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CONTEXT: Needle length plays an important role for the success of ophthalmic block. The standard practice is to use 25 mm needles length; however, unnecessarily long needles may increase the risk of complications especially in the presence of staphyloma or previous scleral buckle. AIMS: This work was designed to compare the efficacy of using 15 and 25 mm needle in performing extraconal block for patients undergoing vitreoretinal surgery. SETTINGS AND DESIGN: Prospective randomized double blinded study. MATERIALS AND METHODS: A total of 120 patients were enrolled in this study and were divided in two groups. In group (1) extraconal block was performed using 25 mm needle, while in group (2) 15 mm needle was used. After primary injection, assessment of the block was done by an anesthesiologist who was unaware of the needle used. If satisfactory akinesia was not achieved a supplementation was provided. At the end of the procedures, patients and surgeons were asked to assess their pain and satisfaction with the anesthetic technique. STATISTICAL ANALYSIS USED: The sample size calculation using N-Quary version 4. Numerical and categorical data were analyzed using an independent sample, a two-tailed t-test, and chi-square test, respectively. RESULTS: The volume of primary injectable was significantly higher in group 2. The two groups were comparable as regards total volume of local anesthetic, supplementation rate, akinesia, pain score, and surgeon satisfaction. CONCLUSIONS: Using 15 mm needle length to perform extraconal blockade for posterior segment procedures is equally effective to 25 mm needle.

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BACKGROUND: Peribulbar blockade is still widely used for phacoemulsification surgery. The potential complications of this technique include central spread, globe perforation and retrobulbar hemorrhage. The 25 mm needle is the most common needle used to perform the block. The aim of this study was to demonstrate the efficacy of a 12.5 mm needle in performing peribulbar blockade for phacoemulsification surgery. METHODS: After obtaining the hospital research and the Human Ethics Committees' approval, 200 patients undergoing the phacoemulsification procedure under local anesthesia were enrolled in this descriptive study. Peribulbar blockade was performed with a 27 G, 12.5-mm-long needle. The needle was inserted transcutaneously through the lower eyelid into the inferotemporal quadrant. Digital pressure was applied by the thumb and index fingers around the needle hub during injection. After negative aspiration, a local anesthetic solution was injected until total drop of the upper eyelid was achieved. Ocular akinesia was assessed 10 min after the block using the simple akinesia score. A score of 3 or less was accepted to provide adequate analgesia for the surgical procedure to be performed. If the block was inadequate for surgery after 10 min, supplementary anesthesia was provided using the same needle. RESULTS: Adequate analgesia after the first injection was reported in 90.5% of the patients while 9.5% required supplementary anesthesia. There were no major sight or life-threatening complications. CONCLUSION: Using a 12.5-mm-long needle for peribulbar blockade produced satisfactory results. This technique is effective for phacoemulsification surgery.

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BACKGROUND AND OBJECTIVES: Lornoxicam is a novel non-steroidal anti-inflammatory drug with marked analgesic property. It has been shown to have analgesic potency similar to morphine and meperidine. Laryngoscopy and tracheal intubation provoke major haemodynamic responses. Minimizing perioperative adverse events in elderly patients is of utmost importance. The aim of this study was to demonstrate the effect of preoperative administration of Lornoxicam on haemodynamic changes during laryngoscopy and tracheal intubation in the elderly. METHODS: Fifty patients aged between 65 and 75 yr were randomly recruited to this randomized, double-blind, placebo-controlled study. They were divided into two groups to receive either Lornoxicam 8 mg or placebo half an hour before surgery. Systolic and diastolic blood pressure, mean arterial pressure, and heart rate were recorded before and after administration of the intravenous anaesthetic, also at 1, 3, 5 and 10 min after tracheal intubation. RESULTS: In the control group, significant increases in the haemodynamic parameters were observed during the first 10 min following tracheal intubation (P < 0.05). CONCLUSION: Preoperative administration of Lornoxicam attenuates the haemodynamic response to laryngoscopy and tracheal intubation in the elderly.

