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Purpose: Preclinical data demonstrated that the use of proton minibeam radiotherapy reduces the risk of toxicity in healthy tissue. Ventricular tachycardia radioablation is an area under clinical investigation in proton beam therapy. We sought to simulate a ventricular tachycardia radioablation with proton minibeams and to demonstrate that it was possible to obtain a homogeneous coverage of an arrhythmogenic cardiac zone with this technique., Material and Methods: An arrhythmogenic target volume was defined on the simulation CT scan of a patient, localized in the lateral wall of the left ventricle. A dose of 25Gy was planned to be delivered by proton minibeam radiotherapy, simulated using a Monte Carlo code (TOPAS v.3.7) with a collimator of 19 0.4 mm-wide slits spaced 3mm apart. The main objective of the study was to obtain a plan ensuring at least 93% of the prescription dose in 93% of the planning target volume without exceeding 110% of the prescribed dose in the planning target volume., Results: The average dose in the planning treatment volume in proton minibeam radiotherapy was 25.12Gy. The percentage of the planning target volume receiving 93% (V93%), 110% (V110%), and 95% (V95%) of the prescribed dose was 94.25%, 0%, and 92.6% respectively. The lateral penumbra was 6.6mm. The mean value of the peak-to-valley-dose ratio in the planning target volume was 1.06. The mean heart dose was 2.54Gy versus 5.95Gy with stereotactic photon beam irradiation., Conclusion: This proof-of-concept study shows that proton minibeam radiotherapy can achieve a homogeneous coverage of an arrhythmogenic cardiac zone, reducing the dose at the normal tissues. This technique, ensuring could theoretically reduce the risk of late pulmonary and breast fibrosis, as well as cardiac toxicity as seen in previous biological studies in proton minibeam radiotherapy., (Copyright © 2024 Société française de radiothérapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Somatotropinomas are the main cause of acromegaly. Surgery is the primary and most efficient method of treatment. The study aimed to compare the radicality of small-sized and medium (<30 mm) somatotropinoma removal and the incidence of postoperative complications in patients with acromegaly when using microscopic and endoscopic techniques., Methods: In this randomized controlled trial, a total of 83 patients with acromegaly underwent transspheroidal endoscopy or microscopic surgery. Somatotropinoma was the cause of acromegaly in all cases. Patients were randomly divided into two comparison groups depending on the applied surgical technique. Group 1 (n = 40) consisted of patients who underwent adenomectomy with transnasal transsphenoidal access by a microscope. Group 2 (n = 43) included patients who underwent the same surgical procedure with an endoscope. The following indicators were assessed: radicality of tumor removal, treatment effectiveness, postoperative complications, and remission rate., Results: The study has shown that removal of somatotropinoma in patients with acromegaly using endoscopic technique increases the radicality of tumor removal in comparison with microscopic technique. Total removal of somatotropinoma was successful in 88.4% of cases when using the endoscopic technique. Secondly, the segmentation of patients according to their tumor characteristics poses challenges, primarily owing to the rarity of acromegaly as a disease. The difference between groups was not statistically significant (p=1.02). There were no statistically significant differences in basal GH level and IGF-1 level between groups (p=0.546 and p=0.784, respectively)., Discussion: Endonasal transsphenoidal endoscopic adenomectomy is proven efficacy, a less traumatic degree, and higher somatotropinoma removal radicality. Both surgical methods lead to disease remission., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Vassilyeva, Mena, Kirov and Diatlova.)

During the last few decades, bat lyssaviruses have become the topic of intensive molecular and epidemiological investigations. Since ancient times, rhabdoviruses have caused fatal encephalitis in humans which has led to research into effective strategies for their eradication. Modelling of potential future cross-species virus transmissions forms a substantial component of the recent infection biology of rabies. In this article, we summarise the available data on the phylogeography of both bats and lyssaviruses in Europe and the adjacent reg ions, especially in the contact zone between the Palearctic and Ethiopian realms. Within these zones, three bat families are present with high potential for cross-species transmission and the spread of lyssaviruses in Phylogroup II to Europe (part of the western Palearctic). The lack of effective therapies for rabies viruses in Phylogroup II and the most divergent lyssaviruses generates impetus for additional phylogenetic and virological research within this geographical region.

The study aims to investigate perioperative indices and immediate outcomes of laparoscopic and robotic surgical interventions in colorectal cancer patients. The study included 163 patients [90 (55.2%) females and 73 (44.8%) males, aged 67.46 ± 6.72 years, on average] who had surgery for morphologically checked colorectal cancer. Of those, 101 patients had laparoscopic surgery (Group 1), and 62 patients had robot-assisted surgery (Group 2). The study found that the safety profile of both robot and laparoscopic procedures for colorectal cancer is comparable. The total complication rate in the laparoscopic group was 6.9% (in 7 patients), in the robot-assisted group-11.3% (in 7 patients) (χ 2  = 0.93, p = 0.34). Robotic surgery for colorectal cancer is a promising direction for improving patients' level and quality of care with this oncological pathology., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: The exposition of cardiac conduction system during breast radiation therapy has never been studied, despite the increasing use of intensity-modulated radiation therapy, which exposes larger volume to low-dose bath. We evaluated conduction node exposure during breast irradiation with volumetric modulated arc therapy and estimated the potential dosimetric benefit with intensity-modulated proton therapy., Materials and Methods: Atrioventricular (AVN) and sinoatrial (SAN) nodes were retrospectively delineated according to published guidelines on the simulation computed tomography scans of 12 breast cancer patients having undergone conserving surgery and adjuvant locoregional volumetric modulated arc therapy. Intensity-modulated proton therapy treatment was replanned on the simulation computed tomography scans for all breast cancer patients. Mean and maximum doses delivered to the SAN and the AVN were retrieved and compared. Correlation coefficients were calculated between doses to the SAN or the AVN and the whole heart., Results: Average mean doses delivered to the SAN and AVN were 2.8 and 2.3 Gy, respectively, for left-sided irradiation and 9.6 and 3.6 Gy, respectively, for right-sided irradiation. Average maximum doses to the SAN and AVN were 3.5 Gy and 2.8 Gy, respectively, for left-sided irradiation and 13.1 and 4.6 Gy, respectively, for right-sided irradiation. Intensity-modulated proton therapy significantly reduced mean and maximum doses to the SAN and AVN. Correlations between doses to the SAN or AVN and whole heart were usually significant., Conclusion: SAN and AVN can be substantially exposed during breast volumetric modulated arc therapy, especially for right-sided irradiation. Cardiotoxicity studies evaluating conduction node exposure might define dose constraints and criteria for additional cardiac-sparing techniques, such as respiratory techniques or proton therapy, which could benefit patients with underlying rhythmic or conduction disorders., Competing Interests: Conflicts of Interest: The authors have no relevant conflicts of interest to disclose., (©Copyright 2023 The Author(s).)

