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Pain is a major problem for patients with burns. Donor sites are a significant source of this pain. In this investigation we hypothesized that bupivacaine infiltration of the donor site before skin harvest would prove to be a safe technique as determined by the measurement of blood levels of bupivacaine at various time intervals after infiltration. Fourteen patients were enrolled and studied. Average age was 14.3 +/- 3.1 years, weight was 43.1 +/- 9.1 kg, and donor site size was 6.3 +/- 2.0% TBSA. Mean dose of bupivacaine infused was 1.86 +/- 0.21 mg/kg. Maximum mean bupivacaine blood level was 0.39 +/- 0.09 microg/ml. The highest level measured in any one patient was 1.2 microg/ml; 4.0 microg/ml is considered to be the safe upper limit in children. Time to maximum blood level was 8.9 +/- 1.7 hours after infusion. Twelve of the 14 patients had measurable blood levels of bupivacaine at 24 hours after infusion. The maximum bupivacaine level was found to correlate significantly with both the mg/kg of bupivacaine infused (r =.60, P =.04) and the donor site size (r = 0.81, P = 0.002). Bupivacaine at a dose of slightly less than 1.9 mg/kg added to donor site infiltration solution is safe, as demonstrated by low blood levels and the absence of clinical signs of toxicity.

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Paediatric patients with acute burns often require many operative procedures in short succession; yet due to inhalation injury or recent extubation their airways may be susceptible to tracheal tube induced damage. We proposed the laryngeal mask airway (LMA) as a useful airway management tool in this setting. In this prospective study, 80 eight (88) patients with mean age (+/- SD) of 7.8 +/- 4.7 years and average percentage total body surface area burned (%TBSA) of 21 +/- 18% had their airways managed with an LMA while in the operating room for 141 procedures. Twenty-five patients (28.4%) had been previously intubated for burn management and 19 (21.6%) had evidence of inhalation injury. During each procedure, the patient was evaluated for airway obstruction, laryngospasm, inability to ventilate, hypoxaemia, evidence of aspiration/regurgitation or any situation which required intraoperative manipulation/removal of the LMA. Of the 141 procedures, 122 were without airway problems. Of the remaining 19, nine required only a simple reseating of the LMA for correction. The other 10 events include arterial desaturation (n = 3), partial laryngospasm (5), airway obstruction (1) and regurgitation without aspiration (1). In each case, corrective action led to resolution of the problem with no patient morbidity. This series demonstrates the LMA is a safe and efficacious airway management device in the paediatric burn population.

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When local recurrence or distant metastasis occurs, the question arises as to which therapeutic concept should be applied. In contrast to the data on systemic immunotherapy, there are no systematic studies on surgical management of metastasis. Local recurrence (a rare condition) is frequently resected, whereby a prolongation of life can be achieved in individual cases. The complete surgical resection of pulmonary metastases has been shown, in a number of studies, to achieve a survival rate of 5 years in up to 44% of the cases. There are only few data regarding resection of osseous metastases; although in this respect some studies have reported an average survival rate of 34 months, the indication for this condition has, up to now, usually been seen as palliative. The prognosis of liver or brain metastasis is unfavorable; the survival rates achieved with the help of surgical procedures are scarcely higher than those resulting from the spontaneous progression of metastatic renal carcinoma (12 months). Thus, there is an urgent need for further studies in order to define the indication for the surgical management of metastasis.

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Postoperative nausea and vomiting (PONV) is a common and unpleasant problem for children with burns who are undergoing reconstructive burn surgery. Ondansetron and dimenhydrinate have been found to be effective for the prevention of PONV in other patient populations, but they have not been directly compared in the pediatric population. A prospective, randomized, double-blind, placebo-controlled comparison of ondansetron and dimenhydrinate was performed. One hundred patients with a mean age of 11.8 years who were undergoing reconstructive burn surgery with general anesthesia were randomly assigned to receive either a placebo, 0.1 mg/kg of ondansetron, or 0.5 mg/kg of dimenhydrinate. The 3 groups were well matched for all demographic and procedural variables. The study drugs were given twice, first at the end of surgery and again 4 hours later, to ensure adequate blood levels during the 8-hour study period. Postoperatively, on the basis of the presence and amount of PONV experienced, all patients were assigned a PONV score by a blinded investigator. Statistically significant reductions in the incidence of PONV in the patients who received ondansetron or dimenhydrinate were found, as compared with the results of patients who received placebo. Postoperative vomiting was reduced from 61% in the placebo group to 29% and 40% in the ondansetron and dimenhydrinate groups, respectively, and PONV was similarly reduced from 69% to 47% and 40%, respectively. The differences between ondansetron and dimenhydrinate were not significant. The average cost to our pharmacy for the prescribed dose of ondansetron was $19.34; the cost for dimenhydrinate was $0.90. In this patient population, dimenhydrinate was as effective as ondansetron for the prevention of PONV and postoperative vomiting, and it was much less expensive.

