The use of nefopam in the prophylaxis and treatment of postoperative shivering]

Chlorhydrate nefopam was used in the prophylaxis and treatment of postoperative shivering in 54 patients undergoing general anesthesia for radical cystectomy with trans-intestinal anastomosis. Postoperative shivering was not observed in any of the patients treated with nefopam before coming round, whereas it occurred in 55% of patients treated with placebo. Chlorhydrate nefopam subsequently stopped shivering in all these patients. The main side effects observed took the form of delayed awakening in 11% of patients receiving prophylactic treatment and somnolence lasting 5-10 minutes in all other patients.     

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.     

Electrospray ionisation mass spectrometry facilitates detection of fibrinogen (Bbeta 14 Arg --> Cys) mutation in a family with thrombosis

We report the first direct detection of a fibrinogen mutation by electrospray ionisation mass spectrometry. The propositus, from a family with a history of thrombosis, came to attention after a pulmonary embolism subsequent to a spontaneous abortion. Prolonged thrombin (41 s) and reptilase times (26 s) together with an impairment of fibrinopeptide B release suggested a mutation at the thrombin cleavage site of the Bbeta chain. Direct mass analysis of purified fibrin chains from a thrombin induced clot showed that 50% of the Bbeta chains remained uncleaved. The measured mass of the mono sialo isoform of this uncleaved chain was 54150 Da, compared to a value of 54198 Da for normal Bbeta chains. This decrease of 48 Da in the intact protein is indicative of either a Bbeta 14 Arg to Cys, or Arg to Leu substitution. Heterozygosity for the Bbeta 14 Arg --> Cys mutation was verified by PCR amplification and DNA sequence analysis.     

Postmortem distribution of nicotine and cotinine from a case involving the simultaneous administration of multiple nicotine transdermal systems

A 31-year-old female was found dead with 18 nicotine transdermal system patches taped to her upper body and a plastic bag taped over her nose and mouth (the cause of death was ruled asphyxiation). Nicotine concentrations in biological fluids and tissues were analyzed using a liquid-liquid extraction followed by injection onto and HP-5890 gas chromatograph (GC) equipped with a nitrogen-phosphorus detector. Cotinine was separated from the biological matrices using solid-phase extraction followed by analysis on an HP-5890 GC with flame ionization detection. A variety of specimens were analyzed, including blood, urine, vitreous, brain, liver, and gastric contents. Heart and femoral blood concentrations (1.4 and 0.46 micrograms/mL, respectively) were 175 and 57 times, respectively, the mean C(max) value reported following the proper administration of a single 7-mg/day patch.     

Appendiceal and peri-appendiceal air at CT: prevalence, appearance and clinical significance

AIM: Appendiceal air has been reported as both a sign of appendicitis and of a normal appendix both at plain radiography and computed tomography (CT). It is the aim of this investigation to determine the prevalence, range of appearances, and significance of appendiceal and peri-appendiceal air at CT. PATIENTS AND METHODS: Appendiceal CT scans of 100 patients with proven appendicitis and 100 patients with a normal appendix were reviewed for the presence of appendiceal and peri-appendiceal air. All cases were correlated with surgical and pathological findings or clinical follow-up. RESULTS: In 100 CT cases of appendicitis, appendiceal and/or peri-appendiceal air was present in one or more forms in 31% of cases. When present, it appeared as intraluminal air bubbles (38.7%) or air-fluid levels (22.6%), appendolith air (41.9%), intramural air (16.1%), peri-appendiceal air bubbles (12.9%), or extraluminal air-fluid level(s) (29.0%). Intramural and extraluminal air correlated with perforation in 60% and 100%, respectively. In 100 CT cases of a normal appendix, air was present in 57%. It was always intraluminal and appeared as small bubbles of air (52.6%), a tubular-shaped air collection (43.9%), or as an air-fluid level (3.5%). The appendiceal lumen was either airless (43%), or minimally (32%), moderately (18%), or completely filled with air (7%). CONCLUSION: Air is a common finding at appendiceal CT in both the normal and inflamed appendix. Intraluminal air is seen in both appendicitis and normal appendices, and cannot be presumed to indicate a patent lumen and thus a normal appendix. Appendolith, intramural and peri-appendiceal air appear diagnostic of appendicitis.