Background: The epidemiology of Crohn's disease (CD) has changed over the past decades, demonstrating a trend toward increased prevalence in developing countries, while in developed countries, its incidence has stabilized. The study aimed to examine the profile of the key pro-inflammatory cytokines in the serum of patients with CD and establish their association with the severity and activity of the disease., Methods: A total of 61 patients (29 women (47.5%), 32 men (52.5%) aged from 18 to 40 years (mean age (30.42 ± 2.51) years) with the verified diagnosis of CD in the active phase were examined. The control group consisted of 30 healthy people of corresponding age., Results: CD is characterized by a reliable increase of pro-inflammatory cytokines in blood compared to healthy people: tumor necrosis factor-α (TNF-α) - by 4.45 times (137.46 ± 9.72 vs. 30.88 ± 2.08 pg/ml in healthy people, p < 0,001), interleukin-1α (IL-1α) - by 5.08 times (51.55 ± 4.36 vs. 10.14 ± 0.93 pg/ml, p < 0.001), interleukin-6 (IL-6) - by 2.16 times (20.03 ± 1.81 vs. 9.27 ± 0.52 pg/ml, p < 0.001), interleukin-8 (IL-8) - by 2.04 times (25.74 ± 2.05 vs. 12.62 ± 1.16 pg/ml, p < 0.001), and interferon-γ (IFN-γ) - by 5.30 times (208.63 ± 14.29 vs. 39.35 ± 2.40 pg/ml, p < 0.001). The authors have established direct correlations between the Crohn's disease activity index and blood content of TNF-α (r = 0.84, p < 0.013), INF-γ (r = 0.61, p < 0.028); between TNF-α and INF-γ content (r = 0.67, p < 0.023), IL-1α (r = 0.49, p < 0.042), IL-6 (r = 0.40, p < 0.045), and IL-8 (r = 0.51, p < 0.033); INF-γ and IL-1α (r = 0.53, p < 0.040), IL-6 (r = 0.37, p < 0.039), IL-8 (r = 0.44, p < 0.040)., Conclusions: Patients with CD were found to have multiple cytokines (TNF-α, IL-1α, IL-6, IL-8, and IFN-γ,). The content of cytokines correlated positively with the CD activity index., (© 2022. The Author(s).)

Purpose: There is increasing evidence that radiation doses to cardiac substructures are associated with cardiac adverse events. Manual delineation of cardiac substructures is time-consuming, and auto-segmentation of cardiac substructure atlases has consequently been evaluated. However, proper automatic delineation of small substructures, such as the left anterior descending coronary artery, is challenging, and auto-segmentation of cardiac conduction system substructures has never been evaluated, despite multiple reports of radiation-induced arrhythmia after thoracic irradiations. The aim of this study was to propose and evaluate a simplified auto-segmentable functional cardiac atlas., Methods and Materials: We created a cardiac substructure atlas based on 20 computed tomography scans from patients with breast cancer comprising the 4 cardiac cavities, a high-risk cardiac zone as a left anterior descending coronary artery surrogate, and the 2 cardiac conduction nodes. Automatic delineation of this atlas by an atlas-based auto-segmentation algorithm was evaluated on a validation data set, consisting of 20 additional computed tomography scans. Dice similarity coefficients were used to evaluate the concordance level between the manual and the automatic contours; a dosimetric comparison between mean and maximum doses to the manual and to the auto-segmented substructures was additionally performed, based on intensity modulated radiation therapy treatment plans of the patients of the validation set., Results: Average dice similarity coefficient values were 0.78 for the 4 cardiac cavities, 0.65 for the high-risk cardiac zones, 0.56 for the sinoatrial node, and 0.15 for the atrioventricular node. Compared with manual contours, auto-segmented substructures were slightly smaller but the dosimetric parameters were similar., Conclusions: We proposed a simplified functional cardiac atlas that included the cardiac conduction system and circumvented coronary delineation difficulties by using a surrogate high-risk cardiac zone. Most cardiac substructures were associated with acceptable atlas-based auto-segmentation properties. Such an atlas could be used for epidemiologic studies and for clinical practice., (Copyright © 2022 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

A new deuterium-tritium experimental, DTE2, campaign has been conducted at the Joint European Torus (JET) between August 2021 and late December 2021. Motivated by significant enhancements in the past decade at JET, such as the ITER-like wall and enhanced auxiliary heating power, the campaign achieved a new fusion energy world record and performed a broad range of fundamental experiments to inform ITER physics scenarios and operations. New capabilities in the area of fusion product measurements by nuclear diagnostics were available as a result of a decade long enhancement program. These have been tested for the first time in DTE2 and a concise overview is provided here. Confined alpha particle measurements by gamma-ray spectroscopy were successfully demonstrated, albeit with limitations at neutron rates higher than some 10 17 n/s. High resolution neutron spectroscopy measurements with the magnetic proton recoil instrument were complemented by novel data from a set of synthetic diamond detectors, which enabled studies of the supra-thermal contributions to the neutron emission. In the area of escaping fast ion diagnostics, a lost fast ion detector and a set of Faraday cups made it possible to determine information on the velocity space and poloidal distribution of the lost alpha particles for the first time. This extensive set of data provides unique information for fundamental physics studies and validation of the numerical models, which are key to inform the physics and scenarios of ITER.

Purpose: The heart is a complex organ at risk. Currently, radiation therapy cardiac delineation atlases do not include conduction system substructures, which exposure may clinically translate into arrhythmia and conduction disorders. We present a method to reproducibly delineate conduction nodes on noncontrast simulation computed tomography scans., Methods and Materials: Localization and dimensioning of the sinoatrial and atrioventricular nodes volumes on noncontrast simulation computed tomography scans were proposed based on radio-anatomic and histologic considerations and agreed upon by a multidisciplinary staff., Results: The proposed atlas enables the dosimetric evaluation of the sinoatrial and atrioventricular nodes exposure, and both contours correspond to 2-cm diameter spheres., Conclusions: This delineation atlas should facilitate the delineation of cardiac conduction nodes in clinical research and daily practice., (Copyright © 2021 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate attenuation of the totally implantable vascular access device (TIVAD) and assess its clinical and dosimetric impact on radiotherapy (RT) of lymphoma patients., Materials and Methods: The first part of the study consisted of an in vitro approach by irradiating the TIVAD with different electron and photon energies. The attenuation data measured were compared with data calculated by our treatment planning system. All patients treated by radiotherapy for Hodgkin's lymphoma with their TIVAD in the target volume were then reviewed to assess the clinical outcome and dosimetric comparison using different plan metrics. All patients were treated by 3D conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy delivered by Helical Tomotherapy (HT)., Results: Nineteen patients treated for stage I-III HL were studied. Seven patients were treated exclusively on the side of TIVAD and 12 were treated bilaterally. Median prescription dose was 30Gy. No significant clinical or dosimetric differences were observed between the side of the TIVAD and the contralateral side in patients treated bilaterally. HT resulted in a significantly higher conformity index (P<0.0022) and a significantly lower healthy tissue coverage (P=0.0008) than 3DCRT. The observed attenuation was 79% for 6 MeV, 59% for 9 MeV, and 46% for 12 MeV for electrons and 9% for 4 MV, 8% for 6 MV, 5% for 10 MV and 15 MV and 3% for 20 MV for X photons., Conclusion: TIVADs induce significant beam attenuation when using electrons, which can be overcome by using high-energy photons or by creating an exclusion zone in when HT is used., (Copyright © 2020 Société française de radiothérapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.)

