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Purpose: A retrospective study was performed to evaluate the clinical, radiological and histological findings of 14 intraosseous meningiomas., Material and Methods: 14 histologically proved intraosseous meningiomas were studied with plain skull film and CT. Pathological records were reviewed., Results: We found 9 calvarial cases and 5 spheno-orbital ones. The most common symptom in the calvarial cases was a lump in the scalp, and in the spheno-orbital lesions it was exophtalmos. Hyperostosis was present in all 5 spheno-orbital cases and in 3 out of the 9 calvarial ones; in the other 6 cases it had a mixed pattern. Enhanced dura was present in 3 calvarial cases and in 2 sphenoidal ones. Dura was involved in 5 cases: 2 with inflammatory changes, 2 with a minimal intradural tumour and one with a subdural tumour., Conclusion: CT better detected both the bony reaction and the intraosseous extension of the tumour. The dural changes were not specific of tumoural involvement. The differential diagnosis comprises: fibrous dysplasia, osteoma, blastic metastasis and mainly meningioma en plaque (MEP). Comparing our findings with other series, we noticed that in some cases the term MEP was used for similar cases. As the name MEP is merely descriptive and both entities share a larger number of similarities than differences, we believe that a differentiation between hyperostotic en plaque meningioma and intraosseous meningioma can hardly be made.

Objective: Rocuronium is a new non-depolarising steroidal muscle relaxant with a short onset time. The present study was undertaken to compare intubating conditions as well as onset and clinical duration of a single dose of 0.6 mg/kg (2 x ED95) with a single dose of 1 mg/kg suxamethonium (3 x ED95)., Methods: After obtaining informed consent and approval of the Ethics Committee, 40 adult patients (ASA I-III) participated in this study. After premedication with oxazepam, anaesthesia was induced with fentanyl and propofol and maintained with propofol, N2O and supplements of fentanyl as needed. Muscular relaxation was assessed by EMG recording of adductor pollicis muscle after supramaximal single twitch stimulation of the ulnar nerve every 10 s. Patients were allocated randomly to receive either rocuronium 0.6 mg/kg or suxamethonium 1 mg/kg. The following parameters were measured: intubating conditions 60 s after injection, onset time and clinical duration of neuromuscular block, % block at intubation, heart rate, blood pressure and arterial oxygen saturation., Results: (mean +/- SD). Intubating conditions after rocuronium and suxamethonium were found to be clinically acceptable (excellent or good) in 90% of patients, though there was only a partial blockade of the adductor pollicis muscle with rocuronium (71 +/- 23%) compared to suxamethonium (95 +/- 14%) (p < 0.05). The onset time and clinical duration of relaxation was shorter after suxamethonium (p < 0.05) and occurred at 0.8 +/- 0.2, 7 +/- 2.1 and 3.2 +/- 1.3, 29 +/- 11 min after suxamethonium and rocuronium respectively., Conclusion: At a dosage of 0.6 mg/kg, rocuronium has an onset time of about 3 min and a clinical duration of relaxation of nearly half an hour. These data are supported by various studies, while others show shorter times, probably due to different monitoring techniques. In spite of the pharmacodynamic differences between suxamethonium and rocuronium, the intubating conditions after administration of both compounds are comparable and develop at the same rate.

The lateral decubitus position is the standard position for nephrectomies. There is a lack of data about the effects of this extreme position upon respiratory mechanics and gas exchange. In 20 patients undergoing surgery in the nephrectomy position, we compared a new closed-loop-controlled ventilation algorithm, adaptive lung ventilation (ALV), which adapts the breathing pattern automatically, to the respiratory mechanics with conventionally controlled mandatory ventilation (CMV). The aims of our study were (1) to describe positioning effects on respiratory mechanics and gas exchange, (2) to compare ventilatory parameters selected by the ALV controller with traditional settings of CMV, and (3) to assess the individual adaptation of the ventilatory parameters by the ALV controller. The respirator used was a modified Amadeus ventilator, which is controlled by an external computer and possesses an integrated lung function analyzer. In a first set of measurements, we compared parameters of respiratory mechanics and gas exchange in the horizontal supine position and 20 min after changing to the nephrectomy position. In a second set of measurements, patients were ventilated with ALV and CMV using a randomized crossover design. The CMV settings were a tidal volume of 10 ml/kg body weight, a respiratory rate of 10 breaths/min, an I:E ratio of 1:1.5, and an end-inspiratory pause of 30% of inspiratory time. With both ventilation modes F1O2 was set to 0.5 and PEEP to 3 cm H2O. During ALV a desired alveolar ventilation of 70 ml/ kg KG.min was preset. All other ventilatory parameters were determined by the ALV controller according to the instantaneously measured respiratory parameters. Positioning induced a reduction of compliance from 61.6 to 47.9 ml/cm H2O; the respiratory time constant shortened from 1.2 to 1.08 s, whereas physiological dead space increased from 158.9 to 207.5 ml. On average, the ventilatory parameters selected by the ALV controller resembled very closely those used with CMV. However, an adaptation to individual respiratory mechanics was clearly evident with ALV. In conclusion, we found that the effects of positioning for nephrectomy are minor and may give rise to problems only in patients with restrictive lung disease. The novel ALV controller automatically selects ventilatory parameters that are clinically sound and are better adapted to the respiratory mechanics of ventilated patients than the standardized settings of CMV are.