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Both rectal diclofenac and paracetamol are commonly used to treat acute postoperative pain in children but combining them to improve the quality of analgesia is controversial. This study aimed to detect whether the pre-operative combined administration of rectal diclofenac and paracetamol is superior to either drug alone. One hundred and eight patients were randomly assigned to receive either rectal diclofenac 1 mg.kg(-1) or paracetamol 40 mg.kg(-1) or their combination 1 h prior to surgery. In the first 24 h postoperatively, pain was assessed using the Wong and Baker Pain Scale. If the patients experienced a pain score of 2 or more, morphine was given. The total dose of morphine and number of doses required were recorded. Children who received the rectal diclofenac-paracetamol combination experienced a lower pain scale and a decreased need for morphine compared with children receiving each drug alone.

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BACKGROUND: Postoperative nausea and vomiting is a common complication following strabismus surgery. This randomized and double-blind study was designed to evaluate the efficacy of midazolam alone or in combination with dexamethasone in reducing the incidence of postoperative nausea and vomiting in children undergoing strabismus repair. METHODS: One hundred ASA I children, aged 4-12 yr, scheduled to undergo elective strabismus surgery, were enrolled. No premedication was given. Anaesthesia was induced with sevoflurane, nitrous oxide and oxygen. After induction, fentanyl 2 microg kg-1 and cisatracurium 0.1 mg kg-1 were administered and an endotracheal tube was inserted. After induction of anaesthesia and before start of surgery, patients were randomly allocated into one of four groups of 25 children each to receive placebo, midazolam 50 microg kg-1, dexamethasone 0.5 mg kg-1 or a combination of midazolam 50 microg kg-1 and dexamethasone 0.5 mg kg-1. Episodes of nausea, and retching and vomiting were recorded during the first 24 h after surgery. RESULTS: The incidence of postoperative nausea was 48%, 32%, 12% and 0% with placebo, dexamethasone, midazolam and the midazolam-dexamethasone combination, respectively. The incidence of vomiting was 52% and 32% with placebo and dexamethasone, respectively; no child vomited with midazolam alone, or with the midazolam-dexamethasone combination. CONCLUSION: Prophylactic midazolam with or without dexamethasone reduces the incidence of PONV in children undergoing strabismus repair.

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BACKGROUND AND OBJECTIVES: Electroencephalographic entropy is used to measure the degree of brain hypnosis and anaesthesia depth. Two parameters are displayed in the monitor, state entropy (SE) and response entropy (RE). Ageing leads to reduction in liver mass as well as hepatic blood flow, which decreases clearance of propofol and increases the risk of cardiovascular adverse effects. The aim of this study is to demonstrate the effect of electroencephalographic entropy on propofol requirement and haemodynamic parameters during induction of anaesthesia in elderly patients. METHODS: We studied 72 elderly patients. Standard monitoring was performed for all patients together with entropy monitor. Patients were allocated randomly either to the control group, which were given the recommended induction dose of propofol, or to the entropy group which was induced with propofol based on entropy reading where the end-point was SE 50 and SE-RE difference less than 10. Propofol induction doses and haemodynamic changes were recorded. Anaesthesia was maintained using sevoflurane and O2 air mixture. RESULTS: After induction of anaesthesia, the systolic, diastolic, mean arterial pressure, RE and SE were significantly lower in the control group (P value < 0.05). Total dose of propofol and the dose kg-1 were significantly reduced by 37.1% and 31.8%, respectively, in the entropy group (P value < 0.01). CONCLUSION: The use of electroencephalographic entropy during induction of anaesthesia in elderly patients reduces propofol requirements and maintains cardiovascular stability.

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BACKGROUND AND OBJECTIVE: Unlike midazolam, melatonin premedication is not associated with cognitive impairment in adults despite its anxiolytic properties. The use of melatonin as a premedicant in children has not been reported. This randomized, double-blind, placebo-controlled study compared the perioperative effects of different doses of melatonin and midazolam in children. METHODS: Seven groups of children (n = 15 in each) were randomly assigned to receive one of the following premedicants. Midazolam 0.1, 0.25 or 0.5 mg kg(-1) orally, melatonin 0.1, 0.25 or 0.5 mg kg(-1) orally each mixed in 15 mg kg(-1) acetaminophen, or placebo only (15 mg kg(-1) acetaminophen). Anxiety and temperament were evaluated before and after administration of the study drug, on separation from parents and on the introduction of the anaesthesia mask. At week 2 postoperatively, the behaviour of the children was measured by the Post Hospitalization Behaviour Questionnaire. RESULTS: Melatonin or midazolam each in doses of 0.25 or 0.5 mg kg(-1) were equally effective as premedicants in alleviating separation anxiety and anxiety associated with the introduction of the anaesthesia mask. A trend was noted for midazolam to prolong recovery times as the dosage increased. The use of melatonin was associated with a lower incidence (P = 0.049) of excitement at 10 min postoperatively, and a lower incidence (P = 0.046) of sleep disturbance at week 2 postoperatively than that observed with midazolam and control groups. No postoperative excitement was noted in the melatonin groups at 20, 30 and 45 min. DISCUSSION: Melatonin was not only as effective as midazolam in alleviating preoperative anxiety in children, but it was also associated with a tendency towards faster recovery, lower incidence of excitement postoperatively and a lower incidence of sleep disturbance at week 2 postoperatively.