Radiation therapy has a prime importance for breast cancer management. However, first-generation techniques delivered significant radiation dose to the heart, which substantially increased cardiac mortality. Breast radiation therapy has fortunately evolved, and state-of-the-art radiation therapy techniques currently efficiently spare the heart without altering local control or overall survival. However, at the present time, potential cardiotoxicity risk is still a matter of concern and controversies exist concerning how to precisely evaluate cardiac radiation exposure, how to predict radiation-induced cardiac adverse events and which dosimetric constraints are clinically relevant. Based on current literature, this paper aims to review the present understanding of cardiotoxicity associated with breast cancer irradiation and to discuss controversies and perspectives about cardiac sparing improvement., (Copyright © 2020 Elsevier B.V. All rights reserved.)

According to data from recent studies from Europe, a large percentage of patients have restricted access to innovative medicines for metastatic melanoma. Melanoma World Society and European Association of Dermato-oncology conducted a Web-based survey on access to first-line recommended treatments for metastatic melanoma by current guidelines (National Comprehensive Center Network, European Society for Medical Oncology [ESMO] and European Organization for Research and Treatment of Cancer/European Association of Dermato-oncology/European dermatology Forum) among melanoma experts from 27 European countries, USA, China, Australia, Argentina, Brazil, Chile and Mexico from September 1st, 2017 to July 1st, 2018. Data on licencing and reimbursement of medicines and the number of patient treated were correlated with the data on health expenditure per capita (HEPC), Mackenbach score of health policy performance, health technology assessment (HTA), ASCO and ESMO Magnitude of clinical benefit scale (ESMO MCBS) scores of clinical benefit and market price of medicines. Regression analysis for evaluation of correlation between the parameters was carried out using SPSS software. The estimated number of patients without access in surveyed countries was 13768. The recommended BRAFi + MEKi combination and anti-PD1 immunotherapy were fully reimbursed/covered in 19 of 34 (55.8%) and 17 of 34 (50%) countries, and combination anti-CTLA4+anti-PD1 in was fully covered in 6 of 34 (17.6%) countries. Median delay in reimbursement was 991 days, and it was in significant correlation with ESMO MCBS (p = 0.02), median market price (p = 0.001), HEPC and Mackenbach scores (p < 0.01). Price negotiations or managed entry agreements (MEAs) with national authorities were necessary for reimbursement. In conclusion, great discrepancy exists in metastatic melanoma treatment globally. Access to innovative medicines is in correlation with economic parameters as well as with healthcare system performance parameters. Patient-oriented drug development, market access and reimbursement pathways must be urgently found., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Despite the efficacy of innovative treatments for metastatic melanoma, their high costs has led to disparities in cancer care among different European countries. We analysed the availability of these innovative therapies in Europe and estimated the number of patients without access to first-line recommended treatment per current guidelines of professional entities such as the European Society for Medical Oncology (ESMO), the European Organisation for Research and Treatment of Cancer (EORTC), the European Association of Dermato-Oncology (EADO), and European Dermatology Forum (EDF)., Materials and Methods: Web-based online survey was conducted in 30 European countries with questions about the treatment schedules from 1st May 2015 to 1st May 2016: number of metastatic melanoma patients, registration and reimbursement of innovative medicines (updated data, as of 1st October 2016), percentage of patients treated and availability of clinical studies and compassionate-use programmes., Results: The recommended BRAF inhibitor (BRAFi) + MEK inhibitor (MEKi) combination was both registered and fully reimbursed in 9/30 (30%) countries, and in 13/30 (43%) (all from Eastern Europe) not reimbursed. First-line immunotherapy with anti-PD1 antibodies was registered and fully reimbursed in 14/30 (47%) countries, while in 13/30 (43%) (all from Eastern Europe) not reimbursed. It was estimated that in Europe 19,600 patients with metastatic melanoma are treated, and 5238 (27%) do not have access to recommended first-line therapy. Significant correlation was found between human development index (HDI, UNDP report 2015), (r = 0.662; p < 0.001), health expenditure per capita (r = 0.695; p < 0.001) and the Mackenbach score of health policy performance (r = 0.765; p < 0.001) with the percentage of patients treated with innovative medicines and a number of reimbursed medicines., Conclusions: Great discrepancy exists in metastatic melanoma treatment across Europe. It is crucial to increase the awareness of national and European policymakers, oncological societies, melanoma patients' associations and pharma industry., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Cigarette smoke (CS) and ethanol (EtOH) are known to synergize in the causation of cancers of the upper aerodigestive tract and of the liver. Little is known about possible interactions between these agents in other organs. These premises prompted us to evaluate the clastogenic effects resulting from the inhalation for 3 weeks of mainstream CS and oral administration of EtOH, which were tested either individually or in combination in cells of adult BDF1 mice and their fetuses. CS exerted clastogenic effects in haematopoietic cells of adult male mice by increasing the frequency of micronucleated erythroid cells both in bone marrow and in peripheral blood as well as the frequency of micronucleated and polynucleated pulmonary alveolar macrophages. Likewise, exposure to CS of pregnant mice resulted in a clastogenic damage in maternal bone marrow cells and in the liver and peripheral blood of their fetuses. Under all experimental conditions, EtOH was consistently devoid of clastogenic effects when given alone. In adult mice, EtOH exhibited a mild stimulating effect on the clastogenicity of CS in haematopoietic cells, while an opposite effect was observed in the respiratory tract, where EtOH attenuated the cytogenetic alterations induced by CS in pulmonary alveolar macrophages. At variance with the mild synergism observed in haematopoietic cells of adult mice, EtOH inhibited the clastogenicity of CS in the liver and peripheral blood cells of transplacentally exposed fetuses. Therefore, the effects of EtOH in CS-exposed mice show different trends depending both on the life stage and on the cells analyzed., Competing Interests: The authors have declared that no competing interests exist.

Arcs are the potentially most dangerous events related to Lower Hybrid (LH) antenna operation. If left uncontrolled they can produce damage and cause plasma disruption by impurity influx. To address this issue an arc real time control and protection imaging system for the Joint European Torus (JET) LH antenna has been implemented. The LH system is one of the additional heating systems at JET. It comprises 24 microwave generators (klystrons, operating at 3.7 GHz) providing up to 5 MW of heating and current drive to the JET plasma. This is done through an antenna composed of an array of waveguides facing the plasma. The protection system presented here is based primarily on an imaging arc detection and real time control system. It has adapted the ITER like wall hotspot protection system using an identical CCD camera and real time image processing unit. A filter has been installed to avoid saturation and spurious system triggers caused by ionization light. The antenna is divided in 24 Regions Of Interest (ROIs) each one corresponding to one klystron. If an arc precursor is detected in a ROI, power is reduced locally with subsequent potential damage and plasma disruption avoided. The power is subsequently reinstated if, during a defined interval of time, arcing is confirmed not to be present by image analysis. This system was successfully commissioned during the restart phase and beginning of the 2013 scientific campaign. Since its installation and commissioning, arcs and related phenomena have been prevented. In this contribution we briefly describe the camera, image processing, and real time control systems. Most importantly, we demonstrate that an LH antenna arc protection system based on CCD camera imaging systems works. Examples of both controlled and uncontrolled LH arc events and their consequences are shown.

