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Aims: Preoperative anxiety, which can affect postoperative recovery, is often present in patients undergoing surgery under loco-regional anaesthesia (LRA). Minimising preoperative anxiety with premedication can be effective but results in drug-related side effects. Therefore, the use of non-pharmacological techniques should be encouraged., Methods: We evaluated whether a virtual reality (VR) incorporating music and a hypnosis session, provided during the performance of LRA, can reduce preoperative anxiety. Fifty patients scheduled for elective hand surgery under an axillary plexus block were enrolled (March-June 2019). The primary outcome measure was the change in the Amsterdam Anxiety and Preoperative Information Scale (APAIS) questionnaire 5 min after the VR session as compared to before the VR session. The secondary outcome measures were the visual analog scale (VAS) for anxiety before and 2 h after the surgery and the Evaluation du Vécu de l'ANesthésie-LocoRégionale (EVAN-LR) satisfaction score., Results: Data from 48 patients were analysed. The APAIS score as well as VAS for anxiety were significantly reduced after a VR session (p < .001 for both scores). Patients were very satisfied (EVAN-LR: 92 (88, 94))., Conclusions: The use of VR incorporating music and a hypnosis session could be an effective tool in the management of a patient's preoperative anxiety during the performance of an axillary plexus block., (© 2021 John Wiley & Sons Ltd.)

Background: Reducing side effects of cancer treatments is a major challenge for clinicians involved in the management of breast cancer patients., Methods: We analyzed data from 63 patients (32 in the general anesthesia group and 31 in the hypnosis sedation group) who were included in 1 prospective non-randomized trial evaluating hypnosis sedation in breast cancer treatment. The patients were followed every 3 months for 2 years. All patients received neoadjuvant chemotherapy with 4 cycles of epirubicin and cyclophosphamide followed by taxanes. Thereafter, patients underwent surgery while on general anesthesia or while on hypnosis sedation. Radiotherapy was administered according to institutional guidelines. Endocrine therapy was prescribed if tumors expressed hormone receptors. Prevalence, intensity and duration of polyneuropathy, musculoskeletal pain, postoperative pain and cancer-related fatigue were assessed at each medical visit., Results: Symptoms duration was statistically reduced for polyneuropathy ( p < 0.05), musculoskeletal pain ( p < 0.05) postoperative pain and cancer-related fatigue ( p < 0.05) in the hypnosis group., Conclusion: Despite the limitations of this study (lack of randomization and small size) we conclude that hypnosis sedation may exert a role on different side effects of breast cancer treatment in patients receiving neoadjuvant chemotherapy, mainly by reducing their duration.

Background: Clinicians traditionally warn patients of pain before peripheral i.v. cannulation (PIVC). However, using words related to pain or undesirable experiences can result in greater pain and anxiety. The use of positive words can improve pain perception and subjective patient experience. We aimed to compare the effects of three types of communication, including hypnotic communication, on pain, comfort, and anxiety in patients during PIVC., Methods: The Effect of Language and Confusion on Pain During Peripheral Intravenous Catheterization (KTHYPE) trial is a randomised, parallel, single-blind, multicentre study of patients undergoing PIVC on the dorsal face of the hand before surgery. Patients from three hospitals were randomly allocated to one of three groups: PIVC performed with a hypnosis technique (hypnosis group), negative connotation (nocebo group), and neutral connotation (neutral group). The primary outcome measure was the occurrence of pain measured with a 0-10 numerical rating scale just after PIVC., Results: Of the 272 subjects analysed (hypnosis, n=89; nocebo, n=92; neutral, n=91), pain after PIVC was lower in the hypnosis group (mean [standard deviation]; range) (1.5 [1.9]; 0-5) compared with the neutral (3.5 [2.3]; 0-9; P<0.0001) and nocebo groups (3.8 [2.5]; 0-10; P<0.0001). Whilst anxiety was higher and comfort lower before PIVC in the hypnosis group, anxiety decreased and comfort perception increased after PIVC when hypnosis was used., Conclusions: This is one of the first well-designed RCTs showing a significant benefit of a hypnosis technique during a routine procedure, such as PIVC. The results could facilitate implementation of hypnosis in daily clinical care., Clinical Trial Registration: NCT02662322., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objectives: The main aim of this prospective nonrandomized study was to evaluate if mastectomy performed with perioperative hypnosedation led to a lower incidence of chronic pain compared with mastectomy under general anesthesia. Methods: Forty-two breast cancer patients who underwent mastectomy either under GA (GA group, n = 21) or HYP (HYP group, n = 21) associated with local and/or regional anesthesia were included. The type of adjuvant therapy as well as the number of reconstructive surgical procedures were well balanced between the 2 groups. The average age of the patients and the type of axillary surgery were also equivalent. Incidence of postmastectomy chronic pain, lymphedema, and shoulder range of motion (ROM) were evaluated after a mean 4-year follow-up. Results: The study shows a statistically significant lower incidence of postmastectomy chronic pain in HYP group (1/21, 1 patient out of 21 experiencing pain) compared with GA group (9/21) with 9 patients out of 21 experiencing pain ( P = .008). ROM for shoulder was also less frequently affected in the hypnosedation group, as only 1 patient had decreased ROM, instead of 7 in the other group ( P = .04). Conclusions: Our study is the first to hint at the potential benefits of hypnosedation on postmastectomy chronic pain. Despite the limitations of this study (nonrandomized, small sample), preliminary results merit further study of hypnosedation.

