Πέμπτη 14 Ιουνίου 2018
The importance of appropriate control groups in perioperative analgesic studies: One size does not fit all
Postoperative pain remains poorly treated [1]. Specifically in the United States, opioids continue to be the main weapon used by clinicians to optimize postoperative analgesia [2]. Nonetheless, opioids can worsen patient reported quality of postoperative recovery [3,4]. In addition, the current national focus in the US to reduce the prescription of opioid analgesics and, subsequently, opioid diversion makes the use of multimodal analgesic strategies a very important topic in the perioperative care of surgical patients [5].
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We need more studies to guide the perioperative management of high risk seniors undergoing surgery
The number of surgical procedures in the ambulatory care setting in the United States has increased by over 300% during the past decade with over 30 million ambulatory surgeries (AS) being performed yearly [1]. Of these, 6 million are done in seniors (≥65years of age) and, with the aging of the US population, the number of seniors undergoing surgery will expand exponentially. In addition, more complex surgeries (e.g. hysterectomy, thyroidectomy, spine surgery) are also now conducted in the ambulatory setting [2–4].
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Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures
Do-not-resuscitate (DNR) status has been shown to be an independent risk factor for mortality in the post-operative period. Patients with DNR orders often undergo elective surgeries to alleviate symptoms and improve quality of life, but there are limited data on outcomes for informed decision making.
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Hypnotic agents for induction of general anesthesia in cesarean section patients: A systematic review and meta-analysis of randomized controlled trials
An ideal induction drug for cesarean section (CS) must have quick action, with minimum side effects such as awareness, hemodynamic compromise, and neonatal depression. Thiopentone is frequently used; however, no reliable evidence is available to support its use as a dedicated hypnotic agent in this setting.
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Infraclavicular and supraclavicular approaches to brachial plexus for ambulatory elbow surgery: A randomized controlled observer-blinded trial
To compare the effectiveness of supraclavicular and infraclavicular approaches to brachial plexus block for elbow surgery.
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Diagnosing Neuropathy in an Obese Patient
We read with interest the recent article by Callaghan et al. (2018), "Better diagnostic accuracy of neuropathy in obesity: A new challenge for neurologists." This is a commonly encountered problem, and the authors are commended for comparing a variety of diagnostic tools for three common types of peripheral neuropathy.
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Central Neuropathic Pain in Paraplegia Alters Movement Related Potentials
Central Neuropathic Pain (CNP) is caused by an injury to the somatosensory system (Jensen et al. 2011) affecting more than 40% Spinal Cord Injured (SCI) patients (Siddall 2003).1 The cortical activity of SCI patients is thus affected by both CNP and paralysis (Boord et al. 2008, Vuckovic et al. 2014). To understand the effect of SCI on EEG during motor tasks, researchers have analysed both event-related synchronisation/desynchronisation (ERS/ERD) (Pfurtscheller et al. 2009) and movement related cortical potential (MRCP) (Castro et al.
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Altered Electrophysiological Correlates of Motor Inhibition and Performance Monitoring in Tourette’s Syndrome
Tourette's syndrome (TS) is a childhood onset neurodevelopmental disorder characterized by the presence of motor and vocal tics. Tics fluctuate in frequency and intensity; they are sensitive to context and often amplified in exaggerated emotional states. Tics are often preceded by a stressful sensation, the premonitory urge (Leckman et al. 1993). Comorbid disorders are common in TS and prominently include obsessive-compulsive disorder (OCD), attention-deficit hyperactivity disorder (ADHD) and affective disorders (Robertson 2006; Simpson et al.
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Reply to “Diagnosing Neuropathy in an Obese Patient”: Measuring neuropathy in obese populations: Nerve conduction studies
We appreciate the comments by Drs. Bodofsky and Carter (Bodofsky and Carter, 2018) pertaining to our article "Better diagnostic accuracy of neuropathy in obesity: A new challenge for neurologists" (Callaghan et al., 2018). We agree that the diagnostic characteristics of the Utah Early Neuropathy Score (UENS) and the Michigan Neuropathy Screening Instrument (MNSI) examination scores may be overestimated secondary to incorporation bias as pointed out in our limitations section. We also agree that the confidence intervals of our AUC estimates do not allow definitive comparisons for all of the neuropathy measures tested.
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Transcranial magnetic stimulation in hereditary ataxias: diagnostic utility, pathophysiological insight and treatment
Transcranial magnetic stimulation (TMS) is a non-invasive method for stimulation and modulation of the human brain allowing the study of corticospinal tract function, facilitation and inhibition in neural networks and brain plasticