Implantable automatic cardioverter-defibrillator: anesthesia experience

To evaluate the anesthetic management and intraoperative events in patients benefiting from an automatic implantable cardioverter defibrillator. We retrospectively reviewed the charts of 12 male patients in whom we had placed automatic implantable defibrillators (AID). In particular we assessed anesthetic management, recording type of anesthetic and intraoperative monitoring, the technique used to implant the AID and complications during and after surgery. Arterial pressure and heart rate were also analyzed. All patients experienced tachyarrhythmia or ventricular fibrillation. Ten of the 12 patients presented left ventricular ejection fractions (LVEF) between 21 and 28%; LVEF in the other 2 patients exceeded 30% (45 and 62%). All experienced statistically significant decreases in arterial pressure coincident with fibrillation. Three patients required dobutamine for sustained hypotension. Six presented ventricular extrasystoles during surgery. Late complications included 1 sudden death after surgery and 1 infection which obliged removal of the AID. AID implantation is not risk-free, given that the patients involved have heart disease with considerable degrees of deterioration in myocardial function. Nevertheless, with extensive preoperative examination of the patient and proper anesthetic management, complications before and after surgery are rare.     

Usefulness of electromyographic techniques of the bulbocavernosus muscle in the diagnosis of neurogenic impotence

OBJECTIVE: To analyze the utility of electromyographic study of the bulbocavernosus muscle. METHODS: 126 impotent patients were evaluated by physical examination and neuroandrologic profile. The physical examination consisted in an exploration of the anal tone and the bulbocavernosus reflex. The neuroandrologic profile consisted in selective electromyography of the bulbocavernosus muscle, the determination of the S2-S4 evoked potentials, somatosensory potential of the pudenal nerve, electromyography of cavernous smooth muscle (SPACE) sympathetic skin response and cystometry. RESULTS: The results of the bulbocavernosus electromyography and S2-S4 evoked potentials were different from the data obtained from the physical examination of the anal tone and the bulbocavernosus reflex. Selective bulbocavernosus electromyography showed a sensitivity of 57% and a specificity of 84%. The S2-S4 evoked potentials showed a sensitivity of 61% and a specificity of 100%. The diagnostic value of the S2-S4 evoked potentials increased at 39 msec cutoff (sensitivity = 66%; specificity = 95%). Exploration of the anal tone is very specific for neurologic lesion in impotence (93%), but has a low sensitivity (30%). The clinical bulbocavernosus reflex showed a good specificity (85%) and sensitivity (75%) in the diagnosis of pudendal efferent lesion, but is less useful in the diagnosis of neurogenic impotence. CONCLUSIONS: The highest diagnostic value was obtained with the S2-S4 evoked potentials. Selective electromyography of the bulbocavernosus muscle showed a moderate diagnostic value. Physical examination of peripheral pudendal innervation does not appear to be useful for screening for neurologic lesion in impotence because of its low sensitivity, which may be due to existing incomplete nervous lesions.     

Squamous carcinoma of the esophagus with extensive pagetoid dissemination

A case of squamous carcinoma of the esophagus with pagetoid spreading in a 59-year-old male in presented. Signs of glandular differentiation (PAS-diastase, Alcian blue) and CEA were negative in the Paget-like cells. Pagetoid spreading of squamous carcinoma and true Paget's disease are very similar histologically and very rare in the esophagus (only 6 cases reported) and they must be differentiated from each other. Paget's disease demonstrates glandular differentiation and the cells are CEA positive. The absence of glandular differentiation in the Paget-like cells of pagetoid spreading versus Paget's disease may be a good criteria to differentiate these diseases.     

A breast cancer case-control study in Girona, Spain. Endocrine, familial and lifestyle factors

This study was designed to explore risk factors for breast cancer with emphasis on the detection of clinical markers of the hormonal imbalance during the perimenarche. Three hundred and thirty women diagnosed with breast cancer and 346 population controls were identified and interviewed in Girona, Spain between 1986 and 89. Cases were more likely than controls to have had long menstrual periods in the first 5 years after menarche [odds ratio (OR) = 3.0], to experience menopause at a late age (OR = 1.5) and to report acne during adolescence (OR = 1.6). Family history of breast cancer was associated with an increased risk (OR = 2.3). Cases reported a lower use of drug treatments for anxiety and sleep disorders than controls. Moderate alcohol drinkers and smokers were at lower risk for breast cancer. No statistically significant association with breast cancer was observed for number of children, age at last pregnancy, oral contraceptive use, hormonal treatment after menopause and weight perception during the teenage years. Hormonal changes in the years following menarche may be relevant to breast cancer risk. The roles of menstrual period length and acne during adolescence should be further explored.     

Postoperative analgesia in herniated disk surgery. Comparative study of diclofenac , lysine acetylsalicylate, and ketorolac

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating musculoskeletal pain and are theoretically ideal for treating postoperative pain of the lumbar column. OBJECTIVES: To compare the analgesic efficacy and side effects of treatment with 3 NSAIDs (lysine acetylsalicylate, ketorolac and diclofenac) in the treatment of pain after surgery for lumbar disc hernia. PATIENTS AND METHODS: We enrolled 75 ASA I-II patients undergoing discectomy because of lumbar disc hernia; balanced general anesthesia was used in all cases. The patients were randomly distributed in 3 groups based on type of analgesia given in the immediate postoperative period. Group A received lysine acetylsalicylate (1800 mg), group B received ketorolac (30 mg) and group C received diclofenac (75 mg). The analgesics were diluted in 100 mg of saline solution and administered through a peripheral vein over 10 min. We evaluated the analgesia attained on a visual analog scale (VAS) and the physiological response to pain was assessed by monitoring changes in arterial pressure, heart rate and breathing frequency. If analgesia was insufficient 30 min after administration of the drug, 200 mg of lysine cloximate was given as a top-up. The side effects of each drug were also recorded. RESULTS: VAS evaluation showed significant reductions in pain 60 min after administration in groups A and B and after 120 min in group C. Nine patients in each group required lysine cloximate. There were no significant differences in physiological response among the 3 groups. No patient suffered major side effects. Mild side effects were reported most often in group B. CONCLUSIONS: The NSAIDs studied were inadequately for treating pain after surgery for lumbar disc hernia. Ketorolac was no better than the other analgesics studied but was associated with a higher number of mild side effects.     

Urethral protrusion caused by blunt trauma of the anterior urethra

We report an uncommon case of complete rupture of the anterior urethra secondary to blunt trauma, with protrusion of the urethral mucosa through the urinary meatus. The singular images of this case are presented and the mechanisms involved in this unusual type of lesion are analyzed.