OBJECTIVE: Although fibre-optic bronchoscopic intubation is well recognized as the most valuable adjunct for elective management of the difficult airway its precise role in oncological head and neck emergencies has not been evaluated. The objective of this study was to evaluate the role of fibre-optic intubation in such emergencies. METHODS: This was a consecutive case series study by a single surgeon (the otolaryngologist) and anaesthetist team, taking place in a regional tertiary-referral head and neck surgical oncology centre. A series of 17 consecutive oncological head and neck emergency patients underwent fibre-optic intubation with a Portex endotracheal tube of inner diameter > or =7 mm, with the aid of a 6-mm (EB-1830T2) Pentax fibre-optic video bronchoscope. The study assessed occurrence of: avoidance of tracheostomy in bleeding emergencies; a well placed, uncomplicated tracheostomy in airway obstruction; and successful intubation. RESULTS: Two cases were decannulated completely. All cases were successfully intubated and a tracheostomy was avoided in all cases in which emergency intubation was required and the patient was bleeding. We conclude that fibre-optic bronchoscopic intubation is a viable option in head and neck oncological emergencies due to upper airway obstruction and tumour bleeding. Clinical and endoscopic judgement and operator experience are the key factors determining success.

We studied the time course and nature of interactions between the subthalamic nucleus (STN) and the motor cortex in 8 Parkinson disease (PD) patients with chronically implanted STN deep-brain stimulation (DBS) electrodes. We first identified the cortical evoked potentials following STN stimulation. The most consistent potential was positive wave with peak latency of 22.2 +/- 1.2 ms from stimulation of clinically effective contacts. We then stimulated the motor cortex with transcranial magnetic stimulation (TMS) at 2-15 ms and at the latency of the evoked potential ( approximately 23 ms) following STN DBS. TMS induced currents in 3 directions: lateral-medial (LM) direction activated corticospinal axons directly, posterior-anterior (PA), and anterior-posterior (AP) directions activated corticospinal neurons transynaptically. Motor-evoked potentials (MEP) elicited by AP and PA TMS were facilitated at short (2-4 ms) and medium latencies (21-24 ms). However, MEPs elicited by LM TMS were not modified by STN DBS. Short-latency antidromic stimulation of the corticosubthalamic projections and medium latency transmission likely through the basal ganglia-thalamocortical circuit led to cortical evoked potentials and increased motor cortex excitability at specific intervals following STN stimulation at clinically effective contacts. Cortical activation may be related to the clinical effects of STN DBS in PD.

We present a case of Scleredema Diabeticorum (SD) in a patient with diabetic neuropathy and restrictive respiratory disease with unusual skin lesion distribution. The onset of dermatologic symptoms heralded a progressive respiratory disease with constrictive component. Painful diabetic neuropathy was noteworthy and difficult to relieve. Predominantly, distribution of the skin lesions on the thighs makes the case exceptional. T2-weighted MRI showed abnormal hyperintensities along the muscles of the thighs in correspondence with the skin lesions. Gait and respiratory symptoms progressively worsened. After a transient remitting period, he developed sudden shortening of breath, arrested and expired at home.The atypical distribution of the skin lesions with further involvement of underlying muscles plus concomitant polyneuropathy and respiratory constrictive disease with sudden death is quite unusual and aggressive presentation of SD.

BACKGROUND: Autoimmune polyglandular syndromes (APS) are complex diseases with diverse clinical presentations resulting from involvement of multiple endocrine glands. Surgery under anesthetic in these patients is challenging. A case of Schmidt syndrome (autoimmune polyglandular syndrome type 11) that developed adrenocortical insufficiency in the postoperative period is reported. Etiology, pathogenesis, types and anesthetic problems associated with these cases are discussed. CASE REPORT: A 41 yr old female patient, diagnosed to have APS (Schmidt syndrome) presented for uterine surgery. She had autoimmune glandular involvement of pituitary, thyroid, parathyroid, adrenals and melanocytes and was on hormone replacements for the deficiencies incurred, which were continued till the morning of surgery. Surgery was conducted under general anesthetic combined with epidural analgesia. In spite of supplementation of steroid in physiological doses prior to surgery, she developed hemodynamic instability in the early postoperative period, but could be successfully resuscitated with additional steroid dosage and fluids. CONCLUSION: This patient presented with multiglandular endocrine involvement necessitating timely, adequate hormone replacement and appropriate fluid management. These challenges require careful approach to anesthetic management.

Acute onset of severe pain in cancer patients may be due to multiple causes. Irrespective of the etiology, adequate analgesia has to be provided as quickly as possible. The standard practices of relieving pain by using syringe pumps (syringe drivers) or infusion pumps may not be feasible in resource-scarce developing nations where many cancer patients first present at advanced stages of disease for management. This study compared the efficacy of the subcutaneous and intravenous routes of morphine administration continuously using a simple and economic technique for cancer pain management. Both routes were found to be equally effective in producing good analgesia without side effects. The drip method is a cost-effective way of providing subcutaneous morphine infusion for cancer patients and is applicable for both inpatients and home care.

Pain is frequently encountered in outpatient oncology practice and its management often is inadequate. Effective analgesia often could be provided for these patients through simple practices like pain intensity monitoring, documentation and treatment accordingly. A survey was carried out among cancer patients attending outpatient pain clinic to evaluate scale preferences, comparison of different scales as well as proxy reporting by caregiver, health professionals, for pain management. The aim of the study was to determine preferences in Indian population and to compare our study subjects' preferences to those previously reported in other cultures. A total of 99 patients participated in the study. The majority preferred a visual analogue scale (VAS). The visual analogue scale and verbal descriptive scale (VDS) were found to be equally reliable pain rating tools. Proxy reports were found to equally representative of patient's pain. VAS was the preferred pain assessment tool. In the absence of VAS scale, VDS also could be used. Proxy reports could be relied upon for management of pain.