Unlabelled: Elderly patients may show an age-related decline in physiologic functions, which may be responsible for the prolonged duration of some neuromuscular blocking agents. Previous studies have yielded conflicting results as to the effects of these drugs in the elderly., Methods: After obtaining informed consent and approval of the Ethics Committee, we compared onset and recovery times of single IV doses of atracurium, rocuronium, and vecuronium given to 108 patients divided into three groups according to age (18-50, 51-64, > or = 65 years). Following oxazepam premedication and fentanyl and thiopentone induction, patients were randomly allocated to receive atracurium, rocuronium or vecuronium (0.5, 0.6, or 0.1 mg/kg, respectively) in < or = 0.8 vol.% enflurane (end-tidal)-nitrous oxide anaesthesia. Muscular relaxation was assessed by electromyographic (EMG) recording of the adductor pollicis muscle after supramaximal single-twitch stimulation of the ulnar nerve every 10 s. Onset time and recovery to 25%, 75% and 90% of twitch control values (DUR25, 75, 90) were recorded. Creatinine clearance predicted from serum creatinine (Ccr) was correlated with recovery from neuromuscular block., Results: Onset time was not different among groups or relaxants. The results showed a prolonged duration of action for atracurium (DUR75, DUR90), rocuronium (DUR25, DUR75), and vecuronium (DUR25) in the elderly. A number of patients did not reach DUR75 or DUR90. There was a significant relationship between age and failure to return to control values during recovery from neuromuscular block, especially after atracurium and rocuronium. Ccr showed a negative correlation with age for all relaxants, but a negative significant correlation between Ccr and recovery was found only for rocuronium., Conclusions: This study suggests that onset time for atracurium, rocuronium and vecuronium is not age-dependent. Recovery was prolonged in the elderly for all three relaxants. This effect appears to be secondary to changes in body composition and function accompanying the aging process. Neither atracurium nor vecuronium depends significantly on the kidney for elimination, but the negative correlation between Ccr and rocuronium suggests an appreciable role for the kidney in the elimination of this relaxant. The long recovery times observed in this study could also be related to enflurane anaesthesia. We suggest that failure of EMG responses to return to baseline values during recovery from neuromuscular block may be related to age, especially for atracurium and rocuronium.

Unlabelled: Blood glucose alterations prior to cerebral ischaemia are associated with poor neurologic outcome, possibly due to extensive lactic acidosis or energy failure. Cerebral effects of hyper- or hypoglycaemia during cardiopulmonary resuscitation (CPR) are less well known. In addition, little information is available concerning cardiac effects of blood glucose alterations. The aim of this study was to evaluate the effects of pre-cardiac-arrest hypo- or hyper-glycaemia compared to normoglycaemia upon haemodynamics, cerebral blood flow (CBF) and metabolism (CMRO2), and regional cardiac blood flow during CPR subsequent to 3 min of cardiac and respiratory arrest and after restoration of spontaneous circulation., Methods: After approval by the State Animal Investigation Committee, 29 mechanically ventilated, anaesthetised pigs were instrumented for haemodynamic monitoring and blood flow determination by the radiolabeled microsphere technique. The animals were randomly assigned to one of three groups: in group 1 (n = 9) blood glucose was not manipulated; in group II (n = 10) blood glucose was increased by slow infusion of 40% glucose to 319 +/- 13 mg/dl; in group III (n = 10) blood glucose was lowered by careful titration with insulin to 34 +/- 2 mg/dl. After 3 min of untreated ventricular fibrillation and respiratory arrest, CPR (chest compressor/ventilator (Thumper) and epinephrine infusion) was commenced and continued for 8 min. Thereafter, defibrillation was attempted, and if successful, the animals were observed for another 240 min. Cerebral perfusion pressure (CPP), CBF, CMRO2, coronary perfusion pressure (CorPP), and regional cardiac blood flow were determined at control, after 3 min of CPR, and at 10.30, and 240 min post-CPR., Results: In group 1. 4/9 animals (44%) could be successfully resuscitated; in group II 4/10 (40%); and in group III 0/10 (0%). Prior to cardiac arrest, mean arterial pressure, CPP, and CorPP in group III were significantly lower compared to groups I and II. In group I. CPP during CPR was 26 +/- 6 mmHg; CBF 31 +/- 9 ml/ min/100g CMRO2 3.8 +/- 1.2 ml/ min/100 g; CorPP 18 +/- 5 mmHg; and left ventricular (LV) flow 35 +/- 15 ml/min/100 g. In group II; CPP = 21 +/- 5; CBF 21 +/- 7; CMRO2 1.8 +/- 0.8; CorPP 16 +/- 6; and LV flow 22 +/- 9; and in group III: CPP 15 +/- 3; CBF 11 +/- 8; CMRO2 1.5 +/- 1.1; CorPP 4 +/- 2; and LV flow 19 +/- 10. During the 240-min post-resuscitation period, there were no differences in CBF, CMRO2, or LV flow between groups I and II., Conclusion: Hypoglycaemia prior to cardiac arrest appears to be predictive for a poor cardiac outcome, whereas hyperglycaemia does not impair resuscitability compared to normoglycaemia. In addition, hyperglycaemia did not affect LV flow, CBF, or CMRO2. However, it has to be kept in mind that haemodynamics and organ blood flow do not permit conclusions with respect to functional neurologic recovery or histopathologic damage to the brain, which is very likely to be associated with hyperglycaemia.