Background: In oncology, hypnosis has been used for pain relief in metastatic patients but rarely for induction of anesthesia., Material and Method: Between January 2010 and October 2015, 300 patients from our Breast Clinic (Cliniques universitaires Saint-Luc, Université catholique de Louvain) were included in an observational, non-randomized study approved by our local ethics committee (ClinicalTrials.gov - NCT03003611). The hypothesis of our study was that hypnosis intervention could decrease side effects of breast surgery. 150 consecutive patients underwent breast surgery while on general anesthesia (group I), and 150 consecutive patients underwent the same surgical procedures while on hypnosis sedation (group II). After surgery, in each group, 32 patients received chemotherapy, radiotherapy was administered to 123 patients, and 115 patients received endocrine therapy., Results: Duration of hospitalization was statistically significantly reduced in group II versus group I: 3 versus 4.1 days (p = 0.0000057) for all surgical procedures. The number of post-mastectomy lymph punctures was reduced in group II (1-3, median value n = 1.5) versus group I (2-5, median value n = 3.1) (p = 0.01), as was the quantity of lymph removed (103 ml versus 462.7 ml) (p = 0.0297) in the group of mastectomies. Anxiety scale was also statistically reduced in the postoperative period among the group of patients undergoing surgery while on hypnosis sedation (p = 0.0000000000000002). The incidence of asthenia during chemotherapy was statistically decreased (p = 0.01) in group II. In this group, there was a statistically non-significant trend towards a decrease in the incidence of nausea/vomiting (p = 0.1), and the frequency of radiodermitis (p = 0.002) and post-radiotherapy asthenia (p = 0.000000881) was also reduced. Finally, the incidence of hot flashes (p = 0.0000000000021), joint and muscle pain (p = 0.0000000000021) and asthenia while on endocrine therapy (p = 0.000000022) were statistically significantly decreased in group II., Discussion: Hypnosis sedation exerts beneficial effects on nearly all modalities of breast cancer treatment., Conclusion: Benefits of hypnosis sedation on breast cancer treatment are very encouraging and further promote the concept of integrative oncology., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The aim of this review is to summarize data published on the use of perioperative hypnosis in patients undergoing breast cancer surgery (BCS). Indeed, the majority of BCS patients experience stress, anxiety, nausea, vomiting, and pain. Correct management of the perioperative period and surgical removal of the primary tumor are clearly essential but can affect patients on different levels and hence have a negative impact on oncological outcomes. This review examines the effect of clinical hypnosis performed during the perioperative period. Thanks to its specific properties and techniques allowing it to be used as complementary treatment preoperatively, hypnosis has an impact most notably on distress and postoperative pain. During surgery, hypnosis may be applied to limit immunosuppression, while, in the postoperative period, it can reduce pain, anxiety, and fatigue and improve wound healing. Moreover, hypnosis is inexpensive, an important consideration given current financial concerns in healthcare. Of course, large randomized prospective studies are now needed to confirm the observed advantages of hypnosis in the field of oncology.

