The relationship between regional blood flow and absorption of lignocaine.

With the increasing application of certain surgical procedures to 'day surgery' cases, there has been greater utilization of local anaesthetic agents. Such procedures are undertaken using single infiltration dosage recommendations for lignocaine, both with and without adrenaline. The present paper describes results obtained from a sheep model that considers the role of the regional blood flow of the injected site as a determinant of lignocaine absorption and resultant pharmacokinetics. The peak concentration of lignocaine in plasma following administration to two selected sites of different vascularity (as determined by a technetium99 washout method), as well as the effect of concomitant adrenaline administration, was shown to correlate with the regional blood flow to the site (rs = 0.73, P = 0.008). Extrapolating these animal data to the clinical situation suggests that larger dosages of lignocaine could be used safely for infiltration anaesthesia in regions of poor regional blood flow without posing a threat of lignocaine-induced toxicity, and that the current dosage recommendations could be modified in respect of the regional blood flow of the particular site to be infiltrated.

Evaluation of the safety of inguinal hernia repair in the elderly using lignocaine infiltration anaesthesia.

Repair of inguinal hernia using local anaesthesia is becoming increasingly popular as it avoids many of the systemic side effects associated with general or spinal/epidural anaesthesia and provides excellent early postoperative pain relief. Dosages of local anaesthetic approaching the recommended maximum are frequently required for adequate anaesthesia of the inguinal region. The present study describes the disposition and safety of lignocaine with adrenaline in 14 elderly patients to ascertain its safety with a view to more widespread application of the technique in more complicated hernia repairs. Serial plasma lignocaine concentrations were determined for up to 24 h following doses approaching the recommended maximum for infiltration (7 mg/kg). Peak lignocaine concentrations (normalized to 7 mg/kg) ranged from 0.23 to 0.90 mg/L (mean of 0.54 mg/L); that is, the maximum recorded concentration was less than one-fifth the toxicity threshold for lignocaine of 5 mg/L. The study suggested that the majority of patients tolerated the local anaesthetic approach very well and that the wide safety margin allowed ample scope to develop the local anaesthetic approach for the repair of more complex hernia repairs (e.g. large, bilateral or strangulated herniae, or those in obese patients) without risk of exposing patients to lignocaine concentrations which may cause toxic side effects.

A case-control study of diet and cancer of the pancreas.

In a population-based case-control study carried out in Adelaide, South Australia, during the years 1984-1987, the diets of 104 cases of cancer of the pancreas 1 year prior to diagnosis were compared with the diets of 253 community controls. A quantitative food-frequency questionnaire was used to assess usual dietary intakes of 179 food items. Cases were compared with controls in terms of both the amounts of individual food items consumed and the estimated contributions of 48 nutrients to the diet. Food items consumed more by cases than controls included boiled eggs and omelettes as well as a number of items that could be collectively described as sweet and fatty. Food items consumed less by cases than controls included several vegetables and fruits. Conditional logistic regression analysis of nutrient intake adjusted for total energy and for alcohol and tobacco usage yielded an estimate of relative risk of 3.19, with a 95% confidence interval of 1.58-6.47 for the highest quartile of cholesterol intake (relative to the lowest quartile). For the top quartile of refined sugar intake, the estimated relative risk was 2.21 (95% confidence interval 1.07-4.55). Several nutrients derived principally from plant foods were statistically significantly associated with lower risks. Alcohol consumption was significantly lower among cases than controls. Current smokers had a relative risk of 1.76 (95% confidence interval 0.93-3.34) relative to those who had never smoked. There was no association of pancreatic cancer with coffee drinking.

Psychosocial and physical activity changes after gastric restrictive procedures for morbid obesity.

Gastric restrictive procedures for morbid obesity are frequently performed to reduce problems arising from the physical limitations and social isolation of massive obesity. Numerous reports have described changes in weight after gastric restrictive operations, yet few studies have documented changes in the secondary effects of obesity. This report deals with changes in psychosocial status and physical activity occurring in 240 patients who remained in the study 3 years after surgery. These patients were members of a group of 310 patients who were entered into a prospective randomized trial to assess the relative benefits of three forms of gastric restrictive procedure. Prior to operation, and at yearly intervals after operation, the physical activities and psychosocial status of each patient was assessed by a standardized semi-structured interview. At the time of the three-year interview the median weight loss for these patients was 29.5 kg which represents 53% of excess weight lost. This weight loss was associated with a marked reduction in the amount of food eaten. There was a significant increase in the number of patients smoking more than 20 cigarettes a day and a mild increase in alcohol intake. There were significant improvements in the level of self-image and state of happiness. The social lives and sex lives of the majority of patients were improved and a significantly greater number of patients reported being in a stable emotional relationship at 3 years after operation than did so pre-operatively. There was a marked increase in the number of patients in full-time or part-time employment from 38% prior to surgery to 60% at 3 years after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric surgery for morbid obesity. The Adelaide Study.

