Summary This study tested the hypothesis that high dose systemic alfentanil administered before and during aMominal hysterectomy would pre-empt post'operative pain to a greater extent than administration of either low dose alfentanil or no alfentanil perioperatively. Patients (ASA I or 2) were randomly assigned to group 1 (r = 15), no opioid; group 2 (n = 15), low dose alfentanil; or group 3 (n = l5). high dose alfentanil. Anaesthesia was induced in group I with midazolam and thiopentone and was maintained with isoflurane andTO% N2O in 02, Anaesthesia was induced in group 2 with midazolam, thiopentone and i.v. alfentanil (30pg kg-l), and was maintained with isoflurane. 70VoN2O in 02, and bolus doses of i.v. alfentanil (10-20pg kg-l) every hour. Anaesthesia was induced in group 3 withmidazolamandi.v. alfentanl (l0opgkg-t),and wasmaintained wtlt70% N2Oin Oz,andanintusionof i.v. alfentanil(l-2pgkg-l min-l). Blood samples were drawn at 30 and 120 min after surgery and assayed for plasma alfentanil. Morphine consumption and VAS pain scores were consistently lowest in group 3 over the 48 h study period, A composite measure of pain and morphine consumption was significantly lower in group 3 than group 2 up to 6 h after surgery and significantly lower than group I up to 12 h. No adverse effects were observed. A 6-month follow-up did not reveal any significant differences among the three groups. It is concluded that intra-operative high dose alfentanil anaesthetic pre-empts post-oporative pain after abdominal hysterectomy, but the effects are small and of short duration.Surgical procedures carried out under general anaesthesia using standard (and even high) doses of opioids intraoperatively provide suboptimal protection from the injury banage brought about by incision and subsequent noxious surgical events.

Objective. To determine the value of routine transthoracic echocardiography in patients with cerebral ischemia without known cardiac disease. Design. The literature from 1990 to 1995 was searched and relevant bibliographies from these papers reviewed. Articles reporting the prevalence and/or risk of stroke for myxoma, vegetation, mitral stenosis, left atrial thrombus, left ventricular thrombus or cardiomyopathy, patent foramen ovale, and atrial septal aneurysm were used. Prevalences and recurrent stroke risk were examined for adult patients less than and greater than 45 years.Results. Both the prevalence of transthoracic echocardiographic findings and recurrent risk of stroke differ by age. The finding of a patent foramen ovale can be expected in nearly half of younger patients with stroke, whilst transthoracic echo can be expected to yield no relevant lesion in three quarters of patients > 45 years. Warfarin anticoagulation appears beneficial in patients with mitral stenosis, left atrial thrombus, left ventricular thrombus, and left ventricular dysfunction, but is of unproven benefit for patent foramen ovale, atrial septal aneurysm, or in the absence of a risk-associated abnormality. Conclusion. For most transthoracic echo findings in stroke, optimal management strategies have not been well defined. Future research is needed to evaluate the appropriate therapeutic approaches.

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