Background: Adjuvants to local anaesthetics for epidural labour analgesia are useful if they reduce side-effects or personnel requirements. Epidural clonidine improves analgesia and provides a significant local anaesthetic-sparing effect., Objective: To compare the number of rescue doses administered by the anaesthesiologist when clonidine or sufentanil is added to epidural ropivacaine., Design: A randomised double-blind trial., Setting: Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium, from June 2009 to June 2010., Patients: One hundred and ninety-five women in labour., Intervention: Epidural analgesia initiated with 10 ml ropivacaine 0.1%, women randomised to receive patient-controlled epidural analgesia (5 ml demand bolus, 15 min lockout) with ropivacaine 0.1% and sufentanil 0.25 μg ml⁻¹ (RS group; n = 65), or ropivacaine 0.1% and clonidine 1.5 μg ml⁻¹ (RC1.5 group; n = 65) or ropivacaine 0.1% and clonidine 3 μg ml⁻¹ (RC3 group; n = 65). Rescue analgesia was available as needed – 10 ml ropivacaine 0.1% (numerical rating scale <6/10) or ropivacaine 0.2% (numerical rating scale ≥6/10)., Main Outcome: Comparison of the total number of rescue doses., Results: The total number of rescue doses was similar among the groups [median (interquartile range): 1 (0 to 1) in the RC1.5 group, 1 (1 to 2) in the RC3 group and 2 (1 to 2) in the RS group; overall P = 0.056]. However, fewer patients in both the RC1.5 and RC3 groups needed two or more rescue doses (25 and 29% versus 52% in the RS group, P = 0.01). The rate of instrumental delivery was higher in both clonidine groups (13 and 12% versus 0%, P = 0.03). Nausea was significantly less frequent in both the clonidine groups. Satisfaction scores, total ropivacaine consumption, maternal sedation, and hypotension and neonatal outcomes were similar among the groups., Conclusion: Compared with sufentanil 0.25 μg ml⁻¹, addition of clonidine (1.5 to 3 μg ml⁻¹) to patient-controlled epidural analgesia with ropivacaine 0.1% provided similar labour analgesia and a similar need for anaesthesiologist-administered rescue doses. Clonidine 3 μg ml⁻¹ did not offer any advantage over clonidine 1.5 μg ml⁻¹. The instrumentation rate was higher in both the clonidine groups.

It is a 29-year-old patient who presented in the postpartum a facial palsy. A few days later she developed progressively a worsening dyspnea accompanied by tachycardia. Examinations have showed severe heart failure. Etiological research demonstrated reactivation of Epstein Barr virus infection with facial neuritis and concomitant myocarditis. The patient has fully recovered and was in complete remission after 6 months. To our knowledge this is the first case where a facial palsy and postpartum cardiomyopathy are associated and may be explained by a common viral etiology.

Introduction: Late termination of pregnancy combines psychological distress with severe physical pain. The present study evaluated the benefit of adding oral pregabalin to epidural analgesia during this procedure., Methods: Healthy women were randomly allocated to receive either oral pregabalin 150 mg/12 h or prazepam 10 mg/12 h at the induction of the late termination of pregnancy procedure. When they felt abdominal pain (numerical rating scale ranging from 0 [no pain] to 100 [worst pain possible]), patient-controlled epidural analgesia was activated and set to deliver ropivacaine 0.1% with sufentanil 0.25 μg/ml, 5 ml/h with a bolus dose of 5 ml/30 min. Rescue analgesia was available as needed by administration of 10 ml ropivacaine 0.1% (pain score less than 60/100) or 0.2% (at least 60/100). The primary outcome was the consumption of epidural analgesics., Results: Forty-eight patients participated in the study. Demographic and obstetric data were similar. Pregabalin reduced total ropivacaine consumption 11.3 ± 3.2 mg/h (mean ± SD) versus 15.1 ± 4.9 mg/h in the prazepam group (P = 0.005), an effect related to a decrease in the need for rescue analgesia. In the pregabalin group, fewer women asked for rescue dose (75 vs. 96%; P = 0.048), and the number of rescue doses per patient was reduced (1 [0-2] vs. 2 [1-3]); median [interquartile range], P = 0.005), particularly the need for ropivacaine 0.2%., Discussion: This is the first study considering the use of pregabalin for labor pain associated with late termination of pregnancy, showing that pregabalin 150 mg/12 h is a helpful adjuvant to epidural analgesia. Modulation of both visceral sensitization and affective component of pain may contribute to the benefits observed.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy., (Copyright © 2010. Published by Elsevier Ltd.. All rights reserved.)