Unlabelled: Cimetidine is a commonly used H2-receptor antagonist that has been recommended for the prevention of acid aspiration syndrome and has been shown to potentiate vecuronium-induced neuromuscular block. The present study was designed to investigate the influence of a single IV dose of cimetidine on the neuromuscular effects of rocuronium, an analogue of vecuronium with a short onset time., Methods: Twenty adults aged 18-65 years were included in the study with their informed consent and approval of the Ethics Committee. Following oxazepam premedication, 10 patients were randomly allocated to receive cimetidine 400 mg IV 30 min before anaesthesia. After fentanyl and thiopentone induction, single-twitch stimulation of the ulnar nerve was performed every 10 s. Following stabilisation of control responses, patients received rocuronium 0.6 mg/kg for intubation. Anaesthesia was maintained with enflurane < or = 0.8 vol.% (end-tidal) and 65% nitrous oxide. Onset time and recovery times to 25% and 75% of the twitch control values were recorded., Results: Onset and recovery times did not differ between groups., Conclusions: The results of the present study demonstrate that cimetidine does not increase the duration of rocuronium neuromuscular blockade. Inhibition of the cytochrome P450 system or a direct effect at the neuromuscular junction have been suggested as the mechanisms of drug interaction associated with cimetidine. Impairment of hepatic microsomal drug metabolism results in a prolonged duration of action of vecuronium, which appears to be eliminated primarily via the liver. Data on the elimination pathway of rocuronium in humans are not available. The fact that cimetidine does not alter the recovery from rocuronium-induced neuromuscular block confirms a previous suggestion that rocuronium may not be eliminated principally by the liver. A direct effect of cimetidine on the neuromuscular junction could not be confirmed by this study. Therefore, cimetidine can be given as premedication without a risk of prolonged rocuronium block.

Objective: This study evaluated the reproducibility of a questionnaire concerned with the clinical and epidemiological aspects of menopause., Material and Methods: The study population consisted of a hundred perimenopausal Mexican women seeking care at gynecology and obstetric health care services. Their participation was voluntary and they answered the same questionnaire two times with a 15-30 day lag between each application., Results: The Kappa coefficient was high (0.81-1.0) for categorical variables such as: type of menstrual cycles, type of menopause, breast-feeding, use of estrogen during menopause and use of hormonal contraceptives. The Kappa coefficient was moderate (0.7-0.8) for symptoms related to menopause such as hot flashes, sweating, painful coitus, vaginal dryness and a decrease in libido. Mean differences were calculated for continuous variables such as age at menarche, age at menopause, time using estrogen and the duration of breast-feeding, the majority had a value of zero and 95% confidence intervals for these mean differences included the null value. The questionnaire also included other characteristics such as tobacco consumption and a short food frequency questionnaire, which showed high concordance (Kappa 0.7-1.0)., Conclusions: The results of this study show that this questionnaire has a high level of reproducibility and can be useful as a research tool to explore menopause in Mexican women.

