No abstract

We assessed neuromuscular block at the thumb and great toe using accelography after the administration of vecuronium in infants. Train-of-four stimuli were simultaneously applied to the ulnar and tibial nerves using cutaneous electrodes. Anaesthesia was maintained with nitrous oxide (66%) in oxygen and sevoflurane (1%). Vecuronium 0.1 mg.kg-1 was used for paralysis and reversed with intravenous neostigmine 0.04 mg.kg-1 with atropine 0.02 mg.kg-1 when the train-of-four ratio on the right great toe returned to 25%. The mean (SD) times from initial administration of vecuronium to completion of maximal block on the thumb and great toe were 78 (21.1) s and 75 (14.3) s, respectively (p > 0.05). The times from maximal block to 25% recovery of twitch height at the thumb and great toe were 46 (9.1) min and 45 (9.0) min, respectively. The reversal time from 25% to 75% of the train-of-four ratio after the administration of neostigmine was 136 (49.1) s. We conclude that neuromuscular monitoring of the great toe in infants may be a suitable alternative when the thumb is inaccessible.

SummaryWe evaluatedpossible differential effects of vecuronium on the thumb andgreat toe using two types of neuromuscular transmission monitor. Train-offour Electrical stimulation of the ulnar or tibial nerves is used to detect the degree of neuromuscular block after the administration of a non-depolarising muscle relaxant [I]. When the tibial nerve is electrically stimulated transcutaneously, the response can be measured by accelography or electromyography (EMG) in addition to other methods. Sopher and colleagues [2] demonstrated that the foot may be used instead of the hand as an alternative site for monitoring neuromuscular function using the EMG. However, we have reported that after vecuronium, the tibial nerve recovers more rapidly than the ulnar nerve when measured by accelography [3]. The response to electrical stimulation of the thumb and great toe, as measured by accelography and electromyography during non-depolarising block, has not been studied. We aimed to quantify possible differential responses to neuromuscular block at the hand and the foot using accelography and EMG after vecuronium during neuroleptanaesthesia (NLA) and sevoflurane-based anaesthesia. MethodsTwenty adult patients, ASA 1 or 2, aged between 24 and 58 years, who were scheduled to undergo elective ENT surgery, were studied after obtaining the approval of the hospital ethics committee and the patients' informed consent. They were within 15% of ideal body weight. Patients with hepatic, renal or neuromuscular disease were not studied.All patients were premedicated with atropine 0.5 mg and hydroxizine 50 mg intramuscularly 1 h before surgery. Patients were randomly allocated to be anaesthetised using either a neurolept technique (see below) or sevofluranebased anaesthesia. Indirect arterial blood pressure and pulse oximetry were monitored on the left arm and venous cannulation was performed on the dorsum of the left hand.Three neuromuscular transmission monitors (two accelographs and an electromyograph) were simultaneously used for each patient. The acceleration transducer of an Accelograph (Biometer) was fastened to the right thumb with adhesive tape and cutaneous electrodes were applied to the right wrist to stimulate the ulnar nerve at a frequency of 2 Hz for train-of-four (TOF) stimulation every 15 s. The positive electrode was positioned over the proximal part and the negative electrode over the distal part (Fig. 1). A second acceleration transducer was fastened to the left great toe and cutaneous electrodes were applied to the left ankle to stimulate the tibial nerve, using the same frequency as before (Fig. 2). Finally, a Relaxograph (Datex) was used for electromyography at the right great toe and cutaneouselectrodes were applied to the right ankle to stimulate the Accepted 6 June 1994.

Background: Before the androgen target therapy era, flutamide was widely used for castrationresistant prostate cancer in Japan. Enzalutamide is currently the recommended treatment; however, the efficacy and safety of enzalutamide and flutamide after combined androgen blockade therapy with bicalutamide, has not been compared. Methods: Patients with castration-resistant prostate cancer who received combined androgen blockade therapy with bicalutamide were randomly assigned to receive either enzalutamide or flutamide. The primary endpoint for efficacy was the 3-month prostate-specific antigen response rate. This trial is registered with ClinicalTrials.gov (NCT02346578) and the University hospital Medical Information Network (UMIN000016301) Results: Overall, 103 patients were enrolled. The 3-(80.8% vs. 35.3%; p<0.001) and 6-month (73.1% vs. 31.4%; p<0.001) prostate-specific antigen response rates were higher in the enzalutamide than in the flutamide group. The 3-month disease progression rates (radiographic or prostate-specific antigen progression) were 6.4% and 38.8% in the enzalutamide and flutamide groups, respectively (hazard ratio [HR]: 0.16; 95% confidence interval [CI]: 0.05-0.47; p<0.001); the 6-month rates were 11.4% and 51.1%, respectively (HR: 0.22; 95% CI: 0.09-0.50; p<0.001). Enzalutamide provided superior prostate-specific antigen progression-free survival compared with flutamide (HR: 0.29; 95% CI: 0.15-0.54; p<0.001). Median time to prostate-specific antigen 4 progression-free survival was not reached and was 6.6 months in the enzalutamide and flutamide groups, respectively. Conclusions: As an alternative anti-androgen therapy in patients with castration-resistant prostate cancer who fail bicalutamide-combined androgen blockade therapy, enzalutamide provides superior clinical outcomes compared with flutamide. Enzalutamide should be preferred over flutamide in these patients.

To clarify the differential effects of vecuronium on the thumb and on the big toe, train-of-four (TOF) stimuli were applied to the ulnar nerve at the wrist and the tibial nerve at the ankle in anesthetized patients using two acceleration transducers. Ten adult patients, aged 21-55 years, were studied. Anesthesia was induced by an intravenous injection of thiopental, and vecuronium 0.1 mg·kg was used for paralysis. Anesthesia was maintained with nitrous oxide (66%)-oxygen-sevoflurane (1 MAC). The duration of time to the maximal twitch depression on the thumb and the big toe was 136.5±32.5 s and 183.0±40.1 s (P<0.05), respectively. The time to 25% recovery of the twitch height on the thumb and the big toe was 48.1±17.3 min and 39.1±11.6 min, respectively; the time to 50% recovery of twitch height on the thumb and the big toe was 54.1±16.1 min and 40.0±9.2 min (P<0.05), respectively. When paralysis was reversed at 25% of TOF ratio on the thumb, the value of the TOF ratio on the big toe was 58.5±18.2% (P<0.01).