The efficacy of three gastric restriction operations were compared in a prospective randomized study of 310 morbidly obese subjects. The median patient age was 34 years (range, 18 to 62 years). They were predominantly female (13:1) and had a median pre-operative weight that was 198% of their ideal weight (range, 160% to 318%). There was an equitable dispersion of perceived risk factors between the groups under study and there were no deaths during the perioperative period. Compliance with follow-up at 3 years was 91%. When success was defined as a loss of more than 50% of excess weight or a current pregnancy, the success rates at 3 years were 17% for gastrogastrostomy, 48% for vertical gastroplasty, and 67% for Roux-en-Y gastric bypass (p less than 0.001). Although the gastric bypass operation took longer to perform, there were similar outcome patterns for the three groups during the postoperative period. We conclude that the Roux-en-Y gastric bypass is the preferred procedure for the surgical treatment of morbid obesity.

The pathology of experimental chronic fibrosing pancreatitis--light microscopic and ultrastructural observations.

The light microscopic and ultrastructural changes seen in a canine model of chronic fibrosing pancreatitis are described. The distribution of the experimental lesion is similar to that of human chronic obstructive pancreatitis. The canine lesion is also compared to that of human chronic calcifying pancreatitis. It is suggested that the common denominator in all these conditions is an increased pressure in the terminal intercalated ducts which produces pressure atrophy of the acinar cells in the periphery of the obstructed lobules.

Nesidioblastosis, islet cell hyperplasia, and adenomatosis in a case of metastasizing insulinoma: contribution to the genesis of the islets of Langerhans.

An unusual case of insulinoma is described in a 40-yr-old woman whose resected pancreas showed multiple adenomas with lymph node metastasis, associated hyperplasia of islets, and nesidioblastosis. The association of nesidioblastosis with this continuum of proliferative changes adds further evidence for a ductular origin of islet cell tumors.

Results of surgical treatment of chronic pancreatitis. Report of 142 cases.

The authors report on 142 patients treated surgically for chronic pancreatitis. They had an average age of 43.5; 34.5% were calcific; 62.7% were alcoholics: 28.9% had cysts; 19% had diabetes; 16.9% had steatorrhea; and all had pain. A follow-up of 55 patients undergoing pancreaticojejunostomy showed that, 4--21 years following operation 16 had marked improvement, 11 had some relief, four were not relieved from pain, and 24 had died, three within one month postoperatively and 21 later. Eighty to ninety-five per cent pancreatectomy was more effective in relieving pain in the 9 patients subjected to this type of resection than was the 50--80% pancreatic resection used in 16 patients. Pancreaticoduodenectomy was of some value in three of five patients so operated. Celiac ganglionectomy, used in 22 patients, and sphincteroplasty, used in 35 patients, were less effective in relieving symptoms than the other procedures.

Pyelo-ureteritis cystica associated with a urinary tract infection due to a coagulase-negative staphylococcus.

A young female presenting with a history suggestive of renal colic was found by intravenous pyelography to have Pyeloureteritis Cystica. In association with this condition she had a urinary tract infection due to a coagulase-negative staphylococcus. Following a two week course of appropriate antibiotic therapy, her urine became sterile and repeat pyelography revealed no abnormality.

Myocarditis and Phaeochromocytomata.

Two case histories are presented in each of which an unexpected postoperative death was associated with a previously unsuspected phaochromocytoma, and post-mortem examination disclosed the presence of myocarditis. It is suggested that the myocarditis and the gross cardiac arrhythmias leading to the death of the patients may be connected. It is urged that this diagnosis should be kept in mind when unexpected arrhythmias develop in relationship to operation, and that the alpha and beta adrenergic blockers may have a therapeutic value in these circumstances.

Feminizing Adreno-Cortical Carcinoma: Report of a Case.

A case of feminizing adreno-cortical carcinoma is reported and features of these tumours are commented on. The differential diagnosis of gynaecomastia and its investigation are discussed. The features of adrenal carcinoma are also discussed, the literature is reviewed and treatment is outlined.