Prognostic value of thoracic recurrent nerve nodal involvement in esophageal squamous cell carcinoma

The authors compared the acceptance and efficacy of rectal and nasal administration of midazolam (MDZ) for premedication. Ninety-five ASA I and II paediatric patients (8 months to 12 years) scheduled for elective surgery were randomly allocated to two groups. Group R received 0.3 mg kg-1 of rectal midazolam (in 5 mL saline). Group N received 0.2 mg kg-1 of nasal midazolam (5 mg ml-1). Both groups were divided in two subgroups according to age (group RA (< or = 6 years, n = 33), group RB (> 6 years, n = 18), group NA (< or = 6 years, n = 28), group NB (> 6 years, n = 16)). At the time of premedication, tolerance to the administration was confirmed. Twenty min after rectal or 10 min after nasal administration the quality of sedation was recorded. The nasal midazolam, in commonly used dosages, induced a sedation similar to that following rectal administration with a shorter delay of onset. Nasal administration was more often painful than rectal administration. Swallowing (nasal midazolam) and concerns about modesty (rectal midazolam) were more frequent in older children. Because of its poor tolerance, nasal premedication should be reversed for cases where there is no alternative. Rectal premedication should be avoided in older children.     

Perioperative physiological and cognitive functions following oral premedication with 3.75 mg midazolam in operations with retrobulbar anesthesia

The number of surgical procedures performed as day surgery has significantly increased in recent years. Therefore, a safe and short postoperative recovery period has become increasingly important. The aim of the present study was to investigate perioperative cognitive and physiological function after oral premedication with low-dose midazolam (3.75 mg), especially during the postoperative period. METHODS: Forty-seven men (age > 69 years, weight 50-90 kg) scheduled for elective cataract surgery under retrobulbar anaesthesia (RBA) were included in the study. The patients were randomly assigned to either group 1 (n = 28), receiving 3.75 mg midazolam p.o. (Dormicum), or group 2 (n = 19), receiving a placebo orally 30 min before RBA. We measured the following parameters: sedation (modified Glasgow coma scale); anxiety (visual analogue scale); numerical and verbal memory (digit span and reproduction of previously presented words); concentration (Revisions test of Stender/Marschner). To identify depression of ventilation, pulse oximetry and nasal end-tidal PCO2 were monitored intraoperatively. RESULTS: After premedication with 3.75 mg midazolam, patients were significantly more sedated (P < 0.01) and systolic blood pressures were significantly reduced (P < 0.05); 30 min after midazolam premedication only concentration was significantly (P < 0.05) decreased. The results of the other cognitive functions did not differ. No differences in cognitive and physiological functions between and groups could be found 2 h after the operation (293 +/- min after premedication). Intraoperatively, there were no significant differences in end-tidal PCO2 and oxygenation between the groups. In both groups anxiety and blood pressure were significantly higher pre- than postoperatively. CONCLUSION: Oral administration of low-dose midazolam (0.049 +/- mg/kg) seems to be appropriate for premedication before ambulatory surgical procedures in elderly patients. In the interest of patient safety, standardised oral premedication with 3.75 mg midazolam may not be sufficient for some of the patients.     

Single vital capacity inhalational anaesthetic induction in adults--isoflurane vs sevoflurane

PURPOSE: To evaluate whether isoflurane is as suitable as sevoflurane for the single vital capacity breath (VCB) method of inhalational induction in patients premedicated with midazolam. METHODS: A randomised, controlled, double-blind study involving 67 ASA I-II patients aged between 18-50 yr undergoing elective surgery under general anaesthesia. All participants received premedication with 0.03 mg.kg-1 midazolam i.v. Using a primed circle absorber circuit, inhalational induction of anaesthesia was performed with the single VCB method using either isoflurane 3.5% or sevoflurane 7.5% in nitrous oxide 67% in oxygen, representing approximately equivalent MAC-multiples of 3.6 MAC. Isoflurane was compared with sevoflurane in terms of rapidity, efficacy, safety and acceptability of induction. RESULTS: With the single VCB method, sevoflurane produced a faster (45 +/- 21 vs 71 +/- 22 sec, P < 0.01), more successful (100% vs 75.8%, P < 0.01) induction of anaesthesia, with fewer induction-related complications (11.8% vs 84.8%, P < 0.01) than did isoflurane. There was also greater patient acceptability of induction with sevoflurane (76.4% vs 42.4%, P < 0.05). CONCLUSION: In adults given midazolam premedication, isoflurane is not as suitable as sevoflurane for single VCB inhalational anaesthetic induction technique as it is associated with slower, more complicated induction and less patient acceptability.     

