal onset multisystem inflammatory disease syndrome: ocular manifestations in a recently recognized chronic inflammatory disease of childhood.

OBJECTIVE: To report on the ocular manifestations of the Chronic Infantile Neurological Cutaneous and Articular/Neonatal Onset Multisystem Inflammatory Disease (CINCA/NOMID) syndrome, a rare, recently identified, pediatric multisystem inflammatory disease with chronic cutaneous, neurological, and articular manifestations. DESIGN: Descriptive case-report study. SETTING: International collaborative study based on a questionnaire. RESULTS: We included 31 patients. The mean age at onset of eye manifestations was 4.5 years. Optic disc changes were the most common feature, occurring in 26 patients (83%), including optic disc edema, pseudopapilledema, and optic atrophy. Anterior segment manifestations varying from mild to severe were seen in 13 patients (42%); chronic anterior uveitis, in 17 patients (55%). Moderate to severe visual acuity loss in at least 1 eye was seen in 8 patients (26%) as a consequence of the disease. Posterior synechia, glaucoma, and white iritis were not observed in any patient. CONCLUSION: Ocular manifestations with potentially sight-threatening complications occur commonly in the CINCA/NOMID syndrome. The distinctive nature of these complications may assist the ophthalmologist in recognizing this rare disorder and distinguishing it from juvenile rheumatoid arthritis.

[Carcinoid tumor of the lung. An unusual form of ocular metastasis]. / Karzinoidtumor der Lunge. Eine ungewöhnliche Form der okulären Metastasierung.

Carcinoid tumors are slowly and locally invasive growing neoplasms. Their main localization is in the ileum or in organs derived from the embryonic foregut, i.e. bronchus, stomach, pancreas and thyroid. The low rate of metastatic manifestation of about 10% indicates their potential malignancy. The endocrine effects vary. We describe the case of a 30-year-old female patient, who had had a carcinoid tumor of the bronchus with infiltration of a hilar lymph node, which had been resected two years previously. The postoperative course was marked by an increased level of urine 5-hydroxyindolacetic acid (5-HIAA). Finally, the patient complained a 4-month history of recurrent episodes of refractory conjunctival hyperemia, visual loss and visual field defects in both eyes. Examination revealed bilateral multiple choroidal masses associated with retinal detachment. As various authors have reported, carcinoid tumor metastases to the eye are extremely rare. Diagnostic approaches and therapeutic considerations are described. Ultrasonic examination of the choroidal lesion, applying standardized A-scan echography at tissue sensitivity, showed solid tissue masses and bilateral circumscribed exudative retinal detachment. The tumor was characterized by medium to high reflectivity and slight sound attenuation. The internal structure showed less irregularity than is usually seen in metastases.

[MK-507 (L-671 152): local tolerance and effectiveness of a new local carbonic anhydrase inhibitor in healthy probands]. / MK-507 (L-671 152): lokale Verträglichkeit und Wirksamkeit eines neuen lokalen Karboanhydrasehemmers bei gesunden Probanden.

A three-dose, randomized, double-blind parallel, placebo-controlled ocular tolerancy study was undertaken in 24 healthy, normal volunteers with two formulations of 2% MK-507 (L-671 152), a novel water-soluble, topical carbonic anhydrase inhibitor. In this study MK-507 was administered to humans for the first time. Subjects received 3 sequential drops of the test drug in one randomly selected eye (at 13:00, 14:00, and 14:10 o'clock): ten received 2% MK-507 formulated with 0.5% hydroxyethylcellulose (HEC); ten, 2% MK-507 with no HEC; two, vehicle with HEC; and two, vehicle without HEC. Local tolerance of 2% MK-507 was good with predominantly mild and transient local symptoms, somewhat fewer for the formulation without HEC. Significant lowering of intraocular pressure (IOP) by up to 7 mmHg was noted when comparing IOP 4 h and 5 h after the first dose with IOP 20 h and 19 h before the first dose in the treated eyes of subjects receiving MK-507. Slightly greater activity was noted when MK-507 was formulated with HEC.

Interactions between insulin and insulin-like growth factor I in the pathogenesis of polycystic ovarian disease.

Concentrations of growth factors were examined in 28 patients with clinical and endocrinologic signs of polycystic ovarian disease (PCOD). Elevated levels of total insulin-like growth factor I (IGF-I) and decreased levels of the human growth hormone (HGH) were found. Studies of carbohydrate metabolism and of insulin receptors on erythrocytes indicated insulin resistance in all PCOD patients. Elevated insulin and IGF-I levels seem to play a pathogenetic role in PCOD by influencing the development and steroid production of ovarian follicles. Interactions between insulin and IGF-I could be shown at different levels. A positive correlation between elevated insulin and IGF-I concentrations was demonstrated in patients with different classes of gestational diabetes. Hyperinsulinemia seems to be the trigger mechanism and therefore the key to the pathogenetic loop of polycystic ovarian disease.