Application of lower hybrid (LH) current drive in tokamak plasmas can induce both co- and countercurrent directed changes in toroidal rotation, depending on the core q profile. For discharges with q(0) <1, rotation increments in the countercurrent direction are observed. If the LH-driven current is sufficient to suppress sawteeth and increase q(0) above unity, the core toroidal rotation change is in the cocurrent direction. This change in sign of the rotation increment is consistent with a change in sign of the residual stress (the divergence of which constitutes an intrinsic torque that drives the flow) through its dependence on magnetic shear.

Opioids increase abdominal muscle activity during anaesthesia. We proposed that opioid activity during anaesthesia would change chest wall size and movement, and contribute to ventilation. Using an optical system to measure chest wall volume, we studied 10 patients during isoflurane anaesthesia, first under the influence of an opioid and then after reversal with naloxone. Measurements were made during quiet breathing and with carbon dioxide stimulation. Airway occlusion pressure was measured to assess inspiratory and expiratory muscle activity. Chest wall volume decreased with the onset of spontaneous breathing, and decreased further when breathing was stimulated by carbon dioxide. Reversal of opioid activity increased chest wall volume. Breathing movements were predominantly abdominal. Opioid action affected the timing and amplitude of breathing but the pattern of abdominal movement was not affected. Since opioids augment abdominal muscle action during expiration, the unchanged pattern of movement can be attributed to both diaphragm and abdominal activity displacing the abdominal wall reciprocally, in the inspiratory and expiratory phases of the respiratory cycle, respectively., (Copyright © 2012 Elsevier B.V. All rights reserved.)

To assess clinical outcome of patients with pacemaker treated with thoracic radiation therapy for T8-T9 paravertebral chloroma. A 92-year-old male patient with chloroma presenting as paravertebral painful and compressive (T8-T9) mass was referred for radiotherapy in the Department of Radiation Oncology, Institut Curie. The patient presented with cardiac dysfunction and a permanent pacemaker that had been implanted prior. The decision of Multidisciplinary Meeting was to deliver 30 Gy in 10 fractions for reducing the symptoms and controlling the tumor growth. The patient received a total dose of 30 Gy in 10 fractions using 4-field conformal radiotherapy with 20-MV photons. The dose to pacemaker was 0.1 Gy but a part of the pacing leads was in the irradiation fields. The patient was treated the first time in the presence of his radiation oncologist and an intensive care unit doctor. Moreover, the function of his pacemaker was monitored during the entire radiotherapy course. No change in pacemaker function was observed during any of the radiotherapy fractions. The radiotherapy was very well tolerated without any side effects. The function of the pacemaker was checked before and after the radiotherapy treatment by the cardiologist and no pacemaker dysfunction was observed. Although updated guidelines are needed with acceptable dose criteria for implantable cardiac devices, it is possible to treat patients with these devices and parts encroaching on the radiation field. This case report shows we were able to safely treat our patient through a multidisciplinary approach, monitoring the patient during each step of the treatment., (Copyright © 2012 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Background: Expiratory muscle action is prominent during anaesthesia and can impair lung function. This activity is exaggerated by the use of opioids. Airway pressure during occlusion of expiration would be a valuable measure in the study of expiratory muscle activation. However, this would only be valid if the imposed occlusion did not itself alter muscle activation. This possibility can be checked by directly assessing muscle activity by electromyography; varying arterial carbon dioxide tensions and opioid action should be considered., Methods: We studied seven spontaneously breathing patients, anaesthetized with nitrous oxide and isoflurane, in four conditions: during an infusion of fentanyl and after naloxone, breathing normally and with breathing stimulated with CO(2). We compared diaphragm and external oblique abdominal electromyogram (EMG) signals during normal and occluded breaths. We also measured chest wall volume and compared airway occlusion pressure, during inspiration and expiration, with the EMG results., Results: Inspiratory occlusion increased the duration of inspiration during hypercapnia by 20%, but not the rate of electrical activation of the diaphragm, indicating that occlusion does not cause a reflex increase in diaphragm contraction. In contrast, expiratory occlusion did not affect either the duration of expiration or the electrical activity of the external oblique muscles., Conclusions: In these conditions, except for a change in inspiratory duration, respiratory muscle activity is unaffected by airway occlusion. Airway occlusion will permit valid measures of muscle activity in inspiration and expiration and provide simple measurements of respiratory muscle function during anaesthesia.

The aim of this study was to determine, in a population with metastatic breast cancer treated with bevacizumab therapy, the incidence of wound dehiscence after placement of an implantable venous access device (VAD) and to study the risk of catheter thrombosis. This study enrolled all VADs placed by 14 anesthetists between 1 January 2007 and 31 December 2009: 273 VADs in patients treated with bevacizumab therapy and 4196 VADs in patients not treated with bevacizumab therapy. In the bevacizumab therapy group, 13 cases of wound dehiscence occurred in 12 patients requiring removal of the VAD (4.76%). All cases of dehiscence occurred when bevacizumab therapy was initiated less than 7 days after VAD placement. Bevacizumab therapy was initiated less than 7 days after VAD placement in 150 cases (13 of 150: 8.6%). The risk of dehiscence was the same from 0 to 7 days. In parallel, the VAD wound dehiscence rate in patients not receiving bevacizumab therapy was eight of 4197 cases (0.19%) (Fisher's test significant, P<0.001). No risk factors of dehiscence were identified: anesthetists, learning curves, and irradiated patients. VAD thrombosis occurred in four patients (1.5%). In parallel, VAD thrombosis occurred in 51 of 4197 patients (1.2%) not receiving bevacizumab therapy (Fisher's test not significant; P=0.43). Bevacizumab therapy was permanently discontinued in five patients related to wound dehiscence and in one patient due to extensive skin necrosis. These data suggest the need to observe an interval of at least 7 days between VAD placement and initiation of bevacizumab therapy to avoid the risk of a wound dehiscence requiring chest wall port explant. The risk of VAD thrombosis does not require any particular primary prevention.

Introduction: Low-dose pancuronium is known to affect serum cholinesterase activity (BChE); however, the dose-response effect of clinical doses of pancuronium on BChE has not been investigated., Methods: Thirteen ASA I-II patients scheduled for elective surgery requiring muscle relaxation were enrolled in this study. All patients had normal BChE before surgery. Incremental doses of pancuronium (10, 20, 50, and 100 microg/kg) were injected in accordance with surgical needs every 45 min. BChE was measured 3 min after injection by an automatic colorimetric method., Results: BChE decreased significantly in all except one patient in comparison to the baseline (P < 0.05). However all values remained within normal clinical range. A dose of 100 microg/kg yielded significant decrease in comparison to 10 microg/kg but not to other dosages. Linear regression was not significant for the dose-response relationship (P = 0.05)., Conclusion: After clinical incremental doses of pancuronium, BChE remained within clinical range.