Role of supervision in assuring quality mental health services in university counseling centers.

Conducted a survey to explore the relation between the role of supervision and practitioners' experience, training, and certification and to determine how these factors affect quality assurance in university counseling centers. Ss were 185 counselors. Findings indicate that time spent in supervision was not significantly related to the dependent variables of educational level, experience, or licensure, and that unlicensed practitioners were less likely to seek supervision. The lack of supervision and licensed practitioners may be inconsistent with the value placed on supervision as a quality control procedure. (13 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Premedication with oral dextromethorphan reduces postoperative pain after tonsillectomy

The aim of the present study was to examine whether premedication with dextromethorphan, a clinically available N-methyl-D-aspartic acid (NMDA) receptor antagonist, could reduce postoperative pain after tonsillectomy. Thirty-six patients scheduled for elective bilateral tonsillectomy were investigated in a double-blinded, randomized study. The patients were randomly assigned to one of three groups: control, dextromethorphan 30 mg (Dex 30), and dextromethorphan 45 mg (Dex 45) groups. In the control group, premedication was with oral placebo and intramuscular (i.m.) midazolam and atropine. In the Dex 30 and Dex 45 groups, patients were premedicated with i.m. midazolam and atropine and oral dextromethorphan 30 mg and 45 mg, respectively. Pain was evaluated repeatedly throughout 7 postoperative days, at rest and on swallowing, using a self-rating visual analog scale (VAS). The total doses of analgesics administered postoperatively were also recorded. The Dex 45 group showed significantly lower VAS scores than the control group both at rest and on swallowing throughout the 7 days. The total doses of postoperative analgesics in the Dex 45 group were significantly less than those in the control group. The Dex 30 group showed significantly lower VAS scores than the control group at rest, but not on swallowing. These results indicate that premedication with Dex 45 reduces postoperative pain after tonsillectomy, not only at rest but on swallowing. IMPLICATIONS: Recently, it has been suggested that central sensitization caused by the activation of N-methyl-D-aspartic acid receptors may contribute to the postoperative pain. We found that premedication with 45 mg of dextromethorphan, a clinically available N-methyl-D-aspartic acid receptor antagonist, reduced postoperative pain after tonsillectomy.     

Midazolam versus placebo before spinal anesthesia

The goal of this randomized, double blind and multicentric study was to compare the effects of midazolam (M) and placebo (P) administered by titration before puncture for spinal anaesthesia on the comfort of 211 patients scheduled for elective surgery after oral premedication with hydroxyzine. The administered dose of midazolam was 3.4 +/- 1.3 mg (mean +/- SD). Anxiety was nil in 92% of the patients of the M group and in 64% of the patients of the P group (p < 0.001) and memorization of the pain of the puncture was reported in 34% of the patients of the M group and in 66% of the patients of the P group (p < 0.001). However cooperation of the patient and easiness of the puncture were similar in both groups. In conclusion titrated sedation with midazolam before puncture for spinal anaesthesia increases the comfort of the patient.     

The role of atropine premedication in fiberoptic bronchoscopy using intravenous midazolam sedation

OBJECTIVE: Atropine premedication is widely used for fiberoptic bronchoscopy and may help by drying secretions, producing bronchodilatation, or preventing vasovagal reactions. The objective of this study was to see whether atropine premedication is really of practical benefit when patients are sedated with i.v. midazolam. DESIGN: In a double-blind study, patients were randomly allocated to receive i.m. atropine (0.6 mg) or saline placebo (1 mL) as premedication 30 to 60 minutes before they were sedated with progressive doses of i.v. midazolam until judged to be lightly asleep. SETTING: A District General Hospital in England. PARTICIPANTS: One hundred consecutive patients referred for bronchoscopy. MEASUREMENTS AND RESULTS: Samples taken during the procedure were washings for microbiology and cytology and brushings for cytology and biopsy, but no transbronchial biopsies. Peak flow readings were recorded before premedication and before the start of the procedure. During the procedure an estimate was made of pharyngeal and tracheobronchial secretions, bleeding, use of saline to wash out secretions, and local anesthetic needed to control coughing. Patients were monitored for saturation and cardiac rhythm. There was no significant bronchodilatation after premedication in either group, nor were there differences in secretions, use of saline, tracheobronchial bleeding, desaturation, and arrhythmias. More local anesthetic was needed to control coughing in the placebo group (mean 357 mg vs 331 mg in the atropine group, p=0.02), but this was not of practical significance. CONCLUSION: When intravenous midazolam sedation is used for bronchoscopy, atropine premedication is not of benefit.     

Psychological aspects of pain experience in amniocentesis

This study describes the psychological aspects and the experience of pain in 2 groups of women undergoing amniocentesis in relation to the different indication for the procedure and duration of gestation in the respective groups. METHODS AND SUBJECTS: Data were collected after amniocentesis from 100 pregnant women, 50 of whom underwent age-related amniocentesis (14 weeks of gestation) and 50 for measurement of amniotic fluid insulin levels (30 weeks of gestation). A semi-structured psychological interview was used to collect information concerning experience of pain, cognition before amniocentesis, knowledge about the procedure and the most distressing aspects of amniocentesis. Visual analog scales (VAS, 0 to 10) were used to assess the degree of pain and emotional mood state. RESULTS: The results showed that emotional mood state before amniocentesis was fair (mean = 4.6) and increased after amniocentesis (mean = 8.1) The degree of pain during amniocentesis was assessed at a mean value of 2.9 measured on the 10-point visual analog scale. Fifty per cent of the sample considered the physical, the other 50% the psychological (anxiety and uncertainty) aspects as the most distressing factor of amniocentesis. Although women were given prior detailed information about amniocentesis they overestimated the degree of pain, related risk factors, and duration of the medical procedure. There were no differences in the investigated variables between the two different indications for amniocentesis or the weeks of gestation. CONCLUSION: The findings of the study indicate the psychological distress associated with amniocentesis, which is limited to a short period of time, and is independent of the indication for amniocentesis.     

Renal lesions in Von Hippel-Lindau disease: the benign, the malignant, the unknown

This study analysed the frequency of distress at induction (DAI) in 2122 paediatric patients. The data were analysed to assess predictors of DAI and to examine associations between predictors of DAI and recovery characteristics. Patient age, preoperative behaviour, premedication (oral midazolam, n = 480) and venue for anaesthesia induction were associated with changes in the incidence of DAI. Distressed preoperative behaviour was a good predictor of DAI in all age groups. Premedication reduced the incidence of DAI in children aged 0.5-2 years old, and in older children who were distressed preoperatively. Induction in the Day Surgery Unit was associated with a reduction of the incidence of DAI in younger children. Children with DAI were more likely to suffer from distress at arousal (P = 0.001). Average early recovery time was prolonged 4.4 minutes and average discharge time in day patients was delayed 36 minutes by the use of oral midazolam premedication. Premedication was not significantly associated with arousal distress. We conclude that a policy of optimizing nonpharmacological approaches for minimizing induction distress, combined with selective premedication with oral midazolam, can produce a low incidence of induction distress and adverse effects.     