Atrial fibrillation is the most frequent cardiac arrthythmia in adults and its prevalence is increasing with age. Therefore, the importance of an adequate therapy is an increasing challenge, in particular considering the demographic shift towards an aging population. Current antiarrhythmic drug therapies for the conversion of atrial fibrillation and the maintenance of sinus rhythm are limited by efficacy, tolerance and safety of the currently available agents. Therefore, a primary goal is to develop effective antiarrhythmic drugs with as little as possible side effects. The following review describes new promising drug therapy approaches to atrial fibrillation that may overcome some of the limitations of current therapies.

A 78-year-old man was referred to our hospital with syncope and palpitation. A Holter electrocardiography (ECG) revealed sick sinus syndrome (SSS), and an enhanced chest computed tomography (CT) scan showed persistent left superior vena cava (PLSVC) and absent right superior vena cava. Myocardial leads and a pacemaker implantation were peformed through left anterior thoracotomy approach. There were only 10 reports of pacemaker implantation in a patient with SSS complicated with PLSVC and absent right superior vena cava in Japan. Open thoracotomy approach was thought to be usuful for these patients.

The aim of the study was to estimate the therapeutic efficiency of complex: ACE inhibitor (perindopril) and traditional antiarrhythmic treatment of atrial fibrillation paroxysms after successful electric cardio version for prevention of repeated attacks of atrial fibrillation and for maintenance of normal sinus rhythm in patients. The proposed scheme of treatment reduced number of recurrences, maintained normal sinus rhythm and allowed reaching relatively rapid normalization of mechanical function of left atrium.

The sinus node hyperpolarization-activated If current generated by the cardiac pacemaker channels HCN2 and HCN4 determines the autonomous beating of the heart. Cardiac arrhythmias, like long-QT syndrome, are often caused by irregularities of the heart action potential generated by mutations in cardiac ion channel genes. Mutations in the HCN4 gene have been associated with sick sinus syndrome and long-QT syndrome. The identification of cardiac arrhythmia disease-associated genes makes possible new therapeutic strategies based on gene-specific drug treatment and gene therapy.

This study aimed to prove that angiotensin-converting enzyme inhibitors (ACEI) could improve sinus rhythm maintenance after electrical or chemical conversion of atrial fibrillation (AF). METHODS: A prospective study of 36 patients with lone AF which undertook chemical or electrical conversion was conducted. Group 1 included 20 patients treated exclusively with a class I C antiarrhythmic (Propafenone, 450 mg daily) and group 2 included 16 patients treated with antiarrhythmic plus ACEI pre- and after cardioversion. RESULTS: These two groups were comparable, with mean age 56.2 +/- 11.8 vs. 57.7 +/- 6.1 years (P 0.709), onset of AF 2.47 +/- 3.72 vs. 5.5 +/- 7.37 months (P 0.205) and echocardiographic parameters: left atrium diameter 45.1 +/- 5.8 vs. 45.0 +/- 6.1 mm (P 0.995); LVTDV 48.5 +/- 5.0 vs. 48.6 +/- 6.4 mm (P 0.998); LVTSV 35.1 +/- 5.0 vs. 36.0 +/- 7.0 mm (P 0.737) and EF 59.0 +/- 6.9% vs. 54.8 +/- 6.1%(P 0.135). The patients were followed up clinically and electrocardiographically 12 months after conversion. Kaplan-Meier analysis showed a higher probability of remaining in sinus rhythm one year after cardioversion for group 2 compared to group 1 (37.5% vs. 20%). The mean time interval for the appearance of recurrences was significantly higher in patients treated with ACEI and antiarrhythmics compared to the patients treated only with antiarrhythmics (7.06 +/- 1.02 vs. 4.50 +/- 0.93 months; Breslow test (generalized Wilcoxon)--4.473, P 0.034). CONCLUSION: The addition of ACEI to an antiarrhythmic decreases the rate of AF recurrences and facilitates the maintenance of sinus rhythm after cardioversion.

Treatment with amiodarone is often associated with sinus bradycardia. We studied 477 patients (mean age 48.7 +/- 0.7 years) with various cardiac rhythm disturbances. Most patients had ischemic heart disease. Average saturation dose of amiodarone was 809.4 +/- 13.4 mg/day, average maintenance dose - 263.2 +/- 5.4 mg/day, average duration of follow-up - 20.85 +/- 1.2 months. Regular Holter ECG monitoring was used for detection of sinus bradycardia (heart rate less than 60/min). Sinus bradycardia was registered in 32 and 11.2% of patients during saturation with amiodarone and maintenance treatment, respectively. Bradycardia usually improved after lowering of amiodarone dose. Heart rate slowing was not pronounced and required neither cessation of amiodarone administration nor electrical cardiac pacing.

The paper contains recommendations on treatment of supraventricular paroxysmal tachycardias (SVPT) during pregnancy. The recommendations are based on contemporary literature data and authors" own data. SVPT in postural syndrome are shown to be benign and to demand no continuous antiarrhythmic therapy, while tachycardiac attacks are terminated by vagal tests and adenosine application. Relapsing and steady forms of SVPT with a high heart rate are accompanied by subjective symptoms and require preventive antiarrhythmic therapy, which should be conducted considering risk/benefit ratio. According to the authors, sotalol is the most effective and safe pharmaceutical.