Objectives: To compare the effectiveness, characteristics, duration of action, hemodynamic and biochemical effects, and side effects of propofol and midazolam used for continuous intravenous sedation of ventilated critically ill patients., Design: Multicenter, prospective, randomized, nonblinded study., Setting: Nine Spanish general intensive care units (ICUs)., Patients: Ninety-eight patients admitted to the ICU who were mechanically ventilated and required sedation for a minimum of 48 hrs., Interventions: Propofol or midazolam was used for induction and maintenance of continuous intravenous sedation for a maximum of 5 days. The effectiveness of those two regimens was assessed according to their effects on ventilatory management and the presence of agitation., Measurements and Main Results: In 93% of the patients studied, there was a medical cause necessitating mechanical ventilation. The mean (+/-SD) duration of sedation was 81 +/- 25 hrs and 88 +/- 27 hrs for the propofol and midazolam groups, respectively. The induction dose was 2.24 +/- 0.43 mg/kg over 318 +/- 363 secs for propofol, and 0.22 +/-0.07 mg/kg over 33 +/-29 secs for midazolam. The maintenance dose was 2.8 +/-1.1 mg/kg/hr for propofol and 0.14 +/- 0.10 mg/kg/hr for midazolam. There was no difference regarding the opiate and muscle relaxant requirements between the two groups. Sedation with propofol was more effective in achieving patient-ventilator synchrony than that with midazolam after the first hour of treatment (p < .01). Patients sedated with propofol awoke more rapidly and with less variability that those patients sedated with midazolam (23 +/- 16 mins vs. 137 +/- 185 mins, respectively, p < .05), particularly in those patients requiring deep sedation (27 +/- 16 mins vs. 237 +/- 222 mins, respectively, p < .01). No hemodynamic or biochemical changes were detected in any of the treatment groups. During induction, five patients in the propofol group and two patients in the midazolam group had hypotension., Conclusions: In this population of critically ill patients, propofol is an effective and safe alternative for sedation, with some advantages, such as short duration of action and high effectiveness over the conventional regimen with benzodiazepines and opiates.

We studied 37 intradiploic epidermoid cysts, reviewing typical and atypical radiological features and the differential diagnosis. The most common clinical feature was a long standing lump in the scalp, occurring in 25 patients (67.7%). Plain films were the most cost-effective radiological technique in diagnosis. The typical finding was a well-defined lytic lesion with sclerotic border, seen in 29 cases (78%). Atypical lesions were those larger than 5 cm and/or with an ill-defined edge, being observed in 8 cases (22%). CT and MRI were the best methods for assessing atypical ones. In all cases with typical radiological findings a preoperative diagnosis of intradiploic epidermoid cyst was suggested.

We present the case report of a diabetic 51-year-old male, who presented with painless mobilization of the superior incisor teeth. The X-ray study showed osteolysis, without any soft tissue mass, in craniofacial and orbital bones. In the control X-ray studies performed during the 2 years' evolution, a progressive increase in the intensity and extension of the osteolysis was observed. The diagnosis of progressive idiopathic osteolysis is one of exclusion, based mainly on clinico-radiological findings, evolution and compatible histological findings.

Background: One of the major difficulties in evaluating the efficiency of Primary Medical Centres is that of integrating quantitative and qualitative data., Methods: This study applies the Involved Data Analysis (DEA) for the purpose of evaluating the efficiency of Primary Medial Centres located in the Province of Zaragoza (Spain). DEA is a lineal programming technique that provides information on the relative efficiency of each unit, as compared to all other units. Output such as doctors and nursing services as well as variables relating to the quality of service, and input (personnel and pharmaceutical expenses) referring to 1994, were obtained from Area Management., Results: Without taking qualitative variables into account, only 13 Primary Medical Centres reached maximum efficiency level 1. with a range of 0.53 to 1. Taking quality variables into account, 24 units reached optimum efficiency, with a range of 0.61 to 1., Conclusions: DEA is a useful tool for both qualitative and quantitative overall evaluation of input and output and identifies units that are inefficient as compared to others. Despite the difficulties involved, the method appears to be beneficial for management as a complementary aid to currently used techniques.

The relationship between gastric (GC) and tracheal (TC) colonization and the development of ventilator-associated pneumonia (VAP) remains controversial. TC, GC, and pharyngeal (PC) colonization were studied serially in 80 patients with mechanical ventilation (MV) to ascertain the routes and onset of TC. Simultaneous sample from pharynx, stomach, and trachea were obtained throughout the MV period. Quantitative cultures were performed. Seventy-two patients (90%) had TC at some time during MV. Only 19 patients presented TC after PC or GC by the same microorganisms. Indigenous gram-negative and gram-positive microorganisms colonized mainly the trachea from the start of or during MV without previous PC or GC (p < 0.05). Pseudomonas were the microorganisms causing TC principally during MV without previous PC or GC (p < 0.005). Enterobacteria produced TC without a preferential route. Of the 12 patients who developed VAP, the microorganisms responsible had already colonized the trachea in 10 patients. Only 10 of the 21 microorganisms isolated in VAP had previously colonized the pharynx or stomach. In summary, although some microorganisms have preferential routes for producing TC, the microorganisms isolated frequently change during MV. TC precedes VAP in most patients, but only a minority develop a VAP; therefore, together with TC other factors must be involved in VAP development.