Purpose: We report the use of Patient-Controlled Intravenous Analgesia (PCIA) with remifentanil in two parturients with twin pregnancies in whom epidural analgesia was contraindicated., Clinical Features: Two patients with a twin pregnancy were admitted to the labor ward at 36 weeks of gestation. Epidural analgesia was contraindicated because of anticoagulation therapy or because of severe thrombocytopenia. PCIA remifentanil was offered to these patients. In the first case, pain from contractions was well controlled during labor, and the first twin was easily delivered. On the other hand, the second twin was in the breech position and an internal version was required rapidly because of fetal bradycardia to deliver the baby as soon as possible. Pain increased in intensity during this maneuver and PCIA remifentanil was insufficient. In the second case, the course of labor was uneventful and the patient easily delivered twins., Conclusion: In the case of twin pregnancy, we recommend remifentanil PCIA only if epidural analgesia is contraindicated (and not as a routine) because of the high risk of obstetrical maneuvers or potential cesarean delivery for the second twin, and the lack of efficacy of remifentanil, at the dose used in this report.

Childbirth ranks among the most intense experiences of acute pain. Neuraxial analgesia (i.e. epidural or combined spinal-epidural technique) is the most effective way to relieve that pain but it is contraindicated or impossible to perform for some parturients. We designed a survey of the current use of analgesic alternatives to epidural analgesia (EA) for labor pain, specifically the use of opioid patient-controlled intravenous analgesia (PCIA), in the French part of Belgium (Wallonia and Brussels). A questionnaire was mailed to the departmental chair of the hospitals with an obstetric unit, both in university and non-university centers (total of 53 centers). The questionnaire evaluated the availability of EA, the alternatives used when EA was contraindicated, the use of opioid-based PCIA for labor analgesia as well as opioid preference and doses, and finally the reasons for not using opioid PCIA. The response rate was 67.5% (36 centers). Among the responding hospitals, EA was available for 68% (range 25-85%) of labors and deliveries. When EA was not available or contraindicated, a parenteral opioid (piritramide, tramadol or pethidine) was proposed in 19% (7/36) of the centers, Entonox in 11% (4/36), a pudendal block by obstetricians in 28% (10/36) and non-pharmacologic alternatives (i.e. hypnosis, sophrology, baths and massages) in 19% (7/36). In 28% (10/36) of the centers however, no analgesic alternative was proposed. Opioid PCIA was employed in 36% (13/36) of the centers and for an additional 11% (4/36) only in case of intrauterine death. Remifentanil was the first choice (76.5% of the PCIA), followed by sufentanil (23.5%). Other opioids (piritramide, morphine, fentanyl) and ketamine were also administered by PCIA. Forty-five percents of the centers reported never using opioid PCIA by either lack of knowledge (7%), fear of maternal or fetal side effects (48%) and unability to provide a correct supervision of the parturient during PCIA use (48%), opposition from the pediatricians or obstetricians (17%) or because they considered the technique as ineffective to relieve labor pain (17%). In conclusion, the survey demonstrated that, when EA is contraindicated, systemic opioid administered by PCIA is used in almost half of the centers (47%) and that remifentanil is the first choice, particularly when a live birth is expected.

Background: Intrathecal clonidine improves intraoperative anesthesia and postoperative analgesia after cesarean delivery. Clonidine also possesses antihyperalgesic properties. Hyperalgesia contributes to postoperative pain and may be associated with increased risk of chronic pain after surgery. In this study, we evaluated the postoperative antihyperalgesic effect of intrathecal clonidine after caesarean delivery., Methods: Ninety-six parturients undergoing elective cesarean delivery were randomly assigned to receive intrathecal bupivacaine-sufentanil (BS group), bupivacaine-sufentanil-clonidine 75 microg (BSC group), or bupivacaine-clonidine 150 microg (BC group). The primary outcome was the extent and the incidence of periincisional punctate mechanical hyperalgesia as assessed by response to application of a von Frey filament at 24 and 48 h after cesarean delivery. Postoperative morphine requirements and pain scores, as well as residual pain at 1, 3, and 6 mo, were also assessed., Results: The BC group had a significantly reduced area of periincisional hyperalgesia at 48 h (median, 25th-75th percentiles): 1.0 (1.0 - 3.3) cm(2) vs 9.5 (5.0-14.0) cm(2) in the BS group vs 5.0 (2.5-12.3) cm(2) in the BSC group (P = 0.02 with the BS group). The incidence of hyperalgesia at 48 h was also lower in the BC group: 16% vs 41% in the BS group vs 34% in the BSC group (P = 0.03 with BS group). Postoperative morphine consumption, pain scores, and incidence and intensity of residual pain did not differ among groups., Conclusions: Intrathecal clonidine 150 mug combined with bupivacaine had a postoperative antihyperalgesic effect expressed as a significant reduction in the extent and incidence of periincisional punctate mechanical hyperalgesia at 48 h after elective cesarean delivery compared with intrathecal bupivacaine-sufentanil and intrathecal clonidine 75 mug-bupivacaine-sufentanil.

Background: Postoperative pain mostly results from sensitization of afferent fibers at injury sites driving central sensitization. Recently, peripheral processes have gained attention as mechanisms of hyperalgesia, and prostaglandins are among highly sensitizing agents. To date, perioperative administration of a single local dose of nonsteroidal antiinflammatory drugs has shown inconclusive efficacy. Rather than a single bolus, the current study evaluates the postoperative analgesic effect of diclofenac continuous intrawound infusion after elective cesarean delivery., Methods: Ninety-two parturients were randomly allocated to receive a 48-h continuous intrawound infusion with 240 ml containing 300 mg diclofenac, 0.2% ropivacaine, or saline. In the ropivacaine and saline groups, patients also received 75 mg intravenous diclofenac every 12 h for 48 h. Postoperative evaluation included intravenous morphine consumption by patient-controlled analgesia and visual analog pain scores. Punctate mechanical hyperalgesia surrounding the wound and presence of residual pain after 1 and 6 months were also assessed., Results: Continuous diclofenac infusion significantly reduced postoperative morphine consumption (18 mg; 95% confidence interval, 12.7-22.2) in comparison with saline infusion and systemic diclofenac (38 mg; 95% confidence interval, 28.8-43.7) (P=0.0009) without unique adverse effects. Postoperative analgesia produced by local diclofenac infusion was as effective as local ropivacaine infusion with systemic diclofenac., Conclusions: After elective cesarean delivery, continuous intrawound infusion of diclofenac demonstrates a greater opioid-sparing effect and better postoperative analgesia than the same dose administered as an intermittent intravenous bolus.

We previously demonstrated the effectiveness of epidural sufentanil and the cholinesterase inhibitor, neostigmine, to initiate selective labor analgesia. Because the traditional lidocaine plus epinephrine test dose (TD) may alter the effect of subsequent epidural drugs, we undertook this investigation to evaluate the impact of a lidocaine TD on analgesia from a combination of epidural neostigmine plus sufentanil administered in early labor. Eighty healthy parturients were randomly allocated to two groups to receive a 3 mL-TD, either lidocaine 2%-epinephrine (1:200,000) or saline-epinephrine (1:200,000), followed 3 min later by epidural neostigmine 500 microg plus sufentanil 10 microg. Pain scores were recorded for 30 min after injection, as was the time elapsed from initial bolus until request for supplemental analgesia. Thirty minutes after injection, adequacy of motor function was evaluated by the parturient's ability to sit, stand up, bend her knees, and walk. Lidocaine TD hastened the onset (5 min vs 15 min) and increased duration (122 +/- 53 min vs 98 +/- 54 min; P = 0.02) of analgesia from epidural neostigmine plus sufentanil bolus. In contrast, the TD did not significantly impair the ability to sit, stand up, or bend the knees. The ability to ambulate, however, was reduced (57% vs 82%; P = 0.04). In conclusion, a traditional lidocaine TD significantly enhances the analgesic effect from the epidural neostigmine plus sufentanil combination, but affects ambulation in early labor.

Purpose of Review: Neuraxial adjuvant drugs are used to improve analgesia and to decrease complications associated with a high dose of a single drug. Opioids are used in routinely, but alpha2-agonists, such as clonidine or cholinesterase inhibitors (neostigmine), have also been used for labour analgesia or to relieve pain following caesarean section. Both drugs possess a common mechanism of action that can be beneficial., Recent Findings: Small doses of intrathecal clonidine (30 microg), combined with local anaesthetics and opioids, prolong labour analgesia. Hypotension can occur and must be promptly treated by ephedrine to avoid fetal side effects. Epidural clonidine (60 to 75 microg) produces prolonged analgesia from local anaesthetics and opioids and allows a ropivacaine sparing effect. Intrathecal neostigmine has analgesic properties, but its gastro-intestinal side effects contraindicate its clinical use. Epidural neostigmine, combined with sufentanil or clonidine, initiates labour analgesia (minimum 6 to 7 microg/kg; 500 microg) without side effects, however, and allows a 'mobile epidural'. Epidural and spinal clonidine can be used to improve postcaesarean section analgesia. Epidural neostigmine at the doses studied produces modest analgesia following caesarean section., Summary: Co-administration of neuraxial drugs may enhance analgesia and reduce the side effects of each drug. Clonidine and neostigmine may be used in obstetrics, under some conditions.

Background: Epidural clonidine produces analgesia without motor impairment, and is associated with a local anesthetic-sparing effect during labor. The authors have recently demonstrated that epidural neostigmine initiates selective labor analgesia devoid of adverse effects. Both drugs possess common analgesic mechanisms mediated through spinal acetylcholine release. This study evaluates their epidural combination in parturients., Methods: At the beginning of labor, parturients were randomly allocated to one of five groups to receive one of the following after a test dose: 150 microg epidural clonidine, 750 microg neostigmine, or 75 microg clonidine combined with 250, 500, or 750 microg neostigmine. A pain score (visual analog scale, 0-100) was recorded before administration and at regular intervals until request for a supplemental injection. Subsequent analgesia was provided by continuous epidural infusion of ropivacaine., Results: Parturients did not differ regarding demographic data and initial pain score. Clonidine 150 microg , neostigmine 750 microg , and 75 microg clonidine plus 250 microg neostigmine produced ineffective and short-lasting effects. Clonidine 75 microg plus 500 microg neostigmine and 75 microg clonidine plus 750 microg neostigmine presented comparable durations of 90 +/- 32 and 108 +/- 38 min (mean +/- SD), respectively, and final analgesic efficacies, with 72.2% and 84%, respectively, of the parturients reporting a visual analog scale score of less than 30 out of 100 after 30 min. Ropivacaine use was significantly reduced in all clonidine groups (average, 9.5 mg/h) in comparison with neostigmine alone (17 +/- 3 mg/h). No adverse effects were observed for 75 mug clonidine combined with any dose of neostigmine while maternal sedation (20%) and hypotension (33%) occurred with 150 microg clonidine alone., Conclusions: Epidural clonidine, 75 microg , with 750 microg neostigmine is an effective combination to initiate selective labor analgesia without adverse effects. Clonidine use further reduces local anesthetic consumption throughout the course of labor.

Background: This study evaluated the efficacy of an epidural single dose of neostigmine combined with sufentanil to provide selective and balanced analgesia at the beginning of labor., Methods: After informed consent, 125 healthy parturients were randomly allocated to receive, after a test dose, a single injection of either epidural sufentanil 20 micrograms (minimal analgesic dose) or 10 micrograms or a combination of sufentanil 10 micrograms with neostigmine 250, 500, or 750 micrograms in a total volume of 12 ml. Pain scores were recorded at regular intervals to determine onset and duration of analgesia. Maternal and fetal vital parameters as well as side effects were closely monitored., Results: Parturients did not differ concerning demographic data. Epidural neostigmine 500 micrograms with sufentanil 10 micrograms produced effective analgesia (visual analog scale <30 mm within 10 min in 72% parturients and within 15 min in 85% parturients; average duration of 119 min, confidence interval 96-142 min) that was as effective as epidural sufentanil 20 micrograms. Epidural combination with neostigmine 250 micrograms was ineffective, whereas 750 micrograms did not produce higher effect than 500 micrograms. No motor block was recorded. Maternal and fetal vital parameters remained stable during labor., Conclusions: Epidural combination of neostigmine 500 micrograms (e.g., 6-7 micrograms/kg) with sufentanil 10 micrograms provides similar duration of analgesia as epidural sufentanil 20 micrograms and allows effective and selective analgesia devoid of side effects in the first stage of labor.