Background: Because the intensity of neuromuscular block at the diaphragm (DIA) is indirectly assessed, the electromyographic measurements of the DIA (DIA(EMG)) from surface electrodes were related to information provided by visual estimation of neuromuscular transmission at the adductor pollicis (AP) and the corrugator supercilii (CSC) during recovery from vecuronium block., Methods: Twelve adult patients were studied during balanced anaesthesia. After induction of anaesthesia and tracheal intubation without neuromuscular blocking agent, supramaximal stimulations were applied to phrenic, ulnar and facial nerves. During recovery from vecuronium 0.1 mg kg(-1) an independent observer blinded to DIA(EMG) counted visually detectable train-of-four (TOF) at CSC (TOF(CSC)) and post-tetanic AP (PTC(AP)) responses. Times to recovery of PTC(AP) = 1, 10, and TOF(CSC) = 1-4 responses were related to DIA(EMG). Values are means (sd)., Results: Reappearance of the first response to PTC(AP) occurred significantly (P < 0.05) earlier and for a lower recovery of DIA(EMG) than that of TOF(CSC) [24 (8) min vs 33 (9) min, and 10 (10)% vs 25 (8)%, respectively]. With PTC(AP)

Background: A recovery profile from neuromuscular block similar to that of abdominal (AB) muscles, but different to that of the adductor pollicis (AP) muscle, has been demonstrated at the corrugator supercilii (CSC) muscle. We hypothesized that neuromuscular transmission (NMT) monitoring of CSC might provide useful information on AB relaxation compared with AP. We compared the visual estimation of NMT at CSC and AP with electromyographic measurements of AB during recovery from a vecuronium block., Methods: Ten adult patients were studied during balanced anaesthesia. After induction of anaesthesia and tracheal intubation without neuromuscular blocking agents, supramaximal stimulations were applied to three nerves: left 10th intercostal, ulnar, and facial. Electromyographic activity (EMG) of AB was measured (ABemg). After a bolus dose of vecuronium 0.1 mg kg-1, an independent observer blinded to the EMG measurements counted visually detectable train-of-four (TOF) responses at CSC and AP. Values of ABemg associated with 1 to 4 TOF responses at CSC and AP were compared. Values are means (sd)., Results: Reappearance of the first and second TOF responses at CSC occurred significantly (P<0.05) earlier and at lower ABemg recovery than that of AP [35 (8) and 41 (9) min vs 51 (10) and 56 (12) min; and 17 (8) and 26 (9)% vs 56 (10) and 75 (11)%, respectively]., Conclusions: We demonstrated that the TOF response count at the CSC, compared with the AP, allowed a better quantification of the degree of AB muscle relaxation during recovery from vecuronium block.

Unlabelled: The endocrine part of the pancreas consist 2% from the mass of the gland and it is built from little cells with name Langerhan's islands. The increased secretion of cells provokes to appearance of classic clinical syndrome, which is conditioned by large quantity of hormone in circulation of the blood. The endocrine tumors of the pancreas (ETP) are arisen out of cells that have large quantity to APUD-system., Material and Method: We present a case report of rare ETP with secretion of cortisol (MEN2 syndrome), which is of interest by reason of the fact that this case report is the first announce in Bulgaria about similar tumor. Corporocaudal resention of the pancreas with spleenectomy has been made., Results: Tumor cells with highly expresion (+++) of hromogranin were determined. The histological conclusion was malignant ETP (APUD system tumor)with secretion of cortisol. A decrease of the level of glucose in blood circulation, a decrease of blood pressure and reduction of the body weight were determined with range of first three postoperative weeks., Conclusion: The aims of the surgical therapy are a control over the level of hormones, clear resection and maximal organ saving operation.

Background: Post-tetanic count is a valuable method to assess profound neuromuscular blockade. However, subsequent responses to repetitive stimulation might be altered due to post tetanic facilitation (PTF). To avoid PTF, it has been advocated to limit the interval of stimulation from 6 to 10 min. The impact of PTF on 90% recovery of the TOF ratio has not been evaluated. Therefore, we assessed the effect of repetitive PTC stimulation on atracurium blockade with the primary outcome being the time to reach 90% TOF recovery in comparison to classical TOF stimulation., Methods: After informed consent 20 patients ASA I-II, scheduled for peripheral surgery under general anaesthesia and requiring tracheal intubation were enrolled into the study. Anaesthesia was induced with fentanyl, propofol, and atracurium, 0.5 mg kg(-1). Neuromuscular characteristics were assessed at the adductor pollicis by a TOF Watch((R)) accelerometer (Organon, Teknika, Holland) on each arm. After onset of maximum neuromuscular blockade, repetitive PTC every 3 min on one arm and repetitive TOF stimulation every 15 s on the opposite arm was performed. The following parameters were recorded: onset of maximum blockade, mean time of PTC stimulation, the maximum number of responses to PTC, time of the first and second TOF responses, and recovery profile until 90% TOF ratio., Results: Time to reach 90% TOF recovery was similar on both arms (48 +/- 9 min), with a difference of 16 +/- 38 s between the arms (P = 0.64). The first and second responses of the TOF on the PTC-stimulated arm appeared at 29 +/- 8 min and 33 +/- 7 min, respectively. On the other arm the responses appeared at 30 +/- 8 min and 35 +/- 8 min, respectively (P < 0.05)., Conclusion: Repetitive PTC stimulation every 3 min hastened the first and second responses of the TOF stimulation but we could not detect a significant difference in the 90% recovery of TOF ratio during atracurium blockade.

Introduction: Potentiation of mivacurium by low-dose pancuronium is mostly due to an inhibition of plasma butyryl cholinesterase (BchE) resulting in a decreased rate of hydrolysis of mivacurium. Nevertheless, an interaction at the receptor site could not be ruled out. By changing the order of the muscle relaxant injections, we may lessen the pharmacokinetic interaction and assess the impact at the acetylcholine receptor level., Methods: Twenty patients scheduled for general anesthesia with propofol and fentanyl, and isoflurane were randomized into two groups receiving, mivacurium 100 microg kg-1 followed by pancuronium 15 microg kg-1 (group 1) or pancuronium 15 microg kg-1 followed by mivacurium 100 microg kg-1 (group 2). BchE before and after injection of each relaxant was measured. Neuromuscular block was assessed with a force transducer at the adductor pollicis measuring the elicited twitch to ulnar nerve stimulation., Results: The neuromuscular block was greater when pancuronium was administered before mivacurium (100% versus 96+/-3%; P<0.05). Times to recovery of the elicited twitch response to 25% and 75% of control value were increased by 100% (P<0.05). After pancuronium, decreases in BchE of 11% and 14% in groups 1 and 2 were observed, respectively., Conclusion: Interaction between mivacurium and low dose pancuronium is significant only when mivacurium is injected after pancuronium.

Changes of the toroidal plasma rotation induced by directed waves in the ion-cyclotron range of frequencies (ICRF) have been identified experimentally for the first time on the JET tokamak. The momentum carried by the waves is initially absorbed by fast resonating ions, which subsequently transfer it to the bulk plasma. Thus, the results provide evidence for the influence of ICRF heated fast ions on plasma rotation.

Background: Cisatracurium unlike atracurium is devoid of histamine-induced cardiovascular effects and this alone would be the greatest advantage in replacing atracurium for the facilitation of tracheal intubation. On the other hand, 2 ED(95) doses of cisatracurium (100 micro g/kg) do not yield satisfactory intubating conditions such as those seen with equipotent doses of atracurium and therefore the recommended intubating dose of cisatracurium is 3 ED(95). To understand this discrepancy better, we evaluated the potency and onset of atracurium and cisatracurium directly at the larynx adductors in humans., Methods: The study was conducted in 54 patients (ASA class I or II) undergoing peripheral surgery requiring general anesthesia. Cisatracurium 25-150 micro g/kg or atracurium 120-500 micro g/kg intravenous (i.v.) boluses doses were administered during anesthesia with propofol, nitrous oxide, oxygen and fentanyl. Neuromuscular block was measured by electromyography (single twitch stimulation every 10 s) at the larynx and the adductor pollicis. The dose-response effect measured at both muscles included maximum neuromuscular blockade achieved (Emax), the time to maximum depression of twitch height (onset) and time to spontaneous recovery of the twitch height to 25%, 75% and 90% (T25, T75, T90) of control value., Result: The onset at the larynx was of 196 +/- 28 s after the 100 micro g/kg cisatracurium dose compared with 140 +/- 14 s after the 500 micro g/kg atracurium dose (P < 0.05). Emax at the larynx was 92 +/- 1% and 98 +/- 1% after 100 micro g/kg cisatracurium and 500 micro g/kg atracurium, respectively (P < 0.05). The time to onset of maximum suppression Emax = 100 +/- 0% after a 150 micro g/kg cisatracurium dose was 148 +/- 29 s. At the larynx, the ED(50) was 25 micro g/kg for cisatracurium and 180 micro g/kg for atracurium and the ED(95) was 87 micro g/kg for cisatracurium compared with 400 micro g/kg for atracurium., Conclusion: The slow onset time at the laryngeal muscles after cisatracurium can be explained by the higher potency as compared with atracurium.

The authors describe observed case of pregnancy and degenerative submucous myoma. Diagnostic difficulties.

Background and Objective: The Datex-Ohmeda neuromuscular transmission module (M-NMT) is a new monitor that is part of the AS/3 anaesthesia monitor. It incorporates a mechanosensor, which is a piezoelectric polymer attached to the hand. The module was compared with a force transducer in 30 patients requiring neuromuscular blockade., Methods: Anaesthesia was induced with fentanyl and propofol, and tracheal intubation was performed without muscle relaxants. Neuromuscular blockade was assessed by the test module on one arm and the force transducer on the other arm. When the response to train-of-four stimulation had been stable in both arms for 3 min, rocuronium 0.2 mg kg(-1) was injected intravenously. During recovery from blockade, the train-of-four ratio was measured in 15 patients, and the ratio of response to double-burst stimulation in the other 15 patients. Data analysis was by difference plots., Results: Both devices had acceptable coefficients of repeatability. The M-NMT module was biased by + 1.3% (upper limit of agreement 14.2%, lower limit -12.9%) for the recovery of the train-of-four ratio, and by + 1.09% (17%, -16%) for the recovery of double-burst stimulation ratio., Conclusions: The Datex-Ohmeda M-NMT gives measurements that are repeatable and gives good enough correspondence with a force transducer that it can be used clinically to assess recovery of neuromuscular blockade, but the limits of agreement rule out research applications.

Background: Mivacurium is potentiated by pancuronium to a much greater extent than other relaxants. In a previous investigation we suggested that this potentiation could be due to the ability of pancuronium to inhibit plasma cholinesterase activity, but we did not measure plasma concentrations of mivacurium. In the current study we performed a pharmacokinetic analysis by measuring the plasma concentration of mivacurium when preceded by administration of a low dose of pancuronium., Methods: After induction of general anesthesia with propofol and fentanyl and orotracheal intubation, 10 patients (pancuronium-mivacurium group) received 15 microg/kg pancuronium followed 3 min later by 0.1 mg/kg mivacurium, whereas 10 other patients (mivacurium group) received saline followed by 0.13 mg/kg mivacurium 3 min later. Plasma cholinesterase activity was measured before and 3 and 30 min after pancuronium dosing in the pancuronium-mivacurium group and was measured before and after administration of saline in the mivacurium group. Arterial plasma concentrations of mivacurium and its metabolites were measured at 0.5, 1, 1.5, 2, 4, 10, 20, and 30 min after injection. Neuromuscular blockade was assessed by mechanomyography., Results: Plasma cholinesterase activity decreased by 26% in the pancuronium-mivacurium group 3 min after injection of pancuronium (P < 0.01) and returned to baseline values 30 min later; however, no significant variation was observed in the mivacurium group. The clearances of the two most active isomers (Cis-Trans and Trans-Trans) were lower in the pancuronium-mivacurium group (17.6 +/- 5.1, 14.7 +/- 5.3 ml. min-1. kg-1, respectively) than in the mivacurium group (32.4 +/- 20.2, 24.8 +/- 13.5 ml. min-1. kg-1; P < 0.05)., Conclusions: A subparalyzing dose of pancuronium decreased plasma cholinesterase activity and the clearance of the two most active isomers of mivacurium. Pancuronium potentiates mivacurium more than other neuromuscular blocking agents because, in addition to its occupancy of postsynaptic acetylcholine receptors, it slows down the hydrolysis of mivacurium.

In order to investigate the effect of metoclopramide on the duration of action of mivacurium, 45 patients were randomized into three groups. Group M10 (n = 15) and M20 (n = 15) received 10 and 20 mg of metoclopramide i.v., respectively, and group S (n = 15) received saline 2 min before induction of anesthesia with fentanyl, thiopental and mivacurium. Plasma cholinesterase activity (pCHE) was measured before induction of anesthesia and 2 min after injection of metoclopramide and saline. Neuromuscular block was monitored by a force transducer using train of four nerve stimulation. Anesthesia was maintained with isoflurane and N2O. Time to recovery of a twitch height of 90% was significantly prolonged in group M10 and M20 (44 +/- 15 and 57 +/- 10 min) as compared to group S, 32 +/- 9 min, P < 0.05). A slight but significant decrease in pCHE was observed in group M20. Because of the risk of prolonged duration of action of mivacurium, neuromuscular blockade should always be monitored whenever metoclopramide is given before injection of mivacurium.

Background: Respiratory muscles are considered to be more resistant to muscle relaxants as compared with peripheral muscles. However, the relative sensitivity of respiratory muscles participating to the pump function has not been compared. We used electromyography to compare pharmacodynamic parameters of the diaphragm and abdominal muscles after mivacurium., Methods: Forty adults undergoing elective surgery were randomly allocated in five dosing groups of mivacurium (50, 100, 150, 200, and 250 microg/kg). Patients anesthetized with propofol and fentanyl underwent intubation without relaxants. Anesthesia was maintained with nitrous oxide and propofol. The right phrenic nerve, the left 10th intercostal nerve, and the ulnar nerve were stimulated. Electromyography of the diaphragm and abdominal muscles was recorded from surface electrodes. Mechanomyography was used to measure adductor pollicis evoked contraction. After a 5-min stable recording period, patients received a single intravenous bolus (20 s) dose of mivacurium. By using log dose-probit effect regression analysis, dose-response curves were constructed. Effective doses and 95% confidence intervals were derived for the diaphragm and abdominal muscles and were compared., Results: The dose-response regression line of abdominal muscles differed from that of the diaphragm. Calculated ED50 and ED90 were higher for the diaphragm than for the abdominal muscles (104 [82-127] and 196 [177-213] microg/kg, and 67 [51-82] and 161 [143-181] microg/kg, respectively). The onset of block was faster and recovery of control responses were shorter at the diaphragm than at the abdominal muscles., Conclusion: Diaphragm and abdominal muscles have differential sensitivity to mivacurium. The diaphragm is more resistant to mivacurium than abdominal muscles are.