[A questionable parasitic macular cyst]. / Fragliche parasitäre Makulazyste.

A 60 year old male patient is introduced who developed a loss of vision caused by chorioretinal cystic alteration in the macula of the left eye 9 months after a routine extracapsular cataract surgery with implantation of posterior chamber lens. There existed no other general symptoms, hematologic values and serology were regular. Having discussed literature the diagnosis of solitary Toxocara canis granuloma was produced.

[A new topical carbonic anhydrase inhibitor (MK-927). Tolerance comparison with betaxolol in healthy probands]. / Ein neuer, lokal anwendbarer Carboanhydrasehemmer (MK-927). Toleranzvergleich mit Betaxolol bei gesunden Probanden.

MK-927 is a new topical carboanhydrase inhibitor with proven ability to lower intraocular pressure in glaucoma patients. Subjective and objective symptoms following topical application of MK-927 were evaluated in a randomized, double-blind, placebo-controlled study in which 24 healthy male volunteers took part. Symptoms were rated according to a visual analog scale by the volunteers and according to a grading scale by the examiner. The study showed good local tolerance of MK-927, comparable to that of Betaxolol.

Congenital generalized cystic lymphangiomatosis diagnosed by prenatal ultrasound.

We describe a previously unknown congenital abnormality of the lymphatic system, characterized by multiple cystic lesions of the lower extremities and thorax. Diagnosis was made by ultrasound in the second trimester. The ultrasound findings, pathology results, and differential diagnosis are presented.

[Birdshot chorioretinopathy: systemic therapy with corticosteroids and nonsteroidal anti-inflammatory drugs]. / Birdshot-Retinochorioideopathie: Systemische Therapie mit Corticosteroiden und nichtsteroidalen Antiphlogistika.

The symptoms and clinical course of a case of birdshot chorioretinopathy are described. The patient was a 40-year-old woman. The condition can be treated with two types of medication, i.e., steroids and nonsteroidal anti-inflammatory drugs. Both appear to have a beneficial effect. Overall, however, the prognosis for this rare disease of unknown etiology remains uncertain. Given the slow progressive course, with spontaneous remissions and exacerbations, it is extremely difficult to evaluate the success of different forms of therapy.

Serum fructosamine and amniotic fluid insulin levels in patients with gestational diabetes and healthy control subjects.

Gestational diabetic pregnancies with fetal hyperinsulinism should be identified because these cases require insulin therapy. To determine the relationship between the serum fructosamine and amniotic fluid insulin concentrations, these substances were measured in 87 pregnant women with impaired glucose tolerance. Fructosamine was also measured in 678 healthy pregnant control subjects, in 113 of whom amniotic fluid insulin levels were available. Fetal hyperinsulinism was rare at serum fructosamine levels of less than 2.6 mmol/L. These results suggest that when both the oral glucose tolerance test and fructosamine level are used, only 30% of women with gestational diabetes need to undergo amniocentesis to assess fetal insulin homeostasis.

[Sacrococcygeal teratoma. Prenatal diagnosis and prognosis]. / Das Sacrococcygeale Teratom. Präpartale Diagnose und Prognose.

The routine use of ultrasonics during pregnancy allows an early diagnosis of a sacrococcygeal teratoma (SCT) with a high degree of certainty. The perinatal management is shown in a four case example prenatally diagnosed. The assessment of N-Acetylcholinesterase in the amniotic fluid in cases of cystic teratomas does not allow a safe differentiation from a myelomeningocele. A puncture of the tumor can be helpful for the verification of the diagnosis. Cells of all three germ layers may be found in the cytological fluid. The sonomorphological differentiation into solid and cystic tumors may play a significant role for the intrauterine growth. Even when diagnosed very early, cystic tumors do not compromise the intrauterine growth. Large solid tumors may lead to hydrops fetalis and intrauterine death. Furthermore, the prognosis depends on concomitant malformation as well as on the intracorporal spreading of the tumor. Therefore, a careful ultrasonic examination allows a good prenatal prognosis as to the severity of the malformation. Delivery is done by caesarean section in cases of large cystic-solid tumors. Small teratomas as well as most cystic tumors allow vaginal delivery after having been punctured previously.

Fructosamine in relation to maternofetal glucose and insulin homeostasis in gestational diabetes.

The problem in screening for gestational diabetes is recognizing fetuses endangered by hyperinsulinism. 21.8% of patients with gestational diabetes (defined as a glucose peak exceeding 160 mg/dl after an oral glucose load of 1 g per kg body weight) develop fetal hyperinsulinism. Thus, is indicated by an elevated amniotic fluid insulin (AFI) concentration and requires insulin treatment. Since fetal hyperinsulinism can be neither predicted nor ruled out by single parameters of maternal metabolism, every patient with gestational diabetes had to undergo amniocentesis for amniotic fluid analysis. In 110 gestational diabetics and 822 controls, fetal hyperinsulinism was predicted by the combination of the oGTT (greater than or equal to 160 mg/dl) and maternal serum fructosamine (greater than or equal to 2.6 mmol/l) with a sensitivity of 95.8% and a specificity of 91.8%. Thus, 73% of gestational diabetics need not undergo amniocentesis. With a sensitivity of 20.8%, the combination of the oGTT and HbA1c is not useful in identifying hyperinsulinemic fetuses.

