for the Scandinavian Organization for Randomized Trials With Clinical Outcome IV (SORT OUT IV) InvestigatorsBackground-Among drug-eluting stents released to date, the sirolimus-eluting stent has demonstrated the least amount of late lumen loss, but its efficacy and safety have not been compared head-to-head with the next-generation everolimus-eluting stent. Methods and Results-The Scandinavian Organization for Randomized Trials with Clinical Outcome IV (SORT OUT IV)trial was a randomized multicenter, single-blind, all-comer, 2-arm, noninferiority trial comparing the everolimus-eluting stent with the sirolimus-eluting stent in patients with coronary artery disease. The primary end point was a composite of safety (cardiac death, myocardial infarction, definite stent thrombosis) and efficacy (target vessel revascularization) parameters. The noninferiority criterion was a risk difference of 0.015. Intention-to-treat analyses were done at 9-and 18-month follow-ups. A total of 1390 patients were assigned to receive the everolimus-eluting stent and 1384 patients to the sirolimus-eluting stent. At the 9-month follow-up, 68 patients (4.9%) treated with the everolimus-eluting stent compared with 72 patients (5.2%) treated with the sirolimus-eluting stent experienced the primary end point (hazard ratio, 0.94; 95% confidence interval, 0.67-1.31; P for noninferiorityϭ0.01). At the 18-month follow-up, this differential remained: 99 patients (7.2%) treated with the everolimus-eluting stent versus 105 (7.6%) treated with the sirolimuseluting stent (hazard ratio, 0.94; 95% confidence interval, 0.71-1.23). At the 9-month follow-up, the rate of definite stent thrombosis was higher in the sirolimus-eluting group (2

A patient with an apical lung tumour invading the brachial plexus (Pancoast's tumour) suffered from unbearable pain unmodijed by daily treatment with morphine 180 mg subcutaneously. An interscalene brachial plexus block was performed using a solution containing 5 mg morphine hydrochloride in 10 ml isotonic saline. Complete analgesia was obtained after 20 minutes, an effect which lasted for the next 36 hours. Neuro-axonal transport of morphine to the spinal cord may be the explanation of the eflect, an hypothesis which ought to be subjected to controlled trials.

No abstract

SummaryA patient with an apical lung tumour invading the brachial plexus (Pancoast's tumour) suffered from unbearable pain unmodijed by daily treatment with morphine 180 mg subcutaneously. An interscalene brachial plexus block was performed using a solution containing 5 mg morphine hydrochloride in 10 ml isotonic saline. Complete analgesia was obtained after 20 minutes, an effect which lasted for the next 36 hours. Neuro-axonal transport of morphine to the spinal cord may be the explanation of the eflect, an hypothesis which ought to be subjected to controlled trials. Key wordsAnalgesics, narcotics; morphine hydrochloride. Anaesthetic techniques, regional; brachial plexus.Morphine has been used systemically for many years for the relief of pain, and more recently has been injected into the epidural space with good results. In a recent uncontrolled investigation, it has been suggested that morphine injected perineuronally may spread centrally by centripetal neuro-axonal transport.' The present report describes a patient where analgesia was obtained by peripheral neural blockade with morphine. Case historyA 71-year-old man was admitted for treatment of chronic pain resulting from growth of a right sided apical lung cancer (Pancoast's tumour) into the brachial plexus. The pain was located in the right side of the neck, shoulder and arm. He had received numerous drugs and radiotherapy, and at the time of admission was receiving morphine subcutaneously in a dose of 180 mg daily, with little effect on the pain. He was therefore referred to the intensive care unit for neural blockade.An interscalene brachial plexus block was performed at the level of C6. Morphine 5 mg in 10 ml isotonic saline was injected. Within 20 minutes complete analgesia resulted, which persisted for 36 hours. The pain relief was so effective that the parenteral dose of morphine was reduced for 2 days. When the pain recurred the patient was considered in a terminal stage and consequently was heavily sedated with methadone and chlorpromazine. DiscussionThe dose of systemically administered morphine necessary to relieve chronic pain is often un-

Summary A patient with an apical lung tumour invading the brachial plexus (Pancoast's tumour) suffered from unbearable pain unmodified by daily treatment with morphine 180 mg subcutaneously. An interscalene brachial plexus block was performed using a solution containing 5 mg morphine hydrochloride in 10 ml isotonic saline. Complete analgesia was obtained after 20 minutes, an effect which lasted for the next 36 hours. Neuro‐axonal transport of morphine to the spinal cord may be the explanation of the effect, an hypothesis which ought to be subjected to controlled trials.