Background: Diffusion of nitrous oxide into the cuff of the endotracheal tube results in an increase in cuff pressure. Excessive endotracheal tube cuff pressure may impair tracheal mucosal perfusion and cause tracheal damage and sore throat. Filling the cuff of the endotracheal tube with saline instead of air prevents the increase in cuff pressure due to nitrous oxide diffusion. This method was used to test whether tracheal morbidity is related to excess in tracheal cuff pressure during balanced anesthesia., Methods: Fifty patients with American Society of Anesthesiologists physical status I or II were randomly allocated to two groups with endotracheal tube cuffs initially inflated to 20-30 cm H(2)O with either air (group A) or saline (group S). Anesthesia was maintained with isoflurane and nitrous oxide. At the time of extubation, a fiberoptic examination of the trachea was performed by an independent observer, and abnormalities of tracheal mucosa at the level of the cuff contact area were scored. Patients assessed their symptoms (sore throat, dysphagia, and hoarseness) at the time of discharge from the postanesthesia care unit and 24 h after extubation on a 101-point numerical rating scale., Results: Cuff pressure increased gradually during anesthesia in group A but remained stable in group S. The incidence of sore throat was greater in group A than in group S in the postanesthesia care unit (76 vs. 20%) and 24 h after extubation (42 vs. 12%; P < 0.05). Tracheal lesions at time of extubation were seen in all patients of group A and in eight patients (32%) of group S (P < 0.05)., Conclusion: Excess in endotracheal tube cuff pressure during balanced anesthesia due to nitrous oxide diffusion into this closed gas space causes sore throat that is related to tracheal mucosal erosion.

There are scanty of available data about the management of myoma of the uterus during pregnancy and birth. The authors describe two cases of such a pathology--big myoma of the uterus > 10 sm diameter (d.), who were treated conservatively and ended successfully, without serious complications. The pregnant women were done cesarean section and during the operation the myomas were excisiert. There were no complications intra- and postoperationem. The authors suggest that myectomy during pregnancy and cesarean section must not be don routinely.

Objective: To study the effect of atracurium on the electromyographic activity of the lateral abdominal muscles and adductor pollicis in anaesthetized subjects., Study Design: Prospective, comparative, open study., Patients and Methods: Sixteen patients, ASA physical status 1 or 2, undergoing elective orthopaedic surgery under general anaesthesia were studied. Anaesthesia was induced with propofol/fentanyl and orotracheal intubation performed after glottic local anaesthesia without using muscle relaxant. Anaesthesia was maintained with isoflurane/nitrous oxide/oxygen and fentanyl reinjections. Supramaximal percutaneous stimulations in a simple twitch mode (0.1 Hz) were applied at the 9th-10th intercostal nerve on the posterior axillary line and at the ulnar nerve at the wrist. The electromyographic responses were registered using skin surface electrodes, placed on the D9-D10 dermatome in regard of the lateral abdominal muscles and of the thenar muscles. After a single bolus dose of atracurium 0.5 mg.kg-1, the following parameters were studied: the maximum effect (Emax), the time for obtaining Emax (Delay) and the recovery time of 5, 10, 25, 50, 75 and 100% of the control neuromuscular response (T5, T10, T25, T50, T75, T100)., Results: The dose of 0.5 mg.kg-1 of atracurium induced 100% block in both lateral abdominal muscles and adductor pollicis. Lateral abdominal muscles blockade had faster onset (136 +/- 4 s versus 205 +/- 29 s) and shorter recovery, T5, T10, T25, T50, T75 and T100 were significantly (p < 0.05) shorter than at the adductor pollicis., Conclusion: Lateral abdominal muscles blockade have faster onset and recovery than adductor pollicis.

Objective: We assessed the neuromuscular characteristics of 0.2 mg.kg-1 of mivacurium while its injection was concomitant to a non invasive blood pressure measurement in the ipsilateral arm., Patients: Thirty-one patients ASA I-II were randomized into two groups. Group cuff (n = 15) and Group control (n = 16)., Methods: General anaesthesia was induced with fentanyl, thiopentone and mivacurium in all patients, however in the cuff group, measurement of non invasive blood pressure was performed immediately after the injection of mivacurium. Comparison was made on neuromuscular blockade of the adductor pollicis (AP) by mechanomyography, and intubating conditions which were guided by the visual estimation of the orbicularis oculi's (OO) response., Results: In the cuff group, six out of 15 patients did not have complete blockade at the OO against one out of 16 in the control group, (Fisher exact test p < 0.05). Intubation time was significantly delayed in the cuff group, 201 +/- 66 s versus 123 +/- 32 s in the control group, (t test p < 0.001). The maximum neuromuscular blocking effect at the AP was significantly greater in the control group 99 +/- 2% against 89 +/- 7% in the cuff group, (t test p < 0.01). The onset of maximum blockade at the AP was longer in the cuff group 294 +/- 40 s versus 179 +/- 92 s, (t test p < 0.001] in the control group. Time to 25% recovery was shorter in the cuff group 16 +/- 3 min versus 20 +/- 5 min, in the control group (t test p < 0.05)., Conclusion: This study suggests that non invasive blood pressure measurement of the ipsilateral arm, concomitant to the injection of mivacurium decreases the potency of mivacurium. This finding is mostly explained by the early hydrolysis of mivacurium in the plasma of the excluded arm.

Unlabelled: The neuromuscular blocking effects of mivacurium are greatly enhanced when mivacurium is preceded by a subparalyzing dose of pancuronium. The mechanism of this potentiation has not been elucidated. This study investigated the effects of the anticholinesterase activity of a small dose of pancuronium on the neuromuscular blocking effects of mivacurium. Forty patients were enrolled in the study. The neuromuscular effects of 7.5 and 15 microg/kg pancuronium, followed by 50 and 100 microg/kg mivacurium, were assessed in Groups PM1 and PM2 (n = 20), respectively. The neuromuscular effects of 65 and 130 microg/kg mivacurium were assessed in Groups M1 and M2 (n = 20), respectively. One arm was excluded from circulation with a tourniquet, which was inflated before the injection of pancuronium and deflated 3 min after the injection of mivacurium. The plasma cholinesterase activity was measured before induction for all patients and 3 min after the injection of pancuronium for Groups PM1 and PM2. The plasma cholinesterase activity was decreased by 16% and 33% after pancuronium administration in Groups PM1 and PM2, respectively. In the nonexcluded arm, pancuronium significantly potentiated the effects of mivacurium. In the excluded arm, no significant block was detected for Groups M1 and M2, whereas the maximal degree of neuromuscular block was 79% and 100% for Groups PM1 and PM2, respectively. Using the isolated-arm technique, we suggest that pancuronium potentiation of the neuromuscular blocking effects of mivacurium is more likely attributable to an increase in the effective plasma concentration of mivacurium than to occupancy of postsynaptic acetylcholine receptors., Implications: Using the isolated-arm technique, we suggest that pancuronium potentiation of the neuromuscular blocking effects of mivacurium is more likely attributable to an increase in the effective plasma concentration of mivacurium than to occupancy of postsynaptic acetylcholine receptors.