Maternal serum fructosamine and maternofetal glucose and insulin homeostasis in normal pregnancy.

Well-defined normal values are necessary to identify pregnancies complicated by gestational diabetes (GD) and thus further reduce perinatal morbidity and mortality from this condition. The present study defined the range for the oral glucose tolerance test (oGTT) in 2578 pregnancies. After exclusion of abnormal results 822 randomized patients were used to define normal values for fructosamine, HbA1c, insulin, glucose and C-peptide in the maternal serum; insulin, glucose and fructosamine in the amniotic fluid; and insulin, glucose, C-peptide and fructosamine in the cord blood.

[Staging of cervix cancer using MRT]. / Staging des Kollumkarzinoms mit MRT.

In a prospective study the results of FIGO staging and MR staging in uterine cervical carcinoma were compared with the findings of stepwise serial examination of en-bloc-resected specimens in 28 patients. Overall accuracy of MR staging was 59% compared to 41% in FIGO staging. Sensitivity in assessing parametrial tumour extension was 85% in MRI and 64% in clinical examination. Specificity was 74% in MRI and 69% in physical examination. Accuracy in parametrial tumour extension was 67 per cent in FIGO-Classification and 80 per cent in MRI.

MK-927: a topically effective carbonic anhydrase inhibitor in patients.

The effects on intraocular pressure of the novel topical carbonic anhydrase inhibitor MK-927 were investigated for the first time in patients. Three drops of 2% MK-927 was administered in a two-center, double-masked, randomized, placebo-controlled, two-period crossover study in 25 patients with bilateral primary open angle glaucoma or ocular hypertension. At 4.5 hours after the dose, MK-927-treated eyes demonstrated a peak mean change of -7.7 mm Hg from a mean intraocular pressure of 27.8 mm Hg immediately before the dose; this compares with a change of -3.9 mm Hg from a mean intraocular pressure of 28.2 mm Hg when the same eyes were treated with placebo. The peak mean percent change in intraocular pressure in eyes treated with MK-927 was -26.7% at 6 hours after the dose compared with a change of -13.7% after treatment with placebo. No contralateral effect on intraocular pressure due to MK-927 was observed.

[The value of prenatal ultrasound screening exemplified by abnormalities of the urogenital system. Data from the Styrian malformation register 1985 to 1987]. / Der Wert des pränatalen Ultraschall-Screenings am Beispiel von Fehlbildungen des Urogenitalsystems. Daten aus dem Steirischen Fehlbildungsregister 1985 bis 1987.

Over a three-year period (1985 to 1987), the number of fetal malformations was entered into Styrian Malformation Register (SMR). The data were compared with those of the Austrian Ministry of Health. The SMR collected 137 cases of urinary tract malformations, but only six appeared in the Health Ministry statistics. This discrepancy resulted from the different data collection methods. Presently only a small percentage of fetal abnormalities is officially registered. Using the example of urinary tract malformations this paper shows the value of prenatal ultrasound screening. Such infants must be treated soon after delivery to avoid progression of parenchymal damage. Ultrasound examinations should not be restricted to pregnant women at defined risk. Registration of all prenatally diagnosed--or missed--malformations is a quality-control measurement and improves prenatal diagnosis.

Magnetic resonance imaging in cervical cancer: a basis for objective classification.

Conventional clinical staging of cervical cancer is subjective because it is based on palpatory findings and inadequate because it cannot assess the single most important prognostic factor--tumor size. To determine the exactitude of in vivo MRI measurements of tumor volume, 22 patients with invasive cervical cancer were studied before surgery. The volumes obtained by MRI correlated well (r = 0.983) with those obtained by histomorphometric analysis of the surgical specimens, but only weakly with clinical stage. MRI may provide a basis for precise classification of cervical cancer and for objective comparison of surgery and radiotherapy.

[Children of insulin-dependent diabetic patients. A determination of status]. / Kinder insulinpflichtiger Diabetikerinnen. Eine Standortbestimmung.

We report on 143 newborns of mothers with insulin dependent diabetes during pregnancy. The mean birth weight was 3.091 (+/- 619) g at a mean gestational age of 38.4 (+/- 2) weeks. Neonatal morbidity was associated with the disease class, insulin levels in the amniotic fluid, urine and cord blood; and especially persistent fetal hyperinsulinism as indicated by repeatedly high amniotic fluid insulin levels during pregnancy. One infant died (neonatal mortality 0.69%) of a severe cardiac malformation combined with a caudal regression syndrome. This was the only major malformation in the group.