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Intermittent thiopentone for teaching fibreoptic nasotracheal intubation.

A technique for teaching fibreoptic nasotracheal intubation is described. Fifty patients presenting for elective dental surgery received thiopentone by intermittent injection for induction and maintenance of anaesthesia whilst a trainee anaesthetist attempted to visualise the vocal cords using an intubating fibrescope. During endoscopy patients spontaneously breathed oxygen-enriched air and passage of the tracheal tube was facilitated by suxamethonium. Arterial blood pressure, heart rate and arterial oxygen saturation were monitored continuously. Time from loss of eyelash reflex to successful intubation was 113 (90) (35-480) s (mean (SD) (range)). Changes in arterial blood pressure and heart rate were similar to those described in previous studies of tracheal intubation. Haemoglobin oxygen saturation remained above 95% in 43 patients, and above 93% in 46 patients; the lowest saturation recorded was 91%. Intermittent thiopentone provides good conditions for teaching fibreoptic nasotracheal intubation whilst maintaining arterial blood pressure and oxygen saturation.

Adolescent↗

Anaesthesia for day-care arthroscopy. A comparison between desflurane and isoflurane.

A study was undertaken to compare desflurane- and isoflurane-based anaesthesia in patients undergoing day-care arthroscopic surgery. Anaesthesia was induced with propofol 2-3 mg.kg-1 and a laryngeal mask airway was inserted after loss of the eyelash reflex. Patients were then randomly divided into two groups to receive maintenance anaesthesia with either isoflurane or desflurane delivered in oxygen and nitrous oxide. Alfentanil was used as the analgesic during the operation. Early recovery was assessed by measurement of the times to eye opening, extubation and ability to give a date of birth. Psychomotor recovery was assessed by performance on the finger tapping and perceptive accuracy tests. Mood was evaluated using visual analogue mood scores and the mood adjective checklist. Discharge times were also measured. Early recovery was significantly quicker following desflurane anaesthesia but no differences between the groups were found in psychomotor tests. The mood adjective checklist showed that patients in the isoflurane group had a greater total mood score and were more calm than those in the desflurane group; this was particularly evident 2 h after anaesthesia. The discharge times were similar for the two groups. Desflurane is a satisfactory alternative to isoflurane for day care anaesthesia.

Adult↗

A comparison of the induction characteristics of sevoflurane and halothane in children.

The induction characteristics of sevoflurane and halothane were compared in 81 children aged 6 months to 6 years. The mean time taken to achieve loss of eyelash reflex was significantly shorter with sevoflurane than with halothane (sevoflurane, mean time (SD) 1 min 41 s (35 s), halothane, mean time (SD) 2 min 17 s (43 s), t = 4.11, p = < 0.01). The mean time taken to complete induction (to achieve steady spontaneous ventilation and small pupils with central gaze) was also shorter in children induced with sevoflurane (sevoflurane, mean time (SD) 3 min 58 s (1 min 8 s), halothane, mean time (SD) 4 min 50 s, (1 min 27 s), t = 2.29, p = 0.027). Effects on heart rate, blood pressure and oxygen saturation during induction were similar for both agents. There were no major complications during induction with either halothane or sevoflurane.

Anesthesia, Inhalation↗

Single-breath inhalation induction of sevoflurane anaesthesia with and without nitrous oxide: a feasibility study in adults and comparison with an intravenous bolus of propofol.

The induction characteristics of sevoflurane in nitrous oxide and oxygen were compared with sevoflurane in oxygen alone and a propofol infusion. A vital capacity technique was used for the gaseous induction groups using a Mapleson A system and a 4-litre reservoir bag. Four end-points of anaesthesia were recorded: time to cessation of finger tapping, time to loss of eyelash reflex, time to jaw relaxation and time to regular settled breathing after laryngeal mask airway insertion. We also recorded sequential blood pressure and pulse rate, the incidence of adverse airway events and the acceptability of the induction technique. Propofol had a faster time to cessation of finger tapping (p < 0.05) and jaw relaxation (p < 0.01). These differences disappeared with the final induction stage and sevoflurane in nitrous oxide and oxygen had the faster time to regular settled breathing, though this did not reach statistical significance. Cardiovascular stability was good and comparable in all groups. There were few adverse airway events in any group and none caused oxygen saturation to fall below 96%. There was more excitation in the gaseous induction groups, though this did not interfere with induction. Patient satisfaction with induction was high.

