Timing of Atropine and Neostigmine in the Reversal of Muscle Relaxants

The antimuscarinic effects of atropine were studied in 46 patients to whom neostigmine had been given after operation to reverse the action of a muscle relaxant. Neostigmine was given to alternate patients three minutes after, or together with, atropine, and the effects of the two procedures were compared by measuring the secretions which collected in the buccal and oropharyngeal cavities and observing the heart rate.It was found that the glands of the oral cavity were stimulated to a greater extent when neostigmine was given with atropine than after atropine. Any dose of atropine sufficient to inhibit peristaltic movements of the bowel is more than enough to block completely secretion by the salivary glands, and the appearance of some secretion in all cases after the administration of neostigmine suggests that the bowel was at liberty to react to the neostigmine in every case, but perhaps particularly so when atropine and neostigmine were given mixed. The integrity of an anastomosis of the bowel could be endangered by vigorous peristalsis in the early postoperative period.Electrocardiograms in about half the patients from each group confirmed earlier work that the muscarinic effects of neostigmine on the heart can be prevented by giving the atropine either before or together with the neostigmine.     

连续全遮盖法治疗双眼屈光参差性弱视的有效性与安全性分析

目的:探讨连续q全遮盖法治疗双眼屈光参差性弱视的有效性与安全性。方法:选择2014年2月到2016年9月在我院诊治的126例双眼屈光参差性弱视患儿作为研究对象,根据治疗方法的不同分为阿托品组60例与遮盖组66例,遮盖组采用连续全遮盖法治疗,阿托品组给予阿托品治疗,两组都治疗观察3个月。比较两组治疗期间不良反应的发生情况、治疗后的总有效率、最佳矫正视力、电位潜伏期、波幅。结果:两组治疗期间都无严重不良反应发生。治疗后,遮盖组与阿托品组的总有效率分别为98.5%和88.3%,遮盖组的总有效率明显高于阿托品组(P0.05)。两组治疗后的最佳矫正视力都高于治疗前,且遮盖组治疗后的最佳矫正视力也明显高于阿托品组(P0.05)。两组治疗后的电位潜伏期都较治疗前明显缩短,而波幅明显增强(P0.05),且遮盖组治疗后的潜伏期明显短于阿托品组,而波幅显著强于阿托品组(P0.05)。结论:连续全遮盖法治疗双眼屈光参差性弱视具有很好的安全性,能提高患儿的治疗效果,改善视力,促进神经元的兴奋性。     

Adverse Reactions to Radiographic Contrast Material

Major adverse reactions to radiographic contrast media will occur more often as contrast material is now also administered during computerized tomographic (CT) scanning. Differentiation of the two major contrast reactions, the vagus reaction and the anaphylactoid reaction, is essential. Bradycardia is the key finding for identifying the vagus reaction. The vagus reaction involving hypotension and bradycardia requires treatment with large doses of atropine given intravenously. The immediate generalized reaction or anaphylactoid reaction should be treated as anaphylaxis with administration of vasopressors, fluids, steroids and antihistamines. Steroids and antihistamines given before the examination may offer protection to those high-risk patients who have had previous anaphylactoid reactions to contrast material.     

Diagnosis of pseudomembranous colitis.

Twenty-eight patients with histologically proved pseudomembranous colitis have been seen in one hospital since July 1975. All patients with the disease had received antibiotics, six for infections not requiring operations; the other 22 cases all occurred after major surgery. All the patients had diarrhoea; six patients also had fever with clinical signs of sepsis, and three had abdominal pain thought to be due to anastomotic dehiscence after colonic resection. Pseudomembranous colitis was associated with white blood counts over 15 000/mm3 in 17 patients and albumin concentrations of less than 30 g/1 in 18. Pseudomembranous colitis was an incidental finding at necropsy in two of six patients who had not had an operation. Of the 22 patients who had had major surgery, nine died from this complication; in all except two of these cases the diagnosis was made only at necropsy. If pseudomembranous colitis is suspected on clinical grounds or if there is an unexplained complication after colorectal surgery repeat sigmoidoscopy and testing for faecal toxins should be carried out to establish the diagnosis so that prompt supportive treatment can be given.     

Effects of cholinergic stimulation and antagonism on plasma insulin concentration in lean and obese human subjects

The effect of cholinomimetic stimulation by infusion of edrophonium chloride or muscarinic blockade by infusion of atropine sulfate on insulin and GIP secretion was studied in normal lean subjects during eu- and hyperglycemia. Cholinomimetic stimulation led to a slight non-significant increase and muscarinic blockade to a slight, non-significant suppression of both GIP and insulin. No modification of the insulin secretion pattern was observed under either condition during hyperglycemia. The effect of atropine infusion on fasting plasma insulin and GIP was subsequently studied in 11 obese patients and 10 lean subjects. Muscarinic antagonism by atropine led to a transient non-significant suppression of GIP and insulin in lean subjects, but to a significant, sustained suppression of these hormones in obese patients. Insulin and GIP levels were however, not suppressed to control values after atropine administration in obese patients. A positive correlation was found between fasting plasma insulin and maximal suppression of insulin attained during the 30 min following administration of atropine. It is concluded that part of the hyperinsulinemia observed in human obesity is under the control of the parasympathetic nervous system. An abnormal balance between sympathetic inhibitory and parasympathetic stimulatory tones on insulin secretion, as observed in the VMH lesioned rat, might be present in human obesity.     

Effects of Neostigmine and Atropine on Motor Activity of Ileum,Colon, and Rectum of Anaesthetized Subjects

In unanaesthetized patients atropine and neostigmine in doses normally used by anaesthetists to reverse muscle relaxants produced a pronounced increase in bowel activity. This response occurred whether atropine was given before or simultaneously with neostigmine.The response still occurred in 38% of patients anaesthetized without halothane, and possibly this increase in motility might endanger a recently constructed anastomosis. The ileum appeared particularly prone to neostigmine stimulation, and anastomoses involving ileum would seem especially at risk. When halothane was used during anaesthesia the response was completely inhibited during the period studied.     

Bleeding varices: 1. Emergency management.

The aim of the emergency management of bleeding varices is to stop the hemorrhage nonoperatively if possible, avoiding emergency shunt surgery, an operation that has a higher mortality than elective shunt surgery. Patients with an upper gastrointestinal hemorrhage should undergo endoscopy immediately to verify the diagnosis of bleeding varices. They can then be categorized according to whether they stop bleeding spontaneously (group 1), continue to bleed slowly (group 2) or continue to bleed rapidly (group 3). Group 1 patients are discussed in the second part of this two-part series. Group 2 patients are initially treated with vasopressin given intravenously; those who fail to respond should undergo emergency angiography and receive vasopressin intra-arterially. If this fails, patients at low surgical risk should undergo urgent shunt surgery; those at high risk do better with endoscopic sclerotherapy. Group 3 patients are also given an intravenous infusion of vasopressin. Patients at low surgical risk who continue to bleed then receive tamponade with a Sengstaken--Blakemore tube. If this fails, they undergo emergency creation of an H-shaped mesocaval shunt. Patients at high surgical risk who fail to respond to vasopressin given intravenously are next treated intra-arterially. If this fails they are given either endoscopic or transhepatic sclerotherapy.     

Effects of epidural lidocaine analgesia on labor and delivery: A randomized, prospective, controlled trial

Background

Epidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems.

Methods

We performed an extensive systematic review to find published cohorts of use of epidural catheters during vascular, cardiac, and thoracic surgery, using electronic searching, hand searching, and reference lists of retrieved articles.

Results

Twelve studies included 14,105 patients, of whom 5,026 (36%) had vascular surgery, 4,971 (35%) cardiac surgery, and 4,108 (29%) thoracic surgery. There were no cases of epidural haematoma, giving maximum risks following epidural anaesthesia in cardiac, thoracic, and vascular surgery of 1 in 1,700, 1 in 1,400 and 1 in 1,700 respectively. In all these surgery types combined the maximum expected rate would be 1 in 4,700. In all these patients combined there were eight cases of transient neurological injury, a rate of 1 in 1,700 (95% confidence interval 1 in 3,300 to 1 in 850). There were no cases of persistent neurological injury (maximum expected rate 1 in 4,600).

Conclusion

These estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding.     

Lip reconstruction following Mohs' surgery: the role for composite resection and primary closure

Surgical outcomes and patient satisfaction with composite resection and primary closure for the management of upper-lip defects following Mohs' surgery were evaluated. Twenty-seven patients underwent upper-lip reconstruction following Mohs' surgery from 1993 to 1997. Twelve of these patients were selected for this report based on adequate follow-up examinations and photographs. There were nine women and three men with a mean age of 46 years (range, 33 to 70 years). Eleven patients underwent Mohs' surgery for basal cell carcinoma and one patient for squamous cell carcinoma of the upper lip. The defects varied in size and location, often extending beyond a single aesthetic subunit. The reconstruction was performed an average of 7 days after Mohs' surgery (range, 1 to 23 days). In 50 percent of the cases, a full-thickness excision was performed, which included orbicularis oris and inner-lip mucosa. The functional results were graded as near normal to normal in all cases. There were no observed changes in oral continence, eating or speech. Two patients experienced numbness medial to the operative site, but this had no adverse affect on lip function. The aesthetic results were graded as very good to excellent in all cases. Eleven of the 12 patients were satisfied with their lip appearance and function. Conventional wisdom dictates that during reconstruction of upper-lip defects, one should attempt to maintain a majority of the uninvolved tissue for the best result. Although these techniques result in wound closure, they fail to consider lip aesthetics. By using a vertically oriented composite resection of the tipper lip with the additional resection of uninvolved tissue, normal lip architecture is maintained. In our experience, this results in a superior aesthetic and functional result.     

The rebound excitation triggered by anticholinergic drugs from ovine pyloric antrum, small bowel and gallbladder.

The effect of anticholinergic drugs on gastrointestinal motility is complex and incompletely recognized. Accordingly, in 6 adult sheep bipolar electrodes and strain gage force transducers were surgically attached to the antral, small intestinal and gallbladder wall at the serosal side. During chronic experiments the myoelectric and mechanical recordings were performed in fasted and non-fasted animals before and after various doses of hexamethonium, atropine and pirenzepine given intravenously. Hexamethonium administration triggered rebound excitation after an inhibitory period almost in all the recording sites. Administration of atropine and pirenzepine evoked these secondary contractions mostly in the small intestine and gallbladder. No rebounds were observed when the anticholinergic drugs were given during feeding. In fasted animals, rebound excitation arrived later but more frequently than in non-fasted animals. The excitatory changes were dose-dependent. In the gallbladder, these values were lower than in the small intestine. The frequency of the recurrent pattern was dependent upon the dose of the anticholinergic drug used. It is concluded that nicotinic receptors are more important than muscarinic receptors in the initiation of the rebound excitation in pyloric antrum while in the small bowel and gallbladder the role of both cholinergic receptors is similar. The anticholinergic drugs should be used with caution in all these clinical situations, where the enhancement of gastrointestinal motility must be avoided.     

Medical Aspects of Chemical Warfare

The first-aid treatment of mass casualties from nerve gas relies mainly upon the use of drugs, and provision for their self-injection is recommended. Means for giving artificial respiration must also be provided, even though its large-scale use is regarded as impracticable. Prophylactic oxime (2 g. PAM chloride orally) is recommended if the situation permits. Some nerve gases are extremely rapid in action, and following exposure (or suspicion of exposure) 4 mg. of atropine and 2 g. of PAM chloride should be injected intramuscularly without delay. Preferably, atropine should be given intravenously. At the same time any clothing contaminated with liquid nerve gas should be removed and the skin cleansed thoroughly with a suitable fluid. Following this, the casualty should be watched closely for one hour. If poisoning develops despite these measures, or is already established, injection of atropine should be continued at short intervals until improvement occurs.     

Action exerted by atropine sulfate on the luteinization phenomenon induced by a total gonadotropic preparation of prehypophysis at several stages of the estrus cycle in the rat

These experiments explored the effect of 70 mg atropine sulfate, and several doses of Gonadormone Byla, given at 1700 on diestrous I or at 1700 on diestrous II in the strains WI and WII rats derived in the authors' laboratory from Wistar rats. In Experiment 1 300 rats, 30 per group, received 2.5 or 5.0 mouse units of Gonadormone per 100 gm body weight at 1700 of diestrous I, with or without atropine, and were killed for serial ovarian sections at 1100 of proestrus. The 2.5 unit experime nt generated significant differences in frequency of luteinization between season of the year (p less than .001), between atropine and no atropine treatment (p less than .001), and season of atropine administration (p less than .05). Atropine decreased frequency of luteinization defined as proportion of a group having luteinized with or without retained ova. There were no differences in mean coefficients of ovulation, i.e., mean proportion of ovulated corpora lutea in each rat among all luteinized follicles, between rat strains or atropine treatments. The 5 unit dose of gonadotropin per 100 gm body weight increased luteinization 100% over the 2.5 unit dose. In the 2nd series of 180 rats, the frequency of luteinization induced by 1.25 units of gonadotropin was decreased by atropine (p less than .01), but the frequency of ovulation and response in the 2 rat strains did not differ. The results were interpreted as due in part to endogenous gonadotropin release, although atropine was thought to act directly on the ovary.     