We report a case of respiratory distress in the post anesthesia care unit following general anaesthesia for a dilatation and curettage related to miscarriage in a 32-year-old woman. The preoperative physical examination showed no abnormalities except for the presence of dry cough during the preceding two or three days. A few minutes after her arrival in the PACU, the patient developed hyperthermia till 40.6 degrees C, cough, polypnea and oxygen desaturation (SpO(2): 82% on FiO(2): 40%). A thoraco-abdominal angioscanner showed pulmonary basal condensations and a thrombosis of the right ovarian vein. The patient had to be transferred to the intensive care unit where she remained intubated and ventilated during 13 days because of a Haemophilus influenzae pneumonia.

Since two decades, sleep breathing disorders are more wisely recognized by the Belgian medical community. Among these, the Obstructive Sleep Apnea Syndrome (OSA) is the best known but its frontiers with others syndromes such as the Upper Airway Resistance Syndrome (UARS), the Central Sleep Apnea Syndrome (CSAS) or the Overlap Syndrome are still matter of discussion. Its causes are plurifactorial, and many recent publications draw the attention to its long term effects in the cardiovascular and neuropsychiatric fields. This article summarizes the present definitions and features associated with OSA, from clinical and neurophysiological perspectives, and the different consequences to which untreated or underdiagnosed patients are exposed.

Unlabelled: Spinal neostigmine produces analgesia without respiratory depression or hypotension but provokes major gastrointestinal side effects. Epidural injection of this drug, however, appears to induce analgesia devoid of such side effects. In this study, we evaluated the effect of a bolus of epidural neostigmine on the duration and magnitude of analgesia in early labor and assessed its eventual sparing effect on subsequent local anesthetic requirements. Epidural neostigmine methylsulfate (maximal dose 4 microg/kg) was added to 10 mL of ropivacaine 0.1%, with and without sufentanil 10 microg, to initiate analgesia. Twenty minutes after injection, pain score, sensory level, and motor block were assessed. Time until request for supplemental epidural medication was also recorded. Patient-controlled epidural analgesia with ropivacaine 0.1% was used for epidural supplementation. Maternal and fetal side effects were closely recorded. Neostigmine (4 microg/kg), when added to ropivacaine 10 mg, provided equivalent analgesia to ropivacaine 20 mg but was less effective than sufentanil 10 microg for the initiation of labor epidural analgesia. Further, neostigmine did not modify the subsequent patient-controlled epidural analgesia local anesthetic requirements during labor. No hemodynamic instability, additional motor block, or bothersome side effects were recorded., Implications: The combination of epidural neostigmine (4 microg/kg) with the local anesthetic ropivacaine, with or without sufentanil, does not significantly enhance neuraxial analgesia during labor. Such a dose, however, has no bothersome side effects.

The diagnosis of narcolepsy-cataplexy is based on three axes: 1) the medical history is strongly suggestive when diurnal sleep attacks (narcolepsy) and drop attacks (cataplexy) are reported or observed; 2) the polysomnography is mandatory and shows nocturnal and diurnal (multiple sleep latency test) REM sleep onsets; 3) HLA typing, practically helps to exclude the diagnosis when HLA DR15-DQB1*0602 is not present. New pathogenetic hypotheses have been proposed, mostly based the absence of hypocretin in narcoleptic cerebrospinal fluid. This neurotransmitter was previously known exclusively by its involvement in alimentary behaviours. The new therapies remain symptomatic, but they are powerful to prevent somnolence, daytime sleepiness, cataplexy and insomnia associated with this syndrome.

Two cases of acute internal carotid dissection are presented. Typical symptoms, pathogeny and imaging features are reviewed. Magnetic Resonance is actually the best technique for the diagnosis of internal carotid artery dissection, which should be searched in young patients presenting neurologic and cervico-facial symptoms.