Adolescent↗

Allergic and irritant contact dermatitis compared in the treatment of alopecia totalis and universalis. A comparison of the value of topical diphencyprone and tretinoin gel.

Diphencyprone is a potent topical sensitizer, but is non-mutagenic in the Ames test (unlike dinitroclorobenzene) and remains relatively stable in solution (unlike squaric acid dibutyl ester). Seventeen patients with total loss of scalp hair (eight alopecia totalis, nine alopecia universalis) were treated by maintaining on one side of the scalp an allergic contact dermatitis induced by 2,3 diphenylcyclopropenone-I ('diphencyprone'), and on the other side an irritant contact dermatitis using tretinoin gel (Retin A). After 20 weeks, treatment with tretinoin was stopped and diphencyprone was applied bilaterally for a further 10 weeks. Satisfactory regrowth of terminal hair on the scalp was achieved in only one patient. Eyebrow, eyelash and beard regrowth was achieved in one individual whilst in another, moderate, but not cosmetically satisfactory, scalp regrowth took place. In no patient did regrowth take place at tretinoin treated sites until after diphencyprone was substituted.

Administration, Topical↗

Familial acanthosis nigricans with madarosis.

We report familial acanthosis nigricans affecting a 35-year-old woman, her 7-year-old son and 5-year-old daughter. Absence of the eyebrows and eyelashes was noted in this family. The mother had no axillary hair and her pubic hair was sparse. The boy also suffered from congenital heart disease and a congenital cataract in the left eye. The combination of acanthosis nigricans and ectodermal defects in this family may represent a distinct nosological entity.

Acanthosis Nigricans↗

Ichthyosis congenital fetalis (Harlequin fetus).

A male fetus which was the product of full-term pregnancy and normal delivery with no family history is presented. The skin was hard and thick, waxy, yellowish in color, and was crossed by horizontal and or perpendicular red fissures. The eyelids were semiclosed, hard, and stiff resulting in ectropion and the conjunctivae were red. The eyelashes and the eyebrows were absent. The nose appeared to be flattened while the nostrils were partly stenosed. The mouth was round and the mucosa was red everted giving a fish-like appearance to the mouth (Fig. 1). There were no ears and they had been replaced by intensive hyperkeratosis with deep fissures, resembling ear lobes without auditory canal, where there was an hyperkeratotic plug (Fig. 2). The inelasticity of the hard and thick skin limited the physiologic movements of the upper and lower extremities and immobilized the interphalangial articular movements. The fetus was treated with corticosteroid ointment but succumbed within the first twenty four hours.

Diagnosis, Differential↗

Tinea capitis in Saudi Arabia.

BACKGROUND: Tinea capitis is a dermatophyte infection of the scalp, eyebrows, and eyelashes caused by species of Microsporum and Trichophyton. The purpose of this study was to discover the incidence and causal agents of tinea capitis in Saudi Arabia. METHODS: Hair roots, skin scrapings, and pus swabs were collected from patients clinically diagnosed with tinea capitis and were processed for fungus. RESULTS: Of 372 patients with tinea capitis investigated in Saudi Arabia, 240 were found to be positive by direct microscopic examination, and the causal agent was isolated from 237 patients. Tinea capitis accounted for 47.7% of all superficial mycoses, and 97% of it occurred in children below 15 years of age. Inflammatory lesions were found in 35% of cases, and 10 of them presented with kerion celsi. Favus-type lesion was found in one. Microsporum canis was the most common etiologic agent, responsible for 82.3% of the infections. Trichophyton violaceum was the next most common agent (13.9%), followed by M. audouini (2.2%); T. mentagrophytes, T. rubrum, T. verrucosum, and T. simii were isolated from one patient each. This is the first report of T. simii infection in a Saudi man. CONCLUSIONS: Although none of the patients owned pets, the predominance of M. canis may be explained by the large number of cats in the neighborhood. The disappearance of favus due to T. schoenleinii may be due to improved socioeconomic conditions. Our results agreed with two previous reports.

Adolescent↗

Universal permanent alopecia, psychomotor epilepsy, pyorrhea and mental subnormality.