椎体后凸成形术治疗老年骨质疏松脊柱压缩骨折的临床分析

目的分析老年骨质疏松脊柱压缩骨折行椎体后凸成形术的治疗方法及临床效果,为临床提供依据。方法回顾性分析我院2014年10月~2015年10月收治的老年骨质疏松脊柱压缩骨折患者40例的临床资料,全部患者均为椎体后壁完整疼痛性骨质疏松脊柱压缩骨折,均接受椎体后凸成形术治疗,经双侧椎弓根、椎弓根旁置入可扩张球囊,将骨折塌陷椎体进行复位,采取骨水泥填充球囊扩张产生的椎体内空腔,术后观察患者症状改善和骨折复位情况。结果 40例患者手术均顺利完成,术后48h内患者疼痛显著缓解,骨折椎体前缘以及中部高度丢失,从手术前的(12.5±2.2)mm、(9.1±1.3)mm减少到手术后的(4.6±1.4)mm、(3.3±1.0)mm;后凸畸形Cobb角从手术前的(22.2±5.1)°矫正到手术后的(9.1±4.6)°,其中1例患者术后出现少量骨水泥渗漏,1例患者手术过程中一侧穿刺管中出现脑脊液,即停止该侧手术。结论老年骨质疏松脊柱压缩骨折行椎体后凸成形术治疗效果显著,可以快速缓解患者的疼痛,使患者脊柱序列得到恢复,值得临床推广使用。     

Mechanism of tachycardia caused by intracarotid PGE2 in conscious ewes

Conscious adult ewes prepared with nonocclusive indwelling vascular catheters were used to determine the mechanism by which heart rate increases during central administration of prostaglandin E2 (PGE2). Heart rate increased 14 bpm during steady-state intracarotid infusion of PGE2, 10 ng/kg/min (P less than 0.05). Intravenous atropine methyl bromide, 1 mg/kg, increased heart rate 26 bpm (P less than 0.05) 5 min after injection. Heart rate remained elevated 30 min after injection. The heart rate response to PGE2 plus atropine was greater than the heart rate response to either atropine or PGE2 alone (P less than 0.05). Propranolol, 1 mg/kg bolus plus intravenous infusion, 0.025 mg/kg/min, did not change resting heart rate. Propranolol attenuated but did not abolish the increase in heart rate caused by intracarotid PGE2. Although heart rate increased in response to PGE2 after administration of either propranolol or atropine alone, the combination of propranolol and atropine prevented any further increase in heart rate during subsequent PGE2 infusion. The increase in heart rate when all three drugs were given together was not different from the increase observed during atropine alone. Thus, both beta-adrenergic activation and muscarinic deactivation contribute to the PGE2-induced tachycardia.     

Rectal administration of metronidazole in severely ill patients.

Ten severely ill patients with life threatening sepsis received metronidazole as suppositories and blood concentrations of the drug were measured twice daily over five days. Therapeutic blood concentrations of metronidazole were maintained at all times in all patients. Rectal administration of metronidazole is accepted as effective prophylaxis against infection associated with surgery and as treatment of established infection. This study shows that in gravely ill patients metronidazole administered as suppositories gives perfectly adequate therapeutic serum concentrations of the drug, but that to achieve these concentrations rapidly the first suppository should be given with an intravenous loading dose.     

Treatment of primary hyperparathyroidism with cyclofenil--a synthetic stilbestrol derivative with minimal feminizing effects

In eight patients with primary hyperparathyroidism (HPT) the laboratory effects of cyclofenil, which is a synthetic stilbestrol derivative with weak feminizing effects, were studied over a period of 5-13 weeks. In all the patients there were during treatment clear reductions of the serum calcium levels as well as the urinary excretions of calcium and hydroxyproline. These findings are in accordance with earlier reports that oestrogens reduce bone resorption mediated by parathyroid hormone. It has previously been demonstrated that cyclofenil can be given, on other indications, for several years to both male and female patients without oestrogenic side-effects. This pilot study, therefore, indicates that treatment with cyclofenil might be of value in some cases of primary HPT where surgery is not considered.     

Concentration of unconjugated adrenogenic hormones and their precursors in normal and polycystic ovaries.