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Renal cell carcinoma (RCC) of the kidney accounts für 1-2% of all cancers and is the most common cancer arising in the adult kidney. The cause of RCC is not known. Several studies have shown a greater risk in smokers. Other factors are long-term dialysis and obesity, e.g. The morphological types of RCC have characteristic cytogenetic changes, but the details of genetic changes in renal tumorigenesis are not well understood. Approximately 13%-18% of patients with RCC have metastatic disease at initial presentation, and their prognosis remains unfavorable, because RCC is resistant to chemotherapy and radiotherapy. Only one-third of patients with RCC cured, and strenous efforts are being made to optimize immunotherapy in patients with advanced or metastatic disease.

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A high level of preoperative anxiety frequently occurs in children undergoing reconstructive burn surgery. Reduction of this anxiety may have a number of physiological and psychological benefits. Various pharmaceutical and nonpharmaceutical regimens to reduce preoperative anxiety have been devised; however, most regimens are not initiated until the period immediately before surgery. Many of the children in our institution report high levels of anxiety beginning the night before surgery. Therefore we hypothesized that sedation the night before surgery would be beneficial. Oral lorazepam 0.025 mg/kg or placebo was given the night before surgery to 45 patients in a prospective, randomized, double-blind fashion; in addition, all patients received preoperative sedation per protocol on the day of surgery. Immediately before induction of anesthesia, all patients (mean age 12.5 +/- 0.9 years, range 6 to 18 years) performed an anxiety self-rating with the use of a validated visual analog scale (VAS). Patient anxiety and quality of anesthesia induction was also rated by one of the investigators. Postoperatively, patients rated their recall of anxiety with the use of the VAS. When queried preoperatively, patients who received lorazepam the night before surgery self-reported significantly less anxiety than those receiving placebo. Investigator observations did not detect this difference; this reinforces the assertion that patient self-rating of anxiety may be the best tool for rating anxiety.

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The American Academy of Pediatrics proposes the following guidelines for the pediatric perioperative anesthesia environment. Essential components are identified that make the perioperative environment satisfactory for the anesthesia care of infants and children. Such an environment promotes the safety and wellbeing of infants and children by reducing the risk for adverse events.

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BACKGROUND: Since 1985, a special work group involved in the coordination of hospital cancer registries in Germany (the Arbeitsgruppe zur Koordination Klinischer Krebsregister) has been collecting, storing, and analyzing data on tumor patients received from cancer centers, oncologic departments, and specialized practices. METHODS: The documentation of tumor patients is based on information concerning localization, histologic findings, and tumor spread, among other things. The data are stored in a central data base administered by the work group. It currently contains data on approximately 500,000 oncologic patients. RESULTS: During the period 1987-1992, 56,013 initial entries were made concerning patients with urologic tumors. Of these cases, tumors of the kidney (n = 11,424) constituted 20.4%. In 94.6% of the cases, histologic investigation revealed a renal cell carcinoma, classified as follows: pT1, 5.8%; pT2, 53.6%; pT3, 37.2%; and pT4, 3.4%. Tumors of the urinary bladder (n = 16,246) constituted 29.0% of all urologic tumors. In 93.8% of cases, a transitional cell carcinoma was detected, classified as follows: pTis, 1.0%; pTa, 36.9%; pT1, 29.6%; pT2, 16.9%; pT3, 11.4%; and pT4, 4.4%. Transitional cell carcinomas of the ureter or of the collecting system (n = 1846) constituted 3.3% of the cases. The proportion of testicular tumors (n 6594) amounted to 11.8%; 53.6% of the germ cell tumors (n = 6281) were seminomas and 46.6% were nonseminomas; 66.3% of the cases were lymph node negative. Tumors of the prostate (n = 19,903) constituted 35.5% of the cases. During the period 1987-1992, the proportion of lymph node positive prostate carcinomas decreased, from 39.8% to 16.2%. CONCLUSIONS: A detailed analysis of these data shows how hospital cancer registries can contribute to the discussion of issues regarding diagnosis and therapy of urologic tumors.