Desmoplastic fibroma is a rare benign neoplasm of bone; only three cases have been reported involving the skull. The radiographic and histological aspects of a case of desmoplastic fibroma involving the parietal bone are reported.

Objective: To describe the main economic-healthcare indicators of Aragon Areas 2 and 5 in 1992. To quantify in economic terms the value of the medical and nursing consultations carried out by Primary Care teams., Design: Cost-analysis type study (total costs). The criteria for attributing indirect costs were established by consensus. The data correspond to 1992 (real spending by each centre). The cost of the consultations was calculated in function of the overall activity undertaken and in line with the type of consultation., Setting: Areas 2 and 5, Aragon. Calculation of the cost per consultation only for Primary Care teams (PCT)., Results: Spending per inhabitant and per year, both overall and broken down into care and pharmacy costs was 20,140 for PCT's (8,805 pesetas + 11,355 pes) and 23,153 pes for the traditional model (7,677 + 15,476 pes). Costs per consultation were: 1,031 pes for General Medicine plus 2,537 on Pharmacy; 1,765 pes for Paediatrics plus 716 on Pharmacy; 972 on nursing. Costs per consultation were also offered in function of the duration of each type of consultation and the health-care delivered., Conclusions: Overall, PCT's generated less expense per each insured person than the traditionally-based Consulting rooms. This situation is mainly due to Pharmacy costs, where the difference is over 4,000 pesetas. The evaluation of service costs in function of attendance supposes that, between two teams of equal composition and the same volume of spending, the more efficient will be that which produces the greater amount of services.

Nasotracheal intubation of the trachea by means of fiberoptic endoscopy is an accepted approach to difficult airways. The associated avoidance of direct laryngoscopy may affect the stress response to nasotracheal intubation. We tested this hypothesis by means of a prospective, randomized, controlled clinical study. METHODS. Informed consent was obtained from 30 patients presenting for maxillofacial surgery for participation in this study. Patients were allocated to three groups: nasotracheal intubation to be performed either fiberendoscopically (group 1) or laryngoscopically, with (group 2) or without (group 3) topical anaesthesia of the larynx. Haemodynamic variables (arterial blood pressure and heart rate) and concentrations of catecholamines* in plasma (adrenaline, noradrenaline; HPLC) were documented at four (two*) time points, respectively: prior to induction of anaesthesia*, after induction, 1 min after tracheal intubation*, 5 min after tracheal intubation. Differences between time points and between groups were analysed with the chi-square test; a probability of P < 0.05 was considered statistically significant. RESULTS. With respect to age, body-weight and gender, the groups were comparable. No major hemodynamic or endocrine stress responses were observed in any group. Diastolic blood pressures were significantly lower in groups one and two, one minute after tracheal intubation. DISCUSSION. Nasotracheal intubation does not provoke a major stress response, when performed in accordance with the protocol of this study. However, topical anaesthesia of the larynx, as well as the fiberendoscopic approach proved superior to control with respect to diastolic arterial pressure. We conclude that fiberoptic nasotracheal intubation, or laryngoscopy preceded by topical anaesthesia of the larynx may be useful in patients for whom an increase in rate pressure product would be undesirable.

The Authors have studied the behaviour of nasal mucociliary transport (MCT) in the chronic phlogistic pathology of the middle ear, in subjects suffering from simple and cholesteatomatous otitis. In both groups the duration of MCT was longer than a control group of normal subjects; instead no significant difference was observed either between the two kind of pathologies nor between the two different phases of the otitis (quiescence and breakthrough). The Authors conclude therefore that, in the recurrent phlogistic pathology of the middle ear, the function of MCT must be carefully studied, possibly corrected if damaged, to prevent the evolution in the breakthrough.

The study has evaluated the behaviour of the nasal resistances, studied using Anterior Active Rhinomanometry, after physical exercise, in normal subjects and in allergic and non allergic vasomotor rhinopathics. The results, in accordance with the literature, show a reduction of nasal resistances in all subjects, particularly in the rhinopathics, immediately after the effort and a return to the starting values after a rest period of 30 minutes. Among vasomotor patients, only the non-allergic group has shown very significant variations in the resistances, because in these subjects there is almost always an exaltation of the neurovegetative system, which we did not observe in the allergic subjects in the intercritical phase. The effort test is therefore, among the aspecific tests of nasal reactivity useful, perhaps, more to therapy than to diagnostic aims.

Potential contamination of nutritional mixtures during preparation in the Pharmacy Services has led to the need for microbiological controls. In our study, we set out the techniques used in the Son Dureta Hospital between 1986 and 1991. During those six years 11,023 nutritional mixtures were prepared, and 1,714 bacteriological controls were carried out, representing 15.5% of the total. Between January 1986 and June 1989, the simple culture technique was used (culture of 10 ml of the prepared mixture). The contamination rate was 1.27%. Between July 1989 and December 1991, the double sample technique was applied, involving a culture of 10 ml of the mixture, keeping a further 10 ml for subsequent verification culture. With this technique, the contamination rate was fixed at 0.34%. The advantages and drawbacks of the techniques used are described, along with the problem of initial false positives, and a review is made of the 39 germs isolated during the period of study.

We have made a study of the energy requirements of liver transplant patients in the immediate post-operative phase, by comparing different methods. A study of energy use was made with indirect Calorimetry (IC), of calculation of Resting Energy Expenditure (REE) according to Fick's formula modified by Liggett, and of the calculation of basal energy Expenditure (BEE) applying Harris-Benedict's equation (HB). The correlation between the REE calculation using indirect calorimetry and that of BEE using Harris-Benedict (r = 0.7567) did not give a correction factor, applied to the Harris-Benedict formula) (REE by IC/BEE), which was uniform for all patients, oscillating as it did between 1.0 and 1.8. We found no correlation between REE by IC and that calculated using the modified Fick method, nor between the modified Fick method and BEE as calculated by Harris-Benedict. Our conclusion is that, with the IC method as reference to evaluate energy use, the Harris-Benedict calculation appears to be more reliable than that using the modified Fick equation and that, in the group of patients studied, and given the individual variations in the REE ratio calculated by IC and the BEE calculated by HB, we were unable to find a suitable correction factor for them all. IC is therefore the ideal method for evaluating energy use in critical patients in the ICU.

To facilitate the control of administering parenteral nutrition (PN), the tendency is to replace traditional infusion equipment with infusion pumps. The aim of this study is to determine the characteristics that a pump should have for infusing PN mixtures and, based on these, to evaluate five models available on the market. The pumps evaluated, all with volumetric programming were: Becton Dickinson VIP II (Prim); Life-Care Pump Model 4 (Abbot-Shaw); Infusomat Secura 1.000 (Braun); Flo-gard (tm) 6,200 (Baxter) and IVAC-591 (Ivac). The following method was used: a) Definition of 16 basic requisites and 7 secondary requisites considered necessary in a PN pump, in accordance with the following criteria: safety, practical usage, comfort and hospital circuits. b) Review and checking of the technical reports on each pump. c) Laboratory tests simulating PN infusion, evaluating the regularity and precision of the infusion speed, and d) Subjective evaluation survey. All the pumps under study complied with the basic requisites. There were differences in the subjective evaluation, although with regard to all concepts and models a score of over 2.5 was reached in a scale of 0 to 5. The highest and lowest values with regard to regularity and precision were within the following ranges: +/- 0.6 ml/h(-)+/- 0.0 ml/h and + 3.4%(-)-1.6% respectively, and no instance of values outside the established ones was detected. The pumps only partly complied with the secondary requisites. Finally, the criteria for defining the most significant requisites was reviewed, based on the services offered by the existing pumps, as well as techniques for determining regularity and precision.(ABSTRACT TRUNCATED AT 250 WORDS)

Should atropine be administered for premedication? This question continues to be controversial; in particular, the combined administration of atropine and succinylcholine has been investigated with conflicting results by numerous researchers. The present study was carried out to assess the effect of premedication with atropine on hemodynamic variables and salivation in patients assigned to ASA class II and III. METHODS. Eighty ASA class II or III patients received pethidine 1.0 mg/kg and promethazine 0.5 mg/kg i.m. 30 min prior to induction of anesthesia and atropine, either 0.01 mg/kg i.v. 10 min or 0.01 mg/kg i.m. 30 min prior to a standardized anesthetic induction with alcuronium (precurarizing dose), thiopental, and succinylcholine. In the control groups (20 patients each), no atropine was given. Systolic, diastolic, and mean arterial pressures (MAP) were measured. The ECG was monitored for arrhythmias. Salivation was assessed semiquantitatively using swabs positioned within the pharyngeal space. RESULTS. Ten minutes after the administration of atropine i.v., a significant increase in heart rate (HR) was observed; this did not occur within 30 min after administration of atropine i.m. At the time of tracheal intubation, HR was significantly increased in both i.v. atropine risk groups. After atropine i.m., an increase in heart rate during intubation was observed in ASA class II patients only. No increase in heart rate occurred in the control groups during tracheal intubation. Neither i.m. nor i.v. atropine had any significant effect on blood pressure. Arrhythmias occurred in a few cases with both routes of administration; several instances of marked tachycardia were recorded.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical picture, treatment and evolution of seven patients presenting snake bites are analyzed. Local symptoms were constant, with a spontaneous favorable evolution in 7 to 10 days. The most relevant systemic manifestations were coagulation anomalies which appeared in two patients. Treatment always included local wound care, antitetanicum antibiotic and anticoagulant prophylaxis with specific antiophidic serum in five patients.