Dehydroepiandrosterone, androstenedione, testosterone, pregnenolone and progesterone concentration was determined by our sensitive gas-liquid chromatographic method in ovarian tissues obtained from surgery of patients without hirsutism and with Stein-Leventhal syndrome. The steroids, except testosterone, were detectable in all ovaries studied. Dehydroepiandrosterone and androstenedione, regarded as preandrogens, were present in an increased amount in almost all patients with polycycstic ovaries. Gas chromatographic evidence was obtained for the presence of testosterone in two of the cases. The delta4/3betaOH ratio reflecting 3beta-hydroxysteroid dehydrogenase activity was decreased only in same patients with the Stein-Leventhal syndrome suggesting that the impaired function of this enzyme is not an obligatory feature of polycystic ovaries. Concentration of pregnenolone and progesterone measured in a part of cases varied in a great range although the determination was caried out before luteal phase. Simultaneous determination of hormones in both ovarian tissues revealed an active and an inactive period of the gland in the given time, since a great difference of hormone concentration in bilateral ovarian tissues were observed. A comparison of hormone content in ovaries and the urinary excretion of metabolites showed poor correlation between the two parameters of hormone production.     

Differences in cardiac but not in neuroendocrine responses in healthy volunteers after administration of two antimuscarinic agents, atropine and pirenzepine

Neuroendocrine and cardiac responses were studied in healthy volunteers with the classical muscarinic antagonist, atropine and the new antimuscarinic agent, pirenzepine. The secretion of prolactin (PRL) and growth hormone (GH) was increased after metoclopramide. Typically, an antidopaminergic drug such as metoclopramide decreases rather than increases GH concentrations in serum. Pretreatment with both atropine and pirenzepine abolished the increase of GH secretion, which suggests an important role of cholinergic mechanisms in the regulation of GH secretion. The increase of PRL secretion was not inhibited by the two muscarinic antagonists. With the doses used, antimuscarinic activities in serum were comparable after atropine and pirenzepine treatments for the most part of the study. Heart rate was, however, significantly increased during atropine and higher than during saline or pirenzepine treatments throughout the study period. When compared to placebo, pirenzepine lowered heart rate slightly but significantly. The exact mechanism of this effect is unclear. We conclude that in contrast to the identical neuroendocrine effects, the cardiac responses clearly differ during atropine and pirenzepine treatments which confirms the ability of pirenzepine to distinguish muscarinic receptor sites in the central nervous system from those of the heart.     

Adjunctive pharmacologic treatment for elective stenting of the extracranial carotid arteries

Endovascular stenting of the extracranial carotid arteries is a viable treatment option to carotid endarterectomy in selected patients. Patients undergoing this procedure must be treated with aspirin 325 mg at least 24 hours prior to the procedure and clopidogrel 75 mg oral, three to five days prior to the procedure (or 300 mg at least six hours prior to stenting). During the intervention, heparin is given to maintain an activated clotting time of at least 300 seconds. Although there are theoretical advantages on the use of a platelet IIb/IIIa inhibitor, their routine use during elective carotid stenting is not recommended until their clinical benefits have been clearly demonstrated in this patient population. Hemodynamic instability during balloon inflation and stent deployment should be treated with intravenous fluids, atropine, and an alpha agonist such as neosynephrine. All the oral antihypertensive must be discontinued after the procedure and if there is persistence of hypotension making discontinuation of neosynephrine difficult, an oral alpha agonist such as midodrine (2.5 to 5 mg two to three times daily) is helpful. In the majority of patients this medication can be tapered off three to five days following stenting.     

Supportive therapy of lung cancer patients

The effectiveness of cancer treatment given to lung cancer patients is indicated by the asymptomatic and non-toxic survival time. The goal is not to prolong the patients' suffering, but to lengthen the duration of the best quality of life lived (Time Without Symptoms and Toxicity-TWIST). Supportive care is the prevention and management of side effects which occur during therapy (chemotherapy, radiotherapy, surgery) given to patients suffering from cancer. Supportive care is the widespread activity of doctors, nurses and social workers, including psychosocial assistance and rehabilitation through the various stages of illness till death. Though palliative therapy is understood to be the high level and professional treatment of terminally ill patients in those cases where curative measures are not possible anymore, supportive and palliative treatment often overlap (e.g. pain control, cachexia, obstructive syndromes). Palliative care is part of supportive therapy. The goal of supportive care is to reduce the patients' subjective symptoms to the minimum ("well being") during therapy, follow up and consequently until death. The essence of supportive care is to keep the patients' quality of life on the highest possible level. This article summarizes the pathophysiology, prevention and therapy of the most frequently occuring side effects observed during the management of lung cancer patients.