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Since 1985 a special work group involved in the coordination of hospital cancer registries in Germany (AKKK) has been collecting, storing and analysing data on tumour patients, received from cancer centres, oncological departments and specialised practices. The documentation of tumour patients is based, among other things, on information concerning localisation, histological findings and tumour spread. The data are stored in a central database administered by the work group. At present it contains data on approximately 500,000 oncological patients. In the period from 1987 to 1992, 56,013 initial entries were made concerning patients with urological tumours. Of these cases, tumours of the kidney (n = 11,424) constituted 20.4%. In 94.6% of the cases, histological investigation revealed a renal cell carcinoma-pT1: 5.8%; pT2: 53.6%, pT3: 37.2% and pT4: 3.4%. Tumours of the urinary bladder (n = 16,246) constituted 29.0% of all urological tumours. In 93.8% of the cases a transitional cell carcinoma was detected-pTis: 1.0%; pTa: 36.9%; pT1: 29.6%; pT2: 16.9%; pT3: 11.4%; pT4: 4.4%. Transitional cell carcinomas of the ureter or of the collecting system (n = 1,846) constituted 3.3% of the cases. The proportion of testicular tumours (n = 6,594) amounted to 11.8%; 53.6% of these germ-cell tumours (n = 6,281) were seminomas and 46.6% were non-seminomas. In all, 66.3% of the cases were lymph-node negative. Tumours of the prostate (n = 19,903) constituted 35.5% of the cases. In the period from 1987 to 1992, the proportion of lymph-node-positive prostate carcinomas decreased from 39.8% to 16.2%. The detailed analysis of these data shows how the hospital cancer registries can support the discussion regarding diagnosis and therapy of urological tumours.

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Flow cytometric examinations were performed consecutively on fresh tumor tissue of 90 patients with testicular germ cell tumours. Measured parameters were the DNA index, the stem-cell shoulder fraction (SSF) as an expression of mitotic activity, and the incidence of tumour population above 5c (5c-exceeding events). The results were correlated with the type of tumour, as determined histologically, the local and clinical stage of the tumour, and clinical outcome. In 94.5% of the cases, flow cytometry detected malignant testicular tumour tissue. The median DNA index in the 53 nonseminoma patients was 1.53, in the 37 seminoma patients, 1.82 (P < 0.01). Four out of 42 patients with nonseminomas had progressive disease. These few patients were more likely to have an increase in the S-phase fraction or a positive 5c-ee index than patients without progressive disease. In 24 patients with nonseminoma, it was also possible to examine lymph node tissue. Lymph node metastases were detected in 92.8% of these cases through aneuploidy: the median DNA index was 1.57, which corresponded to that of the primary tumours. This study confirmed the value of flow cytometry for rapid, automatic diagnosis of malignancy in testicular tumours. The method could aid in discriminating between seminomas and nonseminomas.

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The psychological attitude towards the seat belt of 70 injured motor car passengers could be examined. The belt fastening rate was changed after the experience of having had an accident. Almost 80% of the questioned persons now always fasten their seat belt, whereas this is done only by 43% of the total collective. Although the usefulness of seat belts is not doubted by the majority of the questioned persons, almost 80% of them are afraid of difficulties concerning the loosening of seat belts.

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A lung simulator with variable compliance and resistance components was used to evaluate the dynamic compliance of the Bournes, Babybird, and Pediatric Emerson postoperative ventilators. With increase in airway pressure from combined changes in compliance and resistance, the internal compliance of the Bournes was lowest and the internal compliance of the Emerson was highest. With low constant airway resistance (50 cm/L/sec), the Babybird exhibited tidal volume losses similar to those of the Bournes in the face of decreased lung compliance. With constant lung compliance (10 ml/cm H2O) and increasing airway resistance, the Babybird had marked volume losses at higher volumes. Under all simulated conditions, internal compliance of the Emerson, although large, was relatively constant and the Bournes had the smallest internal compliance.

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