Osteoarthritis of the hip and occupational lifting

OBJECTIVES: The purpose of this study was to determine the effect on quality of care through the implementation of a clinical path for patients receiving transurethral prostatectomy. METHODS: We selected ten quality indicators with important clinical relevance as representative elements of the clinical path. These quality indicators were monitored during the entire hospitalization period of 100 consecutive patients who received transurethral prostatectomy. Monitoring data obtained from these patients were compared to data from 100 patients who received transurethral prostatectomy prior to implementation of the clinical path. Data was assessed to determine the relationship between quality indicators and management processes. RESULTS: Implementation of the clinical path for transurethral prostatectomy significantly decreased the percent of patients with incomplete preoperative tests on admission day, the duration of intravenous antibiotics administration, the percent of patients who required acute pain management postoperatively, the percent of patients who received postoperative bladder irrigation with normal saline and the percent of patients who had their Foley catheter removed after postoperative day 2. Three of the quality indicators had a significant relationship with management processes and may have directly affected the total admission charges. CONCLUSIONS: To evaluate the effect of the transurethral prostatectomy clinical path implementation on the quality of medical care, we compared ten quality indicators before and after implementation of this path. We concluded that implementation of the clinical path resulted in a statistically significant improvement in the quality of medical care.     

Quality assurance in radiotherapy

The quality assurance plays an exceptionally important role in radiation oncology. It must include the following areas: The medical indication and the therapeutic concept, the planning, the therapy, the education of the staff as well as the technical supervision of the used installations. The use of a clinic information system and of a portal vision system can support the quality assurance fundamentally.     

Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation

OBJECTIVES: To compare the effects of dry needling of myofascial trigger points in the neck region to metoprolol in migraine prophylaxis. DESIGN: Randomized, group comparative study. patients, investigator and statistician were blinded as to treatment, the therapist was blinded as to results. SETTING: Outpatient pain clinic in the northern Copenhagen area. Patients were referred by general practitioners or respondents to newspaper advertisements. SUBJECTS: Included were patients with a history of migraine with or without aura for at least 2 years. Excluded were persons with contraindications against treatment with beta blockers, chronic pain syndromes, pregnancy or previous experience with acupuncture or beta-blocking agents. A total of 85 patients were included; 77 completed the study. INTERVENTIONS: After a 4-week run-in period, patients were allocated to a 17-week regimen either with acupuncture and placebo tablets or to placebo stimulation and metoprolol 100 mg daily. RESULTS: Both groups exhibited significant reduction in attack frequency (P < 0.01). No difference was found between the groups regarding frequency (P > 0.20) or duration (P > 0.10) of attacks, whereas we found a significant difference in global rating of attacks in favour of metoprolol (P < 0.05). CONCLUSIONS: Trigger point inactivation by dry needling is a valuable supplement to the list of migraine prophylactic tools, being equipotent to metoprolol in the influence on frequency and duration (but not severity) of attacks, and superior in terms of negative side-effects.     

Premedication with midazolam in children. Effect of intranasal, rectal and oral routes on plasma midazolam concentrations

We report a study performed to compare the time and plasma drug concentrations necessary to achieve a similar state of sedation after midazolam premedication given by various routes in children of 2-5 years old. Children were randomly allocated to one of three groups to receive midazolam 0.2 mg.kg-1 given intranasally, 0.5 mg.kg-1 given orally or 0.3 mg.kg-1 given rectally. Sedation was measured regularly until venepuncture was possible in a cooperative child. At this time, a first blood sample was taken to measure plasma concentration, followed by another 10 min later. Anaesthesia consisted of intravenous propofol supplemented with regional analgesia. At recovery from anaesthesia, a third blood sample was taken. Adequate sedation occurred sooner (7.7, SD 2.4 min) with intranasal than oral (12.5, SD 4.9 min) or rectal (16.3, SD 4.2 min) midazolam. The initial blood levels were lower when the drug was given by the alimentary routes despite higher doses (146, SD 51 ng.ml-1 in 11.5, SD 3.9 min; 104, SD 34 ng.ml-1 in 21 +/- 6 min; and 93, SD 63 ng.ml-1 in 23.1, SD 3.5 min for the intra nasal, rectal and oral routes respectively). Duration of surgical procedures, and of propofol infusion, and recovery from anaesthesia was similar for the three groups. The only problem arose in a 30-month-old boy in the intranasal group who developed respiratory depression with a plasma midazolam concentration of 169 ng.ml-1. Intranasal midazolam is an excellent alternative for rapid premedication provided that respiratory monitoring is used.     