Purpose: To show the use of the short acting opioid remifentanil for labour analgesia when epidural analgesia is considered to be contraindicated., Clinical Features: After Ethics Committee approval and informed consent, six patients (36-40 wk gestation), in whom epidural analgesia was considered contraindicated (women refusing regional analgesia, presenting with coagulation or platelet abnormalities or sepsis) benefited from patient-controlled intravenous analgesia (PCIA) with remifentanil. The Abbott Lifecare patient-controlled analgesia (PCA) pump with remifentanil 50 microg x ml(-1) was set to deliver remifentanil continuous background infusion of 0.05 microg x kg(-1) x min(-1) and 25 microg boluses with a five minutes lockout period. The PCIA was started when the parturients experienced regular painful contractions (cervical dilatation of at least 4 cm) and stopped just before delivery (cervix fully dilated). Maternal monitoring included non-invasive blood pressure measurements, heart rate, percutaneous arterial oxyhemoglobin saturation and respiratory rate. Percutaneous fetal heart rate was continuously monitored. All patients remained alert or sleepy but easily arousable and were satisfied with their analgesia. No particular side effects have been noticed. Apgar scores were between 6 and 10., Conclusion: Remifentanil PCIA combining low continuous background infusion and small bolus doses is an alternative when epidural analgesia in labour is contraindicated. Under careful anesthesia monitoring, the technique seems to be safe for both mother and baby, at least when delivery occurs at or near the normal term of pregnancy.

Expression of a silent aspartate transcarbamylase (ATCase) domain can occur by insertion of a Tyl retrotransposon within the coding sequence of a mutated ura2 allele. This unusual type of Ty-mediated gene activation is possible as the URA2 gene product is a multifunctional protein containing the carbamoyl phosphate synthetase (CPSase), the ATCase and a cryptic dihydroorotase (DHOase) domain. The region in which transcription of the corresponding allele is initiated was determined by RT-PCR experiments. Expression is initiated by a sequence located in the delta element of the Tyl and not by a sequence of the URA2 gene itself. This situation differs with the Ty-mediated gene activation described thus far, in which the transposon substitutes only the 5' regulatory sequences and in which the normal transcription start point is used. The corresponding protein carries both the DHOase-like domain and the ATCase domain, suggesting that the DHOase-like domain is at least involved in the architecture of the protein and necessary to render the ATCase domain functional.

Genetic rearrangements such as deletions or duplications of DNA sequences are rarely detected in the yeast Saccharomyces cerevisiae. We have developed a screening system using the URA2 gene coding for the bi-functional CPSase-ATCase (carbamyl phosphate synthetase - aspartate transcarbamylase) to select positively for these kinds of events. Nonsense mutations in the CPSase region cause a complete loss of the ATCase activity because of their strong polar effect. Thirty-seven ATCase+ revertants were isolated from a strain containing three nonsense mutations in the proximal CPSase region. Genetic and structural analysis of the URA2 locus in these strains allowed us to characterize two major classes of revertants. In the first, an entire copy of a Ty transposon was found to be inserted in the CPSase coding domain. This event, which represents a new form of Ty-mediated gene activation was further analysed by mapping the Ty integration site in 26 strains. In a second class of revertants, we observed chromosomal rearrangements and, in particular, duplication of the ATCase region and its integration in a new chromosomal environment in which this sequence becomes active.

A prototroph revertant (Rev9) selected from an ATCase- mutant of the URA2 gene containing three nonsense mutations was shown to contain two ATCase coding sequences. We cloned both ATCase coding areas to show that the duplicated locus (dl9) was the only functional one. Its size corresponded roughly to the second half of the URA2 wild-type gene. Sequence analysis of the 5' end of dl9 indicated that this duplicated sequence was inserted within the intergenic region close to the MRS3 gene and was transcribed from an unknown promoter divergently from the MRS3 gene. The event leading to the revertant strain Rev9 included a rearrangement that increased the size of chromosome X by about 60 kb. In agreement with such a rearrangement, recombination was undetectable in the vicinity of the locus dl9. Genetic mapping confirms that the MRS3 gene is 2 cM distal to the URA2 gene on the right arm of chromosome X.