Study design: Prospective clinical study of two treatments. Objective: To compare mechanical ventilation (MV) with phrenic nerve stimulation (PNS) for treatment of respiratory device-dependent (RDD) spinal cord-injured (SCI) patients. Setting: Department for spinal cord-injured patients of an insurance-company-run trauma hospital in Hamburg, Germany. Methods: Prospective data collection of treatment-related data over 20 years. Results: In total, 64 SCI-RDD patients were treated during the study period. Of these, 32 of the patients with functioning phrenic nerves and diaphragm muscles were treated with PNS and 32 patients with destroyed phrenic nerves were mechanically ventilated. Incidence of respiratory infections (RIs per 100 days) prior to use of final respiratory device was equal in both groups, that is (median (interquartile range)) 1.43 (0.05-3.92) with PNS and 1.33 (0.89-2.21) with MV (P ¼ 0.888); with final device in our institution it was 0 (0-0.92) with PNS and 2.07 (1.49-4.19) with MV (Po0.001); at final location it was 0 (0-0.02) with PNS and 0.14 (0-0.31) with MV (Po0.001). Thus, compared to MV, respiratory treatment with PNS significantly reduces frequency of RI. Quality of speech is significantly better with PNS. Nine patients with PNS, but only two with MV, were employed or learned after rehabilitation (P ¼ 0.093). The primary investment in the respiratory device is higher with PNS, but it can be paid off in our setting within 1 year because of the reduced amount of single use equipment, easier nursing and fewer RIs compared to MV. Conclusions: PNS instead of MV for treatment of SCI-RDD reduces RIs, running costs of respiratory treatment and obviously improves patients' quality of life.

SummaryWe compared the effects of rectally administered diclofenac (12.5 mg) with paracetamol (12s mg) on pre-and postoperative behaviour and the need for supplementary analgesia in 44 children scheduled for adenoidectomy (with or without myringotomy). The study drugs were given in combination with diazepam (0.5 mg.kg-') about 20 min before the children were taken to the operating theatre. On arrival there, the children who had received diclofenac were significantly quieter ( < 0.05), easier to handle ( p < 0.01) and cried less ( p < 0.05) than those in the paracetamol group. During recovery. children in the diclofenac group needed fewer supplementary doses of intravenous pethidine than those receiving paracetamol ( p < 0.001). There were no obvious differences between the groups in intra-operative bleeding (as estimated by the surgeon), or in measured blood loss. No postoperative complications became evident. The pre-operative rectal administration of diclofenac for pain relief after adenotomy is safe and effective. Key wordsAnalgesics; diclofenac, paracetamol. Anaesthesia; paediatric. Pain; postoperative.The use of nonsteroidal anti-inflammatory drugs (NSAIDs) for supplementation of postoperative pain treatment has gained wide acceptance. Because of their mode of action it is preferable that these drugs are given prophylactically before the synthesis of prostaglandins is initiated by tissue trauma. This method has been shown to provide improved analgesia after superficial surgery when compared to postoperative medication [ 11, although other workers have produced conflicting results [2, 31.Paracetamol is a widely used analgesic in small children. It lacks many of the serious side effects of opioids and is only slightly sedating. Diclofenac is a well established NSAID which is known to have useful postoperative analgesic proporties in adults and which is now available for use in small children.The aim of the study was to compare, in small children, the behavioural and analgesic effects of rectally administered diclofenac (12.5 mg) with paracetamol (125 mg). MethodsThe study was approved by the Ethics Committee of Tampere University Hospital and written informed parental consent was obtained. Forty-four children, ASA I, weighing 11.0-14.0 kg and scheduled for adenoidectomy (with or without myringotomy) entered the study. Patients were not studied for the following reasons: suspected or manifest bleeding disturbances, allergy to aspirin-like drugs, atopy, bronchial asthma, or a history of serious side effects due to aspirin-like drugs.Before operation the children were allocated randomly to receive, in a double-blind manner, a rectal suppository of either paracetamol 125 mg (Panadol, Winthorp Ltd) or diclofenac 12.5 mg (Voltaren, Ciba Geigy AG). Both were given with rectal diazepam (0.5 mg.kg-') (Apozepam, Dumex AL) on the ward 20min before leaving for the operating theatre. In all cases EMLA cream (Astra Ltd) was applied beforehand to sites suitable for venous cannulation. On the advice of parents, comforters, d...

Background-The possible role of nitric oxide in the regulation of the sphincter of Oddi is not known in species with a resistor-like sphincter of Oddi such as humans and pigs. Methods-Sphincter of Oddi perfusion manometry and simultaneous electromyography (EMG) were recorded transduodenally in eight anaesthetised pigs. Acetylcholine (4 µg/kg) was given intraarterially, with or without sodium nitroprusside (10-100 µg/kg), an exogenous nitric oxide donor. For in vitro studies the sphincter was removed from the eight pigs and from six patients undergoing pancreaticoduodenectomy, cut into rings, and the amplitude of contraction was measured in an ex vivo bath. Each ring was stimulated with acetylcholine (100 µM) and KCl (125 mM). The stimulation was repeated after incubation with L-NAME (a stereospecific competitive inhibitor of nitric oxide synthase), with L-NAME plus L-arginine (a substrate for nitric oxide synthase), and with sodium nitroprusside. The sphincter rings were then submersed in liquid nitrogen and stored. Immunohistochemical analysis was used to localise nitric oxide synthase in the pig and human sphincter specimens. Results-In vivo EMG revealed 2-3 phasic bursts per minute with the basal pressure variation 6-40 mm Hg. Acetylcholine induced a large electrical burst and the pressure increased by (mean (SE)) 20 (10) mm Hg (p <0.01) for 17 (4) seconds. After sodium nitroprusside (10 µg/kg) acetylcholine did not induce pressure changes and electrical activity was almost abolished. In vitro, L-NAME increased the KCl induced sphincter contraction in both pig and human specimens (p<0.01). In human, but not in pig, specimens L-NAME increased the amplitude of acetylcholine induced contraction (p<0.01). L-Arginine partly reversed the eVect of L-NAME in both pig and human specimens. Sodium nitroprusside decreased the acetylcholine and KCl induced contractions in both pig and human specimens. Immunohistochemical studies localised nitric oxide synthase to rich plexi of nerve fibres in the mucosa and the muscle in both pig and human sphincter of Oddi. Conclusions-The sphincter of Oddi in both pigs and humans has endogenous nitric oxide synthase activity and immunoreactivity. Inhibition of endogenous nitric oxide production enhances contractility while exogenous nitric oxide decreases sphincter contractility and electrical activity. (Gut 1997; 41: 375-380) Keywords: NO; nitric oxide synthase; nitroprusside; sphincter of Oddi; pig; human The sphincter of Oddi (SO) regulates bile flow into the duodenum by behaving either as a pump (category I) or as a passive resistor (category II), depending upon the species of animal.1 2 The physiological control of the SO is complex and includes both neural and humoral factors. In recent years much attention has been focused on the role of nitric oxide (NO), a potent smooth muscle relaxant produced by enteric nerves, in the regulation of gastrointestinal smooth muscle function. NO is known to cause relaxation of the SO in category I species (with a pump-like sphincter) s...