Construct validity of the computerized version of the Category Test

PURPOSE: This study compared the sedative effects of sublingual tablet midazolam (Roche Dormicum 7.5 mg) with the oral route as premedication. METHODS: One hundred ASA physical status I and II gynaecological patients were randomly selected to receive a 7.5 mg tablet of midazolam either sublingually or orally as premedication about one hour before elective surgery. There were 50 patients in each group. The degree of sedation was assessed according to the Ramsay scale initially and then at 20, 30, 45 and 60 min intervals by a second observer blinded to the route of administration. The time for complete drug dissolution was studied in the sublingual group by the inspection of tablet residue under the tongue every five minutes for 20 min, then the patients were interviewed regarding their acceptance of taste. RESULTS: The sedation scores in the sublingual group were higher than in the oral group at 30 and 60 min after drug administration. (P = 0.0054 and P = 0.008) Seventy-two percent of the sublingual group had complete drug dissolution within 10 min and 64% of the patients in the sublingual group found the tablet acceptable with regard to its taste. CONCLUSION: Midazolam 7.5 mg sublingual is a more effective pre-anaesthetic sedative than by the oral route.     

Inhaled induction and emergence from desflurane anesthesia in the ambulatory surgical patient: the effect of premedication

We studied the effect of premedication (1 microgram/kg fentanyl and 0.04 mg/kg midazolam 5 min before induction of anesthesia) on airway reactivity and hemodynamic stability during inhaled induction using desflurane in 10 ambulatory surgical patients. Eight patients who were anesthetized without premedication served as the controls. Induction and emergence were rapid and unaffected by premedication. End-tidal and inspired concentrations of desflurane at loss of consciousness were significantly reduced by premedication (10.1% end-tidal/14.1% inspired, no premedication, vs. 5.3% end-tidal/8.9% inspired, premedication). Airway irritability was markedly attenuated by premedication (100% no premedication versus 30% premedicated), as was apnea (37.5% no premedication versus 0% premedicated). We observed an increase in mean arterial blood pressure and heart rate after loss of consciousness (mean arterial pressure 103 vs 121 mm Hg, heart rate 73 vs 100 bpm) in the unpremedicated patients, whereas both groups demonstrated a decrease in mean arterial blood pressure with no change in heart rate when baseline values were compared to those at incision (103 vs 74 mm Hg, no premedication, 99 vs 81 mm Hg premedicated). Patient acceptability was satisfactory and unchanged by premedication. We recommend the use of such premedication when desflurane is used during the induction of anesthesia.     

Should interstitial thermometry be used for deep hyperthermia?

This study was performed to determine whether premedication with midazolam and fentanyl prevents reliable detection of an i.v. lidocaine test dose. Thirty ASA physical status I or II patients received either 3 mL of saline or 1.5 mg of midazolam (1.5 mL) plus 75 microg of fentanyl (1.5 mL) i.v. in a randomized, double-blind fashion. Five minutes later, lidocaine 1 mg/kg was injected i.v. At 1.5 min before and every minute after lidocaine administration, each subject was questioned regarding the presence of four symptoms of systemic lidocaine toxicity. Any new tinnitus, perioral numbness, metallic taste, or light-headedness within 5 min after lidocaine administration was considered a positive response. All 15 patients in the saline group (100% sensitivity) had a positive response to i.v. lidocaine, but only 9 of 15 patients in the sedation group had a positive response (60% sensitivity; P = 0.017). We conclude that midazolam and fentanyl premedication decreases the reliability of subjective detection of i.v. lidocaine. Implications: Anesthesiologists often rely on subjective symptoms to prevent local anesthetic toxicity while performing regional anesthesia. Sedatives are often administered during the administration of regional anesthesia. This study demonstrates that typical sedation decreases the reliability of detection of local anesthetic toxicity by subjective symptoms.     