Background: We report the experience of the World Health Organization (WHO) Melanoma Program concerning sentinel lymph node (SLN) biopsy for detecting patients with occult regional nodal metastases to submit to selective regional node dissection., Methods: From February 1994 to August 1998, in 12 centers of the WHO Melanoma Program, 892 SLN biopsies were performed in 829 patients with clinical stage I melanoma (male: 370; female: 459; median age: 50 years old). The location of the primary melanoma was as follows: trunk 35%; lower limbs, 45%; upper limbs, 18%; and head and neck, 2%. Blue dye injection for SLN identification was performed in all cases; preoperative lymphoscintigraphy was done in 440 patients, and an intra-operative probe for a radio-guided biopsy was used in 141 cases. Overall, the SLN identification rate was 88%. In 68% of the patients, only one SLN was identified, whereas two and three or more SLN were detected in 24% and 8% of the remaining cases, respectively., Results: Overall SLN positivity rate was 18%. Intra-operative frozen section examination was performed in 39% of the cases and was helpful in detecting occult localizations only in 47% of the positive SLNs. Distribution of positive cases by primary thickness was as follows: < 1mm: 2%; 1-1.99 mm: 7%; 2-2.99 mm: 13%; and > or = 3 mm: 31%. Positive nonsentinel lymph nodes were found in 22% of cases with positive SLN submitted for selective dissection. No complications due to the procedure were registered. Of 710 patients who were evaluated, 40 (6%) presented a regional nodal relapse after a negative SLN biopsy and underwent a delayed therapeutic dissection. From the 710 enrolled cases, 638 (88.5%) were alive without evidence of disease at the time of this writing. A multivariate analysis showed SLN status as one of the most significant prognostic factors (P = .000) along with thickness (P = .001) and ulceration (P = .015) of primary tumor., Conclusions: These data confirm the feasibility and safety of the SLN technique for selecting patients to submit to a radical node dissection. The data represent the basis for a future trial by the WHO Melanoma Program in this field to evaluate the most appropriate surgical approach for treating patients with occult regional nodal metastases.

The authors make a review on this problem for first time in Bulgarian literature and for the first time by us operated with the Misgav Ladach method--cesarean section. The authors describe 50 cases wit Ladach method and as control 20 with Pfannenstiel. The authors establish shorter duration of the operation-Si] and 56.3 min. respective in benefit for Misgav method; the babies were extracted at 5.5 and 12.3 min. respect. The mothers with Misgav had better prognosis at the time of dehospitalization.

Background: Paralysis of the vocal cords is one objective of using relaxants to facilitate tracheal intubation. This study compares the neuromuscular blocking effect of succinylcholine and rocuronium on the larynx, the diaphragm, and the adductor pollicis muscle., Methods: Electromyographic response was used to compare the neuromuscular blocking effect of succinylcholine and rocuronium on the laryngeal adductor muscles, the diaphragm, and the adductor pollicis muscle. Sixteen patients undergoing elective surgery were anesthetized with propofol and fentanyl, and their tracheas were intubated without neuromuscular blocking agents. The recurrent laryngeal and phrenic nerves were stimulated at the neck. The electromyographic response was recorded from electrodes placed on the endotracheal tube and intercostally before and after administration of 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium., Results: The maximum effect was greater at the adductor pollicis (100 and 99%) than at the larynx (96 and 97%) and the diaphragm (94 and 96%) after administration of succinylcholine and rocuronium, respectively (P < or = 0.05). Onset time was not different between the larynx (58+/-10 s), the diaphragm (57+/-8 s), and the adductor pollicis (54+/-13 s), after succinylcholine (all mean +/- SD). After rocuronium, onset time was 124+/-39 s at the larynx, 130+/-44 s at the diaphragm, and 115+/-21 s at the adductor pollicis. After succinylcholine administration, time to 90% recovery was 8.3+/-3.2, 7.2+/-3.5, and 9.1+/-3.0 min at the larynx, the diaphragm, and the adductor pollicis, respectively. Time to 90% recovery after rocuronium administration was 34.9+/-7.6, 30.4+/-4.2, and 49.1+/-11.4 min at the larynx, the diaphragm, and the adductor pollicis, respectively., Conclusion: Neuromuscular blocking effect of muscle relaxants on the larynx can be measured noninvasively by electromyography. Although the larynx appears to be resistant to muscle relaxants, we could not demonstrate that its onset time differed from that of peripheral muscles.

Religion can play an important role in the lives of psychiatric patients. We assessed how often a psychotic illness can lead to a change in the strength of religious faith and how commonly religion is used for coping with such illnesses in a sample of consecutively admitted patients. 52 patients with psychosis were interviewed regarding their religious beliefs after their index admission. 69.4% of the patients were religious, and 11 (22.4%) stated that religion was the most important part of their lives. 30.4% of the sample described that there had been an increase in their religiousness after the onset of illness. 61.2% of patients were using their religion for coping with the illness. Such patients had a better insight into their illness and were more compliant with antipsychotic medication. We conclude that the experience of a psychotic illness is likely to lead to an increase in religious beliefs. Such beliefs are commonly used for coping with the illness and some patients attach a great importance to them.

Although subjects often report difficulty with swallowing shortly after receiving neuromuscular blocking agents, difficulty with swallowing during recovery from neuromuscular blocking agents appears to be infrequent. We have used electromyography to compare onset and recovery at the diaphragm and geniohyoid airway muscles after an intubating dose of mivacurium (0.2 mg kg-1) to determine if the geniohyoid muscles were particularly sensitive to neuromuscular blocking agents. Twelve adults undergoing elective surgery were anaesthetized with propofol and fentanyl and the trachea intubated without neuromuscular blocking agents. The left hypoglossal and right phrenic nerves were stimulated with percutaneous needle electrodes and the electromyogram recorded with surface electrodes. EMG responses were measured after a bolus dose of mivacurium 0.2 mg kg-1. Recordings were also made of the mechanical response of the adductor pollicis to supramaximal ulnar nerve stimulation. There was no difference in the rate of onset of block for geniohyoid muscles and the diaphragm, but recovery to 25% and 90% of the control response was shorter at the diaphragm (median 14.5 (95% confidence limits 12.9-15.3) min and 23.8 (21.7-26) min) than at the geniohyoid muscle (19.4 (15.6-20.1) min and 29.2 (26.3-31.4) min), respectively (P < 0.05). When the train-of-four ratio of the mechanical response of the thumb reached 70%, the diaphragm and geniohyoid muscles had recovered completely in all patients.

The molar concentrations of the catalytic sites of serum cholinesterase (ChE--EC 3.1.1.8.) and cholinesterases (ChEs-acetylcholinesterase (AChE)--EC 3.1.1.7. and ChE) from brain and perfused liver of male birds, rats, swine and sheep were determined. A positive correlation between the molar concentrations of the catalytic sites of ChEs and the resistance of the animals to some organophosphorus compounds (OPhCs) was found. In addition, the present study also showed that the difference of the molar concentrations of catalytic sites of ChEs in the brain, blood serum and liver can cause varied resistance to some OPhCs.

For the first time in Bulgaria a case is reported of facial melanoma metastases in the vagal nerve. They were successfully removed together with cervical lymph dissection. Surgical treatment was followed by radiotherapy and chemotherapy. Control check up one year after the operation failed to disclose relapse or new metastases.