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PURPOSE: To evaluate the metabolic, hormonal and gastric fluid and pH changes after administration of a small volume of different preoperative feeding regimens. METHODS: In a prospective, randomized, double-blind study 375 adult patients were allocated to one of five groups. Patients ingested 60 ml honey, glucose-fructose-sucrose-maltose mixture (GFSM), apple juice or water two hours before surgery or continued their overnight fast (controls). Blood samples were obtained from an indwelling venous catheter before the administration of feeding regimens and before induction of anesthesia for determination of glucose, triglycerides, insulin, epinephrine and norepinephrine concentrations. Before anesthesia induction, patients were asked to grade the degree of thirst and hunger. After tracheal intubation residual gastric volume (RGV) was suctioned through an orogastric tube. RESULTS: Administration of honey, GFSM, apple juice or water resulted in increases in RGV without changes in the gastric pH. The median RGV values were 15 ml in controls and 20-25 ml in other groups. Thirst was noted after administration of fluids containing sugars. Hunger was noted in the apple juice group. Plasma concentrations of glucose increased and triglycerides decreased after ingestion of fluids containing sugars. Plasma insulin concentrations decreased in GFSM and apple juice groups. Norepinephrine concentrations increased in the control, apple juice and water groups. CONCLUSIONS: Small volumes of fluid increased RGV (P < 0.05). Apple juice resulted in increased incidence of thirst and hunger and plasma glucose and norepinephrine concentrations. Compared with GFSM or apple juice, honey had a gentler effect on plasma glucose and insulin concentrations.

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PURPOSE: To study the dose-response relationships for neostigmine and edrophonium during antagonism of neuromuscular block induced by atracurium and cisatracurium. METHODS: One hundred and twenty eight, ASA group 1 or 2 adults were given either 0.5 mg x kg(-1) atracurium or 0.1 mg x kg(-1) cisatracurium during fentanyl-thiopental-nitrous oxide-isoflurane anesthesia. The neuromuscular block was measured by an acceleration-responsive transducer. Responses were defined in terms of percent depression in the first twitch (T1) and train-of-four (TOF) response. When spontaneous recovery of first twitch height reached 10% of its initial control value, edrophonium (0.1, 0.2, 0.4, or 1 mg x kg(-1)) or neostigmine (0.005, 0.01, 0.02, or 0.05 mg x kg(-1)) was administered by random allocation. Neuromuscular function in another sixteen subjects was allowed to recover spontaneously. RESULTS: At five minutes, unlike edrophonium, neostigmine was equally effective against atracurium and cisatracurium with respect to T1 recovery. The neostigmine T1-ED50 was 10.3 +/- 1.06 (SEM) microg x kg(-1) after atracurium and 11.2 +/- 1.06) microg x kg(-1) after cisatracurium. The edrophonium ED50 was 157 +/- 1.07 microg x kg(-1) with atracurium and 47.4 +/- 1.07 microg x kg(-1) with cisatracurium, giving a neostigmine:edrophonium potency ratios of 15.2 +/- 1.7 and 4.2 +/- 0.41 (P < 0.001) for atracurium and cisatracurium, respectively. At 10 min neostigmine was 13 +/- 1.4 times as potent as edrophonium for achieving 50% TOF recovery after atracurium paralysis. After cisatracurium the potency ratio was 11.8 +/- 1.3 (NS). CONCLUSIONS: Although there were differences at five minutes, neostigmine:edrophonium potency ratios at 10 min, were similar in both relaxants studied.

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PIP: The views and background of the 1992 recipient of the Organon Family Planning Scholarship, the Egyptian El Mouelhy, were summarized; a report was also provided on the population views of Egyptian Dr. Maher Mahran, a professor of gynecology and obstetrics at Ain Shams University and director of the Egyptian National Population Council (NPC). El Mouelhy stated that the population problem in Egypt is a reflection of 98% of the population being settled on only 4% of the land area. The average number of children per family is 4, and the growth rate is 2.4%. Population growth is expected to reach 93 million, a doubling by 2025. Illiterates have the highest fertility; illiteracy in rural areas can be as high as 6.4%. Her solution is to rely on the cooperative efforts of government and nongovernmental groups to improve the status of women. Dr. Mahran reports that one goal of the NPC is to encourage redistribution of the population along the northern coast and Red Sea areas and to develop satellite communities outside Cairo. There are currently 14,000 societies in Egypt devoted to the goals of family planning and better health care for women and children. Local health motivators have also been successful at outreach. The location of the Third UN World Population Conference in Cairo this year is a positive impetus to the family planning effort. Egypt is the first Muslim country to reach 50% contraceptive use. NPC will be directing efforts to underserved rural areas. El Mouelhy on her return will be preparing a national population plan of action.^ieng

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Uterine prostaglandin (PG) levels and cellular reaction in response to IUDs were elevated in sixty women. Short-term users (n = 30) were studied in a control cycle and 3 months after IUD insertion, and long-term users (n = 30) were studied at least 2 years after device insertion. A uterine wash was performed in the proliferative and luteal phase of each investigated menstrual cycle; the cellular components were counted and levels of PGE2, PGF2 alpha and their 13,14-dihydro-15-keto metabolites measured. A significant rise in PG levels was observed in the uterine wash shortly after IUD insertion, particularly in the luteal phase. However, there was a significant reduction in PG levels among long-term users, though the cellular reaction showed a continued increment. The absence of correlation between the biochemical and biological responses indicated that neither of them was totally dependent on the other. The decreased PG levels among long-term users does not support the concept of a key role for these substances in the mechanism of action of IUDs. The temporary post-insertion rise in PG levels coincides with the phase of increased bleeding and pain.

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The effect of oral administration of indomethacin (100 mg/day), a potent inhibitor of prostaglandin (PG) biosynthesis, on the PG levels and cellular profile in the uterine flushings in response to the use of an IUD (Lippes Loop size C) was studied in sixty women. Indomethacin reduced the cell counts in both follicular and luteal phases of menstrual cycles before and after IUD insertion. The anti-inflammatory drug decreased PGE2 and PGF2 alpha levels in both phases of the cycle before IUD insertion. After insertion, it inhibited only the formation of PGF2 alpha and its 13,14-dihydro-15-keto metabolite in the luteal phase but not in the follicular phase. In long-term users, however, the drugs reduced the levels of all PGs studied in the luteal phase and only PGF2 alpha and its metabolite in the follicular phase. The implications of these findings in the mechanisms of contraceptive action of IUDs and their side effects are discussed.

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The ultrastructure of 15 cases or rhinoscleroma have been studied. The epithelium showed intercellular edema, a reaction to the polysaccharide coat of intact bacilli, passing through defects in the basal lamina and subsequently inviting polymorph migration. The transitional stages between normal and 'reactive' plasma cells to the formation of the Russell body and the Unna cell were demonstrated, thus supporting the theory of an intracellular formation of the Russell bodies.

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The ultrastructure in 15 cases of scleroma was studied. The vacuoles of the Mikulicz cells had a definite limiting membrane containing two types of granular material, "A" considered to be antibody, and "B" considered antigenic. Inside the vacuoles infrequent beaded filamentous crystalloid structures were seen, probably of a proteinaceous nature. An enzymatic etiology causing disruption of the limiting vacuolar membrane was considered. New ultrastructural characteristics of the 'early' Mikulicz cell are described. The capillaries occasionally showed subendothelial amyloid deposition. The seromucinous glands were infrequent but of normal character.

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Significant changes in the urinary cellular pattern can be attributed to renal allograft radiation, as distinct from those associated with immunologic rejection of the transplated kidney. These changes consist of nuclear multiplicity, wrinkling of the nuclear membrane, a "coffee bean" appearance of the nucleus, and increase in nuclear size, areas of decreased density and vacuolation of the cytoplasm, and perinuclear halos. The severity of the changes was categorized as "mild", "moderate", or "marked", according to the number of the above changes which were present, and was more evident in cells of transitional epithelial origin than of tubular origin. Some correlation was found between the severity of the cellular radiation changes and the survival time of the kidney.

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