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Study Objective: This meta-analysis aimed at identifying the risk factors for and their strengths in predicting difficult mask ventilation (MV) through a systematic approach., Design: Meta-analysis of observational studies., Setting: Operating room., Intervention: Airway- or patient-related risk factors for difficult MV reported in over 20% of eligible studies identified through literature review., Patients: Adults receiving anesthetic induction with requirement of MV., Measurements: Databases including EMBASE, MEDLINE, Google Scholar, and Cochrane Library were searched from inception to July 2022. The primary outcomes were the identification of commonly reported risk factors for MV and a comparison of their strengths in difficult MV prediction, while the secondary outcomes were the prevalence of difficult MV in the general population and those with obesity., Main Results: Meta-analysis of 20 observational studies involving 335,846 patients identified 13 risk factors with predictive strengths (all p < 0.05): neck radiation (OR = 5.0, five studies, n = 277,843), increased neck circumference (OR = 4.04, 11 studies, n = 247,871), obstructive sleep apnea (OSA) (OR = 3.61, 12 studies, n = 331,255), presence of beard (OR = 3.35, 12 studies, n = 295,443), snoring (OR = 3.06, 14 studies, n = 296,105), obesity (OR = 2.99, 11 studies, n = 278,297), male gender (OR = 2.76, 16 studies, n = 320,512), Mallampati score III-IV (OR = 2.36, 17 studies, n = 335,016), limited mouth opening (OR = 2.18, six studies, n = 291,795), edentulous (OR = 2.12, 11 studies, n = 249,821), short thyroid-mental distance (OR = 2.12, six studies, n = 328,311), old age (OR = 2, 11 studies, n = 278,750), and limited neck movement (OR = 1.98, nine studies, n = 155,101). The prevalence of difficult MV was 6.1% (16 studies, n = 334,694) and 14.4% (four studies, n = 1152) in the general population and those with obesity, respectively., Conclusions: Our results demonstrated the strengths of 13 most common risk factors for predicting difficult MV, which may serve as an evidence-based reference for clinicians to incorporate into their daily practice., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023. Published by Elsevier Inc.)

Background: The efficacy and safety of gefapixant in adults with chronic cough remain unclear. Our objective was to assess the efficacy and safety of gefapixant using updated evidence., Methods: MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and Embase databases were searched from inception through September 2022. Subgroup analysis based on dose of gefapixant ( i.e. ≤20, 45-50 and ≥100 mg twice daily for low, moderate and high doses, respectively) was performed to explore a potential dose-dependent effect., Results: Five studies involving seven trials showed the efficacy of moderate- or high-dose gefapixant for reducing objective 24-h cough frequency (estimated relative reduction 30.9% and 58.5%, respectively) ( i.e. primary outcome) and awake cough frequency (estimated relative reduction 47.3% and 62.8%, respectively). Night-time cough frequency was only reduced with high-dose gefapixant. Consistently, the use of moderate- or high-dose gefapixant significantly alleviated cough severity and improved cough-related quality of life, but increased the risk of all-cause adverse events (AEs), treatment-related AEs and ageusia/dysgeusia/hypogeusia. Subgroup analysis showed dose dependency in both efficacy and AEs with a cut-off dose being ≥45 mg twice daily., Conclusions: This meta-analysis revealed dose-dependent efficacy and adverse effects of gefapixant against chronic cough. Further studies are required to investigate the feasibility of moderate-dose ( i.e. 45-50 mg twice daily) gefapixant in clinical practice., Competing Interests: Conflict of interest: The authors declare no conflicts of interest., (Copyright ©The authors 2023.)

Salt stress has negative impact on plant development and growth. Jasmonic acid (JA), a phytohormone, has been shown to involve in salt-induced inhibition of primary root growth. The Arabidopsis Glucosinolate transporter1 (GTR1/NPF2.10) is characterized as a JA-Ile, a bioactive form of JA, transporter. However, whether GTR1 participates in salt responses is not clear. In this study, we confirmed that GTR1 is induced by both JA and salinity. Salt-induced JA signaling is affected in gtr1 mutant. The JA responsive genes, JAZ1, JAZ5, MYC2, LOX3, are down-regulated in gtr1 mutant. Phenotypic analyses showed that the salinity-induced lateral root growth inhibition is enhanced in gtr1 mutant, suggesting that GTR1 plays a positive role in lateral root development under salt stress. Interestingly, the expression of a Na + transporter, HKT1, is upregulated in gtr1. Since HKT1 is a negative regulator for lateral root development under salt stress, we proposed that GTR1 alleviates the repression of lateral root development by salt stress by mediating JA signaling and repressing HKT1 expression. This study demonstrates that GTR1 is the molecular link between salt stress, JA signaling, and lateral root development., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Propofol is an anesthetic agent moderating GABA receptors in the nervous system. A number of studies have demonstrated that propofol exerts a negative effect on neural stem cell development in the neonatal mouse hippocampus. However, to the best of our knowledge, there is no study available to date illustrating whether neonatal exposure to propofol affects Leydig stem/progenitor cell development for normal male reproductive development and functions, and the regulatory mechanism remains elusive. In the present study, TM3 cells, a mouse Leydig stem/progenitor cell line, was treated with propofol. The data illustrated that propofol significantly reduced TM3 cell viability. TM3 subG1 phase cell numbers were significantly increased by propofol assayed by flow cytometric analysis. Annexin V/PI double staining assay of the TM3 Leydig cells also demonstrated that propofol increased TM3 cell apoptosis. In addition, cleaved caspase‑8, ‑9 and ‑3 and/or poly(ADP‑ribose) polymerase (PARP) were significantly activated by propofol in the TM3 cells. Furthermore, the expression levels of phospho‑JNK, phospho‑ERK1/2 and phospho‑p38 were activated by propofol in the TM3 cells, indicating that propofol induced apoptosis through the mitogen‑activated protein kinase (MAPK) pathway. Additionally, propofol diminished the phosphorylation of Akt to increase the apoptosis of TM3 cells. On the whole, the findings of the present study demonstrate that propofol induces TM3 cell apoptosis by activating caspases and MAPK pathways, as well as by inhibiting the Akt pathway in TM3 cells. These findings illustrate that propofol affects the viability of Leydig stem/progenitor cells possibly related to the development of the male reproductive system.

In the western world, there is an increasing trend of occurrence in testicular cancer. Treatment of malignant testicular cancer is primarily combined surgery with various chemical drugs. Propofol has been frequently used as an anesthetic and sedative induction agent, which could modulate different γ‑aminobutyric acid receptors in the central nervous system. Studies demonstrated that propofol activates endoplasmic reticulum stress to induce apoptosis in lung cancer. However, it remains elusive whether propofol regulates caspase and/or mitogen‑activated protein kinase (MAPK) pathways to induce apoptosis in Leydig tumor cells. In the present study, MA‑10 mouse Leydig tumor cells were treated with propofol, and possible signal pathways associated with apoptosis were investigated. Results demonstrated that increasing dosage of propofol (300‑600 µM) for 24 h significantly decreased cell viability in MA‑10 cells (P<0.05). In flow cytometry analysis, the amount of sub‑G1 phase cell numbers in MA‑10 cells was significantly increased by propofol (P<0.05). Additionally, Annexin V/propidium iodide double staining further confirmed that propofol could induce MA‑10 cell apoptosis. Furthermore, cleaved caspase‑8, ‑9 and ‑3, and/or poly(ADP‑ribose) polymerase were significantly activated following treatment of propofol in MA‑10 cells. In addition, c‑Jun N‑terminal kinase, extracellular signal‑regulated kinase 1/2, and p38 were significantly activated by propofol in MA‑10 cells (P<0.05), indicating that propofol may induce apoptosis through the MAPK pathway. Additionally, propofol diminished the phosphorylation of Akt to activate apoptosis in MA‑10 cells. In conclusion, propofol may induce MA‑10 cell apoptosis by activating caspase and MAPK pathways, and inhibiting the Akt pathway in MA‑10 cells, demonstrating that propofol may be a potential anticancer agent against Leydig cell cancer.

Human osteosarcoma (bone cancer) is a highly malignant and the most prevalent bone tumor affecting children. Despite recent advances in the understanding of the molecular mechanism by which anticancer drugs kill osteosarcoma or block its growth, however, the mortality rate has declined only modestly. Thus, a new therapeutic approach is needed to be established. 7-hydroxystaurosporine, UCN-01, abrogates the G2 checkpoint thus enhancing the cytotoxicity of chemotherapeutic agents. In addition, it has been evaluated in clinical trials as a single antineoplastic agent in treating several cancers. However, the effects of UCN-01 on treating bone cancer has never been tested. In this study, we found that UCN-01 induced cell cycle arrest and apoptosis in the human osteosarcoma, U2-OS cells. In addition, the migration ability was also reduced, suggesting UCN-01 inhibited cell growth and migration. When U2-OS cells were treated with UCN-01, DNA damage response was triggered. The ataxia telangiectasia mutated (ATM) and the non-canonical downstream effector, ERK, was activated by UCN-01. In addition, depletion of ATM or inhibition of ERK deteriorated the cell viability in UCN-01-treated U2-OS cells. Furthermore, UCN-01 induced autophagy activation for protecting cells from apoptosis. Thus, UCN-01 might function as a single antineoplastic agent in treating human osteosarcoma., (© 2017 Wiley Periodicals, Inc.)

Purpose  To evaluate the potential of routine assessment of intracranial translucency (IT) and other posterior brain parameters in the early detection of open spina bifida during the 11 - 14 weeks screening examination. Materials and Methods  This prospective, multicenter longitudinal study was conducted with the participation of 20 certified DEGUM II or III experts in Berlin, Germany, between June 2010 and October 2013. All pregnant women undergoing a first trimester screening were included in the study and in every patient were the IT, brain stem (BS), cisterna magna (CM), BS to occipital bone distance (BSOB) and BS/BSOB ratio measured. All patients with continuing pregnancy underwent a second trimester scan. Our data was used to develop our own reference ranges. The primary outcome parameter was the presence of open spina bifida. Results  A total of 15 526 women with 16 164 fetuses were examined. Median of the IT was 2.1 mm, of the CM 1.6 mm, of the BS 2.7 mm, of the BSOB 5.5 mm, and of the BS/BSOB ratio 0.49. There were 11 cases with open spina bifida (incidence of 6.8/10 000). The detection rate was 100 % and in all cases of spina bifida, the anomaly was detected either at the first examination (n = 8) or considered suspicious and the lesion then detected a few weeks later (n = 3). Considering individual measurements, however, the detection rate was 18 % with the complete absence of the IT and 45 % with cut-off values. For the CM measurement, the detection rate was 64 % with the absence of the CM and 73 % with cut-off values. The other parameters proved not to be predictive of open spina bifida. Conclusion  In the hands of an expert, open spina bifida can be reliably diagnosed early in gestation during the 11 - 14 weeks screening. The measurement of different parameters of the posterior brain, especially the CM and the use of cut-off values are of tremendous benefit in achieving a high sensitivity in the detection rate., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To gain more information about the knowledge of the clinical management of uterine sarcoma., Materials and Methods: This survey was performed among members of the North-Eastern German Society of Gynecological Oncology (NOGGO) and the German Society of Psychosomatic Medicine in Gynecology and Obstetrics (DGPFG) on the treatment of uterine sarcomas., Results: Altogether, 374 gynecologists took part. When asked about the surgical therapy of leiomyosarcoma, 64% indicated hysterectomy with bilateral adenectomy and lymph node dissection. Answers on the extent of lymphadenectomy in leiomyosarcoma differed widely. When asked about the preferred chemotherapy regimen for metastatic uterine sarcoma, more than 60% of all gynecologists would not apply any chemotherapy. Almost 40% recommended any kind of radiotherapy in this situation., Conclusion: There is a great uncertainty about the standard treatment of uterine sarcoma, even among specialists of gynecological oncology. It is time for organized efforts to improve the treatment of uterine sarcoma.