A syndrome of congenital and permanent universal alopecia, involving absence of scalp hair, eyebrows, eyelashes, axillary and pubic hair, and the rest of the body hair is reported. Mental subnormality was noted in eight and psychomotor epilepsy in seven out of 12 affected individuals. Pyorrhea was observed in all ascertained patients. No abnormality of nails or skin (apart from absence of hair) was noted. The disorder, which affected seven females and five males from six sibships, was transmitted through four generations. Utilizing the simple sib method, a ratio of 6/12 was obtained for affected individuals. The vertical transmission of the disorder, implication of both sexes, male to male transmission, and the 1:1 (affected: unaffected) segregation ratio support autosomal dominant inheritance. Penetrance appears to be complete.

Adult↗

A distinct variant of the Ehlers-Danlos syndrome.

Two unrelated males presented a distinct syndrome, consisting mainly of mental retardation, short stature, wrinkled facies, curly and fine hair, scanty eyebrows and eyelashes, telecanthus, periodontitis, hypermobility of the joints, hyperextensibility and fragility of the skin, multiple nevi, papiraceous scars, bruisability, varicose veins, pectus excavatum, winged scapulae, pes planus and bilateral cryptorchidism. Since some features were typical of Ehlers-Danlos Syndrome (EDS), the clinical data were analyzed comparatively with the different types of EDS. The individualization of a distinct variant is concluded. Increased paternal age at the birth of both cases suggests a de novo dominant mutation.

Adolescent↗

Hypotrichosis and nail dysplasia: a novel hidrotic ectodermal dysplasia.

We report a unique isolated hair and nail ectodermal dysplasia in a 3-year-old girl. Clinical examination revealed short, sparse scalp hair, absent eyebrows, short eyelashes and nail dystrophy in all digits. Nail changes included shortened nail plate with distal onycholysis and loss of the cuticle. Sweating and teeth were normal. Development was normal. Scanning electron microscopy of the hair only demonstrated trichorrhexis nodosa. There was no pili torti. Vertically sectioned scalp biopsy revealed hypoplastic hair follicles and a horizontally sectioned biopsy showed a decrease in the overall number of hair follicles present. Treatment with topical minoxidil 5% 1 mL twice each day massaged into the scalp led to only minimal improvement and was discontinued after 12 months.

Child, Preschool↗

Pegylated interferon-induced eyelid and eyebrow trichomegaly during chronic hepatitis C.

One of the most common skin and hair growth disorders related to interferon therapy is alopecia. Hypertrichosis has also been reported as a rare side-effect of interferon therapy, especially in eyelashes. Herein is reported a case of eyelid and eyebrow trichomegaly in a patient treated with pegylated interferon and ribavirin for chronic hepatitis C associated with porphyria cutanea tarda.

Antiviral Agents↗

The presence of the parasite Demodex folliculorum on the skin surface of the eyelid.

It is well established that Demodectic mites can infest the meibomian glands, eyelash and hair follicles of the eyelid. In this study, scanning electron microscopy revealed Demodex folliculorum occurring freely on the skin surface of the eyelid. This indicates some mobility and implies further vector potential. Exoskeletons from these parasites also occur on the eyelid.

Animals↗

A comparison of sevoflurance to halothane in paediatric surgical patients: results of a multicentre international study.

Induction, emergence and recovery characteristics were compared during sevoflurane or halothane anaesthetic in a large (428) multicentre, international study of children undergoing elective inpatient surgical procedures. Two hundred and fourteen children in each group underwent inhalation induction with nitrous oxide/oxygen and sevoflurane or halothane. Incremental doses of either study drug were added until loss of eyelash reflex was achieved. Steady state concentrations of anaesthesia were maintained until the end of surgery when anaesthetic agents were terminated simultaneously. Time variables were recorded for induction, emergence and the first need for analgesia in the recovery room. In addition, in 86 of the children in both groups, venous blood samples were drawn for plasma fluoride levels during and after surgery. There was a trend toward smoother induction (induction of anaesthesia without coughing, breath holding, excitement laryngospasm, bronchospasm, increased secretion, and vomiting) in the sevoflurane group with faster induction (2.1 min vs 2.9 min, P = 0.037) and rapid emergence times (10.3 min vs 13.9 min, P = 0.003). Among the children given sevoflurane, 2% developed bradycardia compared with 11% in the halothane group. Postoperatively, 46% of the children in the halothane group developed nausea and or vomiting versus 31% in the sevoflurane group (P = 0.002). Two children in the halothane group developed cardiac dysrhythmia and were dropped from the study. In addition, a child in the halothane group developed malignant hyperthermia, received dantrolene, and had an uneventful recovery. Mean maximum inorganic fluoride concentration was 18.3 microM.l-1. The fluoride concentrations peaked within one h of termination of sevoflurane anaesthetic and returned rapidly to baseline within 48 h. This study suggests that sevoflurane may be the drug of choice for the anaesthetic management of children.

Adolescent↗

Single-breath vital capacity rapid inhalation induction with sevoflurane: feasibility in children.

BACKGROUND: Single-breath vital capacity technique is currently administered for inhalation induction of anesthesia with sevoflurane in adults. Because sevoflurane is used in children, the aim of this open nonrandomized trial was to explore the feasibility and acceptance of this technique in midazolam premedicated patients aged from 4 to 15 years old. METHODS: A pediatric population (n = 118) was instructed in the vital capacity technique after their arrival in the induction room in a standardized and playful manner. Induction was performed with a circle-absorber breathing circuit, primed with sevoflurane 7% in 100% O2. Success of the single-breath vital capacity, delay of induction, hemodynamic and airway tolerance, acceptance by the children and side effects were analyzed. A multivariate logistic regression model was used to identify independent risk factors associated with the failure of the vital capacity technique. RESULTS: Single-breath vital capacity technique was achieved by 57% of the children. The success rate highly correlated with age and ranged from 10% in 4-5 years old to 75% at 11 years and 95% by 14 years. Other factors for success were cooperation and understanding. The need for more than two explanations of the technique was predictive of failure. Delays in the loss of the eyelash reflex and central pupil myosis were obtained in 34 s (18-50) and 242 s (145-278), respectively [median (interquartile ranges)]. Hemodynamic tolerance was good with few airway complications. CONCLUSION: Rapid anesthesia induction using a single-breath technique with 7% sevoflurane is effective and well tolerated in children, particularly in those above 9 years of age, and in fact, success rate was markedly lower in the young age groups.

Adjuvants, Anesthesia↗

A retrospective evaluation of congenital ocular defects in Australian Shepherd dogs in Australia.

OBJECTIVE: A retrospective survey of ocular defects in Australian Shepherd dogs was conducted following concerns raised by breeders and owners in Australia. This is the first known such study conducted for this breed. RESULTS: Data from this survey indicate that persistent hyaloid remnants (PHR) were the most common eye defect noted in the Australian Shepherd. Collie eye anomaly (CEA) is the second most common defect noted by veterinary ophthalmologists in the breed in Australia, and extra eyelashes (ectopic cilia/distichia) the third most common. CONCLUSIONS: The data also support the hypothesis that PHR may be inherited in this breed. Further investigation is needed to reveal the status of PHR in this breed.

Animals↗

Trichotillomania +/- trichobezoar: revisited.

Trichotillomania is an intriguing psychosomatic entity in which there is an irresistible desire to pull out the hair from the scalp, eyelashes, eyebrows and other parts of the body. The process results in an instant release of tension, a sense of relief and security. However, non-scaring alopecia is its clinical presentation. The development of trichobezoar following ingestion of the pulled hair is its salient complication in a few cases. Subsequently, it may cause symptoms pertaining to the gastrointestinal tract culminating in intestinal obstruction, perforation, pancreatitis and obstructive jaundice. The Rapunzel syndrome (trichobezoar) may occur when gastrointestinal obstruction is produced by a rare manifestation of a trichobezoar with a long tail that extends to or beyond the ileocecal valve. In most cases in children, trichotillomania +/- trichobezoar is a habit disorder and thus has a better prognosis. However, in adults the psychopathology is usually deeper and thus entails a poor prognosis. The diagnosis is made after taking a thorough history, noting the clinical features and evaluating a hair-root examination, where telogen hair is (almost) completely lacking, which distinguish trichotillomania from other hair disorders. Treatment modalities vary in childhood and adult varieties. Apart from psychotherapy, the drug treatment involves several agents including selective serotonin reuptake inhibitors (SSRIs) and domipramine. Trichobezoar/Rapunzel syndrome requires surgical intervention.

Adolescent↗

Ablepheron macrostomia syndrome.

Two male children are reported with similar features, including absent eyelids, eyebrows, eyelashes and hair, fusion defects of the mouth, expressionless facies, rudimentary external ears (but normal hearing), ambiguous genitalia, absent or rudimentary nipples, coarse dry skin with redundant skin folds and delayed expressive language development. The relationship of this syndrome to previously reported cryptophthalmos syndromes is discussed.

Child↗