Hyperosmolar solutions have recently been introduced as test-substances in the nasal provocation of vasomotor rhinitis subjects. In order to establish a norm, the test was carried out in 40 subjects without nasal pathologies, stimulating with solutions at increasing level of concentrations of NaCl (0.9% - 1.8 - 3.6% - 5.4% - 7.2% - 9%). In all subjects an increase in nasal secretion was verified in proportion to the concentration of the solutions and this increase was statistically significative, with respect to the base, from the concentration 3.6% (p less than 0.001) on words. The statistical analysis has not, however, evidenced any significant differences in secretion between male or female subjects. As far as the variation of nasal resistance is concerned, the rhinomanometric registration has revealed that the hypertonic solutions modify such resistances in a rather casual, absolutely irregular and unimportant way. These results lead to believe that the test is extremely useful in the study of the secretion component of vasomotor rhinopathy.

Nasal reactivity to histamine was evaluated in 40 normal subjects. The application of a chloride histamine solution (1 mg) registered in 90% of the subjects the appearance of sneezing with the number of sneezes ranging between one and fourteen (5.7 +/- 3.76) and an average increase in the total resistence in the inspiration phase of 93.1% (+/- 63.2) and in the expiration phase of 98.1% (+/- 60.5) with a range between 37.7% and 24.1%. The authors conclude that sneezing and above all nasal congestion evaluated rhinomanometrically represent two important parameters in the evaluation of nasal reaction; an increase greater than or equal to 200% of the total nasal resistance can surely be considered an index of nasal hyperreactivity.

The tidal volume (TV) delivered by conventional anesthesia ventilators is dependent on fresh gas flow rate (FGF). When FGF is reduced, the TV declines; this must be corrected by increasing the ventilator bellows excursion. In addition, the falling bellows produce a negative pressure during the expiratory phase, which may result in positive negative pressure ventilation (PNPV). We have measured the performance of three ventilators: AV 1 (Dräger), VIVOLEC (Hoyer), and ELSA (Engström) that are equipped with a reservoir bag supplied with fresh gas and from which the bellows is filled. METHOD. Two breathing bags with a corrugated tube of 1 m length were connected to a Y-piece to simulate clinical conditions. Starting from 10 l/min, FGF was decreased by 1 l at a time down to 1.0 l/min. Measurements were made at each level of FGF and also at 0.5, 0.3, and 0.2 l/min using a constant inspiration: expiration ratio of 1:2, displacement of the bellows of 700 ml/breath, and a rate of 10/min. Measurements of peak pressure, positive end-expiratory pressure (PEEP), and delivered TV were made at each FGF setting. RESULTS. The course of TV-dependence on FGF is shown in Fig. 1, that of peak inflation pressure and PEEP in Table 1. Reducing FGF had no effect on TV and inflation pressure with ELSA. VIVOLEC lost 17% of the initial TV when FGF was reduced to 0.2 l/min. By closing the relief valve, the loss of TV could be reduced to 4.5%. AV 1 lost about 10% of the initial TV when FGF was reduced to 0.5 l/min. Peak pressure and PEEP were lower with minimal flow. The reservoir bag collapsed when the plateau pressure exceeded 18-20 mbar. CONCLUSIONS. The TV delivered by the ventilators studied was found to reflect closely what had been preset on the bellows displacement scale, within a range of less than or equal to 17%, irrespective of FGF. Hence, the problem of FGF-dependence of TV is largely negated in anesthesia ventilators equipped with a reservoir bag. With ELSA, there was no loss of TV even under minimal flow conditions. VI-VOLEC (with the relief valve closed) and AV 1 had a loss of less than 10% of the initial TV. Adding a reservoir bag to anesthesia ventilators is an effective method of guaranteeing a TV independent of FGF. The three ventilators tested here proved suitable for minimal-flow anesthesia.

The variations of nasal resistance, after lateral right, lateral left and supine recumbency have been studied in 20 normal subjects. These variations were in order of constant succession by rhinomanometry. In lateral right recumbency (first recumbency), the mean increase of nasal resistance in lower nasal cavity was 35%; on the contrary in the following recumbency the increase was twice as large as the first one. In supine recumbency the results were abnormal. In fact, with respect to the same nasal cavity, some of our subjects showed a congestion, while some showed a decongestion. It may be concluded that utilization of postural tests, like index vasomotor reactivity, must keep the increase of nasal resistance in normal subject, following postural variations in mind, in order to express a judgement of significative pathological difference.