Objective: To compare the complication rates of bowel perforation during colonoscopy performed with or without anesthesia., Methods: We retrospectively analyzed 9501 case records of colonoscopy performed at the Chi Mei Medical Center between 2000 and 2004, and compared the rates of bowel perforation between patients receiving anesthesia during the procedure versus those that did not receive anesthesia. Poisson distribution was used for statistical analysis., Results: Only one case of perforation was found in the non-anesthetized group (n = 2460) compared with two cases in the anesthetized group (n = 7041). No statistical difference was found (p = 0.6173; risk ratio = 0.6988; 95% confidence interval by Byar's method = 0.063-7.705)., Conclusion: During colonoscopy, anesthesia per se does not affect the rate of bowel perforation.

Unlabelled: The aim of this study was to investigate the influence of sex hormone levels on tumor biology and patients' outcome in ovarian cancer., Patients and Methods: One hundred and six patients with ovarian cancer were enrolled into this prospective study. Serum and ascites samples were obtained intraoperatively. Concentrations of estradiol, FSH, LH and prolactin were measured and correlated with parameters of tumor biology, such as FIGO stage, tumor spread and postoperative tumor residual mass. Patients with primary ovarian cancer were compared to patients with recurrent disease. Influence factors on progression-free survival and overall survival were analyzed using the Kaplan-Meyer method., Results: Serum FSH concentrations were significantly higher and estradiol concentrations in ascites were significantly lower in patients with recurrent disease. According the multivariate analysis, only FSH level in ascites was seen to be an independent prognostic factor for patients' survival., Conclusion: High level of FSH in the ascites provides prognostic information in patients with ovarian cancer and is inversely correlated with patients' survival.

Study Objective: To evaluate compliance of anesthesiologists and nurse anesthetists with personal hygiene and anesthetic equipment disinfection procedures in Taiwan., Design: Survey instrument., Setting: Anesthesiologists and nurse anesthetists working in medical and non-medical centers in Taiwan., Participants: 81 anesthesiologists and 181 nurse anesthetists working in medical and non-medical centers., Measurements and Main Results: Questionnaires were sent to 500 anesthesiologists and nurse anesthetists in Taiwan. Two hundred sixty-two (52%) completed questionnaires (127 from medical centers and 135 from non-medical centers). Completed questionnaires were divided into two groups: those from medical centers (Group A) and those from non-medical centers (Group B). There was no significant difference in personal hygienic practices (wearing gloves and washing hands) between Groups A and B. There were significant differences between anesthesiologists and nurse anesthetists in wearing gloves (65.3% vs. 82%; P = 0.001) and hand washing (52.6% vs. 70.4%; P = 0.003). Medical center anesthesiologists and nurse anesthetists performed better than their non-medical-center counterparts when using disinfection procedures and disinfectants for laryngoscope blades and the cleaning of fiberscopes., Conclusions: Teaching programs should include anesthesia infection control in the curriculum for anesthesiologists and nurse anesthetists.

Objectives: The fact that ovarian cancer remains confined to the peritoneal cavity even in advanced stages has allowed us to surmise that local immunosuppressive factors could be involved in the tumor biology of ovarian cancer. In this context, IL-10 can be one of the key factors. By studying the kinetics of IL-10 concentrations prior to and after surgery, this study attempts to reveal once more the ability of tumor micro-environment to produce IL-10. Some studies indicate that IL-10 concentration correlates with the tumor burden and can thus predict the surgical outcome. Data concerning this aim from patients with ovarian cancer do not seem to exist., Methods: In this prospective study, serum blood was collected from 27 patients, one day prior to surgery as well as 24h, 4 and 8 days after surgery. The concentration of IL-10 was determined using ELISA., Results: While IL-10 levels rise within the first day post-OP, they are found to be reduced significantly when measured at later time points. IL-10 levels also correlate statistically significantly with the tumor grade, with lower IL-10 levels observed in well-differentiated and higher IL-10 levels in undifferentiated or only poorly differentiated tumors., Conclusion: IL-10 expression levels appear to be a good surrogate marker for tumor grading. If validated, this may in future contribute to the understanding of the biology stage cancers.

Objective: To compare the efficacy and safety of vaginal applications of three different principles of cervical priming prior to first trimester curettage, isosorbide mononitrate (ISMN), misoprostol and Dilapan-S, a hygroscopical cervical dilator., Study Design: Pregnant women with missed abortion between 6 and 12 gestational weeks were included and randomly assigned to receive either 80 mg ISMN vaginal gel (group 1) or 200 microg of misoprostol vaginal gel (group 2) or Dilapan-S, a hygroscopical cervical dilator (group 3), for cervical ripening before curettage. Outcome parameters were cervical dilation at the time of operation and maximum dilation reached with Hegar's dilator and the degree of difficulty in mechanical dilation as well as safety and side effects of the preparations., Results: Sixty-five pregnant women with missed abortion were included and assigned to the three study groups (n=22 for group 1, n=22 for group 2, n=21 for group 3). Misoprostol vaginal gel and Dilapan-S were significantly more effective than ISMN vaginal gel in cervical dilation reached with priming (p<0.005 and p<0.005) and in the degree of difficulty in cervical dilation assessed by the surgeon (p<0.001 and p<0.01). Mild discomfort was indicated by all patients after Dilapan insertion, whereas no patient complained about discomfort after misoprostol or ISMN insertion (p<0001). Three patients suffered from mild hypotension and headache after ISMN treatment, and two had increased vaginal bleeding due to uterine atony during surgery (p<0.05)., Conclusion: A vaginal gel of ISMN is less effective for cervical ripening prior to first trimester curettage compared to misoprostol vaginal gel or Dilapan-S. The latter could be an effective and safe alternative to prostaglandin priming avoiding preoperative contractions caused by prostaglandin preparations.

Our objective was to compare two rapid strip tests for the detection of amniotic fluid, based on the detection of insulin-like growth factor-binding protein-1 (IGFBP-1) and of placental alpha-microglobulin-1 (PAMG-1). Samples of amniotic fluid were taken in 20 pregnant women between 31 3/7 and 41 2/7 gestational weeks at elective cesarean section before delivery of the newborn. These samples were diluted with 0.9% saline solution in a dilution series down to concentrations of 1:320. Immunoassay strip tests were then compared in their ability to detect remaining concentrations of amniotic fluid. In 5 cases, both test methods showed the same results. In all remaining 15 cases, the test based on PAMG-1 proved to be superior by detecting amniotic fluid at least at one descending concentration below the test based on IGFBP-1. Thus, the rapid strip test based on PAMG-1 seems to be a more sensitive bedside test compared with the test based on IGFBP-1 for the detection of amniotic fluid.

The study was conducted to assess the prevalence of sensitization to latex in a group of women with a high risk for atopy and to determine whether the use of condoms is a relevant risk factor. In a prospective study, 100 atopic women (defined as having specific IgE to common aero- or nutritional allergens) were screened for specific IgE antibodies to latex after delivery: Ten of the 100 women (10%) showed specific IgE to latex. Total IgE concentrations were higher with a history of occupational exposure or of symptoms after contact with latex (p < 0.05, and p < 0.005, respectively), but condom users were not significantly more frequent in the latex-positive group. Our results indicate that prior use of condoms does not appear to be a specific risk factor for sensitization to latex in post-partum women at high-risk for atopy. Latex-free condoms should only be recommended to women already known to be sensitized to latex., (Copyright 2002 Elsevier Science Inc.)

Background and Objectives: Brachial plexus block (BPB) has been cited as a treatment modality for complex regional pain syndrome type I (CRPS I) of the upper limb. However, there are no reports using axillary BPB with patient controlled analgesia (PCA) for the treatment of CRPS I. This report is based on the retrospective observations of the outcome and effects of axillary BPB with PCA in a patient with CRPS I., Case Report: A 32-year-old man suffered from CRPS I of the right upper limb after surgical release of carpal tunnel syndrome of the right hand. Symptoms and signs over the right hand were alleviated under rehabilitation and conventional pharmacological management, but severe painful swelling of the right wrist persisted. Axillary BPB with PCA was performed on the 32nd postoperative day, which soon resulted in significant reduction of pain with gradual improvement of function of the right wrist., Conclusions: Axillary BPB with PCA may provide patients with CRPS I of the upper limb a feasible and effective treatment. .

The present study was designed to test whether tramadol is effective in the control of neuropathic pain in rats. Chronic constriction injury (CCI) of the sciatic nerve was induced over the left hind limb in male Sprague-Dawley rats. Identical surgery was performed on the opposite side except that the sciatic nerve was not ligated (sham surgery). Paw withdrawal latency (PWL) to heat was tested for each hind paw 1 day before surgery and on the 4th day after surgery to ensure the development of thermal hyperalgesia. In the acute treatment groups, saline or tramadol was administered subcutaneously at doses of 10, 20 or 30 mg/kg, and PWLs were measured 30, 60, 90, 120, 150 and 180 min after treatment. In the semi-chronic treatment groups, continuous systemic administration of tramadol 40 mg/kg/day or saline for 7 days was provided at a uniform rate via osmotic mini pumps. Tramadol reversed PWL in a dose-dependent manner in the acute treatment groups. PWLs were significantly reversed at 2 days after tramadol infusion, and this effect was sustained throughout the remainder of the treatment period in comparison with the saline group. Tramadol also resulted in a decreased sensitivity to thermal stimulus on the sham limb both in acute and semi-chronic administration. We conclude that both acute and semi-chronic tramadol treatment relieves thermal hyperalgesia effectively in rats with CCI of the sciatic nerve. This indicates that tramadol shows promise as a potential treatment for relief of neuropathic pain in humans.

We examined the effects of chronic morphine treatment with regular intermittent administration in a modified chronic constriction injury (CCI) model of the rat sciatic nerve originally introduced by Bennett and Xie. A painful neuropathy was induced over the left hind limb with sciatic nerve ligation, and sham surgery was done on the opposite side in male Sprague-Dawley rats. Paw-with-drawal latency (PWL) was obtained one day before surgery (pre-op baseline) and on the fourth day after surgery (post-op) to assure the development of thermal hyperalgesia. Morphine hydrochloride (5, 10, 15, and 20 mg/kg per day) was subcutaneously administered for 7 days to four experimental groups. The control group received normal saline rather than morphine under the same injection protocol. PWLs were evaluated on days 5, 7, 9, and 11 of the treatment. PWL decreased to 50-60% of the pre-op baseline or sham limb on the fourth day after surgery. Morphine's ability to reverse PWL appeared dose-related, and no tolerance developed during treatment with chronic intermittent administration. This may indicate that prolonged use of intermittently-administered morphine can be a feasible regimen for relief of neuropathic pain.

Background: Propofol has several properties beneficial to intracranial operation such as reduction in cerebral metabolic rate and cerebral blood flow (CBF) in a dose-dependent manner while leaving autoregulation intact. Several studies have demonstrated that the responsiveness of CBF to changes in arterial carbon dioxide tension (PaCO2) is maintained during propofol anesthesia in both humans and animals. These studies showed a significant difference in the CBF-CO2 reactivity slope between awake and propofol anaesthetized groups, but no comparison with different doses of propofol was made. To determine the dose effect of propofol on cerebrovascular CO2 reactivity, we used laser Doppler flowmetry (LDF) to detect the changes of CBF during propofol anesthesia., Methods: Ten rabbits were studied using LDF on the parietal cortex. After surgical preparation, anesthesia was maintained with 66% N2O in O2, morphine 10 mg/kg and pancuronium. Three experimental conditions were studied sequentially with intravenous administration of the following drugs: (1) normal saline (control), (2) propofol 20 mg/kg/h i.v., (3) propofol 40 mg/kg/h i.v. Mean arterial pressure, rectal temperature and hematocrit were kept constant. The arterial carbon dioxide tension (PaCO2) was adjusted to three levels during each condition: 20-25 mmHg (hypocapnia), 35-40 mmHg (normocapnia) and 45-50 mmHg (hypercapnia). CBF was measured continuously and recorded after the target PaCO2 had been reached., Results: There were no differences among all conditions in mean arterial pressure and heart rate. The changes of CBF as PaCO2 increased at the three different CO2 levels during each of the conditions were significantly different. The slope of CBF-CO2 reactivity among three different propofol doses was not significantly different., Conclusions: These data indicate that cerebral vasomotor responsiveness to CO2 during propofol anesthesia is preserved and that the slope of CBF-CO2 reactivity is independent of propofol doses as mean arterial blood pressure is maintained.

Background: The use of neuraxial opioid was very popular in recent years, and they may augment the analgesia produced by local anesthetic through direct binding with the spinal opioid receptors. Hemodynamic stability is very important during Cesarean section. Theoretically, the reduction of local anesthetic by addition of fentanyl would provide better hemodynamic stability and good anesthetic status., Methods: Thirty healthy parturients undergoing Cesarean section were assessed in a randomized fashion. They were divided into two groups. Each subject received 5 mg hyperbaric bupivacaine plus 25 micrograms fentanyl (0.5 ml) and cerebrospinal fluid (CSF) 0.6 ml (Group M + F) or 8 mg hyperbaric bupivacaine plus 0.5 ml of CSF (Group M). The effects of hemodynamic stability, side effects, and complete analgesic duration were observed., Results: It was disclosed that the hemodynamic status was more stable in group M + F. The incidence of nausea and vomiting appeared to be not statistically significant between groups. The incidence of pruritus was apparently higher in group M + F (93.5% vs. 0) but the incidence of shivering was much lower in group M + F (0 vs. 33.3%). The complete analgesic duration was longer in group M + F (146 +/- 47 min vs. 104 +/- 44 min). There were no significant differences in the anesthetic and surgical status, 1-min and 5-min Apgar scores, and the time of regression of sensory level to T10., Conclusions: The combination of small-dose bupivacaine with fentanyl could provide more stable hemodynamic status, longer postoperative analgesia, and lower incidence of shivering. The incidence of pruritus in group M + F was high, but it was usually mild.

A 43-year-old HIV-positive male was referred to our pain clinic one month after his fourth attack of herpes zoster infection. He complained of intermittent intolerable sharp and lancinating pain accompanied by numbness over the inner aspect of the left upper extremity, left anterior chest wall and the back. Physical examination revealed allodynia over the left T1 and T2 dermatomes without any obvious skin lesion. The pain was treated with epidural block made possible by a retention epidural catheter placed via the T2-3 interspace. After the administration of 8 ml of 1% lidocaine in divided doses, the pain was completely relieved for 4 h without significant change of blood pressure or heart rate. A pump (Baxter API) for patient-controlled analgesia (PCA) filled with 0.08% bupivacaine was connected to the epidural catheter on the next day and programmed at a basal rate of 2 ml/h, PCA dose 2 ml, lockout interval 15 min, with an one-hour dose limit of 8 ml. He was instructed to report his condition by telephone every weekday. The pump was refilled with drug and the wound of catheter entry was checked and managed every 3 or 4 days. The epidural catheter was replaced every week. During treatment, the pain intensity was controlled in the range from 10 to 0-2 on the visual analogue scale. He was very satisfied with the treatment and reported only slight hypoesthesia over the left upper extremity in the early treatment period. Epidural PCA was discontinued after 28 days. He did not complain of pain thereafter but reported a slight numb sensation still over the lesion site for a period of time. In conclusion, postherpetic neuralgia in an HIV-infected man was successfully treated with ambulatory therapeutic modality of epidural PCA for 28 days.

Tracheomalacia is a condition characterized by weakness of the tracheal walls and supporting cartilage. It may be congenital, occurring in association with other lesions, such as vascular ring, tracheoesophageal fistula, dyschondroplasia, congenital cysts or tumors, or it may be acquired, most commonly as a result of protracted endotracheal intubation and less often of irradiation, trauma or neoplasm. We present a case of acquired tracheomalacia in a 15-year-old boy, a victim of Proteus syndrome (hemihypertrophy, subcutaneous tumors, and macrodactyly), who had congenital scoliosis with secondary chronic restrictive pulmonary disease, for which he was admitted to our hospital for surgical correction of the spine. Unfortunately, his conditions, particularly of respiratory, worsened after the operation, which called for an emergent tracheostomy. During the procedure, high airway pressure and CO2 retention developed, and an extreme narrowing of the tracheal lumen was revealed by fiberoptic bronchoscopy. Acquired tracheomalacia was diagnosed. The probable mechanisms, diagnostic tests, and treatments of tracheomalacia are hereunder discussed.