Modulation of the stress response in children in the preoperative preparation

Anxiolysis with drugs and psychoprophylaxis are both recognised methods of preoperative preparation. The beneficial effects of anxiolytics, however, appear to be difficult to prove. In this study a comparison was made of heart rate (HR), blood pressure (BP), and norepinephrine, epinephrine, and cortisol levels. In group I 19 children received only psychological treatment, while in group II 21 children received 0.2 mg/kg midazolam orally. Measuring points were directly before medication, 30 min afterward, and at induction of anaesthesia. During the observation period the patients (5-10 years old) remained calm. At the beginning of the study the parameters of all patients were within a normal range; 30 min after premedication the HR and BP were significantly higher in group I than in group II. In contrast to group I, epinephrine levels in group II were lower at the beginning of anaesthesia than before premedication. In both groups, norepinephrine levels were the same at induction of anaesthesia as before premedication. Cortisol decreased only in patients who received midazolam. HR, BP, as well as humoral stress parameters indicate that midazolam in a dose of 0.2 mg/kg orally is sufficient to reduce preoperative stress in children.     

优质优价与质量监督管理

太钢内部工序间实行优质优价,涉及到物流管理,技术标准、质量监督、价格管理、计量管理等方面,本文着重从质量监督管理角度出发,论述了公司内部工序实行优质优价的进展情况,以及质量监督管理在各个阶段的作用,并根据工作体会谈了对优质优价工作的认识及其展望。     

Early pregnancy termination with mifepristone and misoprostol in the United States

BACKGROUND: Mifepristone and a prostaglandin have been used successfully to terminate pregnancy in Europe and China. We report the results of a large U.S. study of mifepristone and misoprostol in women with pregnancies of up to nine weeks' duration. METHODS: We administered 600 mg of mifepristone and then 400 microg of misoprostol two days later to 2121 women seeking termination of their pregnancies at 17 centers. The women were observed for four hours after the administration of misoprostol and returned on day 15 for final assessment. RESULTS: Two thousand fifteen women completed the final assessment. Among them, pregnancy was terminated in 762 of the 827 women pregnant for < or =49 days (92 percent), 563 of the 678 women pregnant for 50 to 56 days (83 percent), and 395 of the 510 women pregnant for 57 to 63 days (77 percent) (P<0.001). Termination occurred within 4 hours after the administration of misoprostol in 49 percent of the women and within 24 hours in 75 percent. Failures, defined as cases requiring surgical intervention for medical reasons or because the patient requested it, the abortion was incomplete, or the pregnancy was ongoing, increased with increasing duration of pregnancy. The largest increase was in failures representing ongoing pregnancy, which increased from 1 percent in the < or =49-days group to 9 percent in the 57-to-63-days group (P<0.001). Abdominal pain, nausea, vomiting, diarrhea, and vaginal bleeding also increased with advancing gestational age. Two percent of the women in the < or =49-days group, as compared with 4 percent in each of the other two groups, were hospitalized, underwent surgical interventions, and received intravenous fluids (P=0.008). CONCLUSIONS: This mifepristone-misoprostol regimen is effective in terminating pregnancies, especially in women with pregnancies of 49 days' duration or less.     

Subtalar staple arthroereisis for planovalgus foot deformity in children with neuromuscular disease

This double-blinded study was undertaken to prospectively evaluate the role of halothane and sevoflurane and the use of IV ketorolac on the anesthetic emergence in a group of children undergoing bilateral myringotomy with pressure equalization tube procedures. Two-hundred ASA physical status I and II patients were premedicated with nasal midazolam (0.2 mg/kg) and randomized to one of four groups (Group 1 - halothane and ketorolac; Group 2 - halothane and placebo; Group 3 - sevoflurane and ketorolac; Group 4 - sevoflurane and placebo). A blinded nurse observer characterized the quality of the anesthetic emergence and recorded the incidence of emesis and the use of pain medications in the recovery room. There were no differences in age, weight, previous anesthetic experience, or duration of anesthesia among the four groups. There was no difference in the incidence of emergence agitation for patients anesthetized with sevoflurane compared with halothane, regardless of whether they received ketorolac or placebo. Regardless of the anesthetic, the incidence of emergence agitation was significantly less in patients who received ketorolac compared with patients who received placebo. The incidence of emesis in the recovery room, the total 24-h incidence of emesis, and the use of at-home pain medications were similar in all four groups. IMPLICATIONS: We conclude that the incidence of emergence agitation in children undergoing ultrashort anesthetic procedures is similar for sevoflurane and halothane and that ketorolac markedly diminishes emergence agitation and/or pain behavior.