A group of 117 subjects suffering from vasomotor rhinopathy (33 with nasal polyposis) were studied with the nasal provocation test with carbacholine in order to evaluate aspecific nasal reactivity. The results obtained by quantifying the variations in nasal secretions and rhinomanometric resistance after application of the test substance indicate the following: a marked hypersecretory response and obstruction in 80% of the vasomotor rhinitis cases; a more marked aspecific reactivity in perennial allergic rhinitis sufferers than in those with seasonal atopic rhinopathy; a lack of statistical significance between the group of those with atopic polyposis and those with a negative skin test. The authors conclude by confirming the usefulness of the test for aspecific reactivity in the diagnosis of vasomotor rhinopathy and propose its use for better screening those patients to undergo specific hyposensitivity therapy.

Marked adeno-tonsillar hypertrophy is certainly the most common respiratory disturbance found among children. Most particularly obstructive sleep apnea (OSA) leads to serious, at times fatal, consequences on the cardio-respiratory apparatus. Thus opinion in the literature unanimously holds that said syndrome is one precise indication for tonsillectomy and/or adenotomy. The present case study was performed on 19 children, age range 21 months to 6 years, with serious obstructions of the respiratory tract due to tonsillar or adeno-tonsillar hypertrophy (14 cases) or to isolated adenoid hypertrophy (5 cases). The sample was divided into 4 groups, taking into consideration the severity of the nighttime sleep obstruction and the type of obstruction. Polygraphy performed during sleep recorded objective OSA in 10 subjects with tonsillar or adeno-tonsillar hypertrophy, but no case was recorded in any subject with solely adenoid hypertrophy. The severity of the obstruction was likewise shown, judged both on the basis of frequency and duration of the pauses as well as on the cardio-respiratory complications, especially in the smallest children (less than 3 years). Furthermore, in the most serious cases significant hematological alterations were recorded. Tonsillectomy, performed in 9 of the 10 children with OSA, completely resolved the sleep disturbances and improved, or normalized, the broncho-pneumonic picture as well the hematological findings in those cases where preoperative complications were present. Even for those children who did not manifest OSA, tonsillectomy and/or adenotomy led to a more uniform rhythm and quality of their sleep.(ABSTRACT TRUNCATED AT 250 WORDS)

Whole serum complement (CH50) and C3, C4, and C3PA plasma values were studied in 48 patients: 9 with nonseptic shock; 20 with sepsis; 14 with septic shock caused by gram-negative bacteria; 5 with septic shock caused by gram-positive bacteria. All were compared with a control group of 25 healthy individuals. Determinations were made upon admission and again 48 and 96 h later. No significant differences in complement values were found between the patients with nonseptic shock and the control group. In the patients with sepsis, decreased CH50 (p less than 0.001) and increased C3PA (p less than 0.02) values were observed, while C3 and C4 remained unaltered. In the patients with septic shock, markedly decreased levels of CH50, C3, and C4 were seen (p less than 0.001, and p less than 0.001, and p less than 0.001, respectively) without changes in C3PA levels. There were no differences between septic shock due to gram-negative and gram-positive bacteria, or between patients who died and those who survived. After 96 h, the altered values returned to the normal range. This underlines the transitory activation of the complement system through the classic pathway and suggests its possible role in the pathogenesis of septic shock in man.

After description of etiopathogenetic, anatomopathological and clinical aspects of the disease, the authors relate about a case of ochronotic arthropathy, lining on its typical radiological patterns. Scintigraphic study with 99mTc-pertechnetate and with 99mTc-pyrophosphate, excluding any phlogistic component, agree with dysmetabolic and degenerative nature of this arthropathy.

In a prospective study of patients with ventilatory support, six (38 percent) of 16 patients who had ventilatory support because of aspiration pneumonia developed pneumothorax and pneumomediastinum. In contrast, the incidence of barotrauma in the entire group of patients who had ventilatory support during a year was 4 percent (22/553) (P less than 0.001). This greater incidence in the group with aspiration pneumonia was also observed when patients who were receiving ventilatory support with positive end-expiratory pressure were excluded.

We present the case of an asymptomatic male in whom bilateral hilar and right paratracheal lymph node enlargement was a casual finding. An esophagogram was performed to evaluate possible mediastinal nodes and an esophagobronchial fistula was discovered. In view of the coexistence of lymph node enlargement and esophagobronchial fistula, the case was presumed to be tuberculosis, as was confirmed by sputum culture positive for Mycobacterium tuberculosis. After tuberculostatic treatment, the course was favorable. Closure of the fistula was confirmed in a later follow-up.