Annals of medicine
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High-dose chemoradiotherapy (HDCRT) followed by autologous stem cell (ASC) rescue is now widely used in a number of childhood malignancies. The most common to date is neuroblastoma, where it now has an established role as consolidation of initial complete remission in children over the age of 1 year with stage 4 disease. High-dose melphalan alone prolongs progression-free survival, with a small increase in long-term survival. ⋯ It is possible that inherently chemosensitive tumours, such as Wilm's tumour, may be candidates where standard treatment has failed. The replacement of bone marrow reinfusion with cytokine-primed peripheral blood stem cell (PBSC) rescue has reduced the morbidity of these procedures. The issue of the potential risk of reinfusing tumour cells has been addressed in neuroblastoma where purging using immunodepletion or in vitro chemotherapy has been carried out.
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Review Comparative Study
Differences in lipolysis between human subcutaneous and omental adipose tissues.
Hydrolysis of triglycerides to fatty acids and glycerol in fat cells (lipolysis) is of importance for the control of lipid and carbohydrate metabolism. This process is regulated by several hormones and parahormones acting on cyclic AMP formation or breakdown, which in turn influences the activity of hormone sensitive lipase. The latter enzyme stimulates hydrolysis of triglycerides in fat cells. ⋯ The antilipolytic insulin receptors, alpha 2 adrenoceptors and adenosine receptors are most active in the subcutaneous fat cells. In subjects with upper-body obesity the regional variations in the action of catecholamines on lipolysis are further enhanced. Decreased action of beta 2-adrenergic receptors and increased activity of alpha 2-adrenergic adrenoceptors in combination with defects in hormone sensitive lipase function inhibits the lipolytic effect of catecholamines in subcutaneous fat cells whereas increased activity of beta 3-adrenergic receptors and decreased activity of alpha 2 adrenoceptors augment the lipolytic response in visceral fat cells.(ABSTRACT TRUNCATED AT 250 WORDS)
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The concept and value of 'multimodal' or 'balanced' analgesia in the treatment of postoperative pain is reviewed. Based upon the relatively few multimodal studies compared to unimodal studies, it is concluded that a combination of analgesics will improve pain relief including movement-associated pain. Since analgesic combination therapy is rational, further studies are needed to evaluate the optimal combination for each surgical procedure, as well as to assess the risk of side effects and need for surveillance in large-scale studies.
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Patient-controlled analgesia (PCA) is a newer technique for pain management. Patients are allowed to self-administer small analgesic bolus doses into a running intravenous infusion, intramuscularly, subcutaneously or even into the epidural space. Demands are usually controlled by computer-driven infusion pumps, but can also be delivered by disposable devices. ⋯ PCA has proved its importance for pain studies, e.g. for algesimetry, to determine predictors of postoperative pain, to describe drug interactions, to evaluate the concept of pre-emptive analgesia or for pharmacokinetic designs. It is concluded that PCA results have been urgently required in order to change the mind of physicians and nursing staff with respect to individual pain management strategies. Once this goal is achieved, PCA concepts should also be used for the improvement of more conventional techniques.
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Basic scientific evidence suggests that an analgesic intervention made before surgery will produce a better outcome than the same intervention made after surgery. The evidence from randomized controlled trials (RCTs) which tested this hypothesis in patients is reviewed. Four studies with paracetamol or NSAIDs did not show any pre-emptive effect. ⋯ The opioid studies which did show a pre-emptive effect had other technical weaknesses. One way to combat lack of power would be to combine data (meta-analysis). This is very difficult in this field because of the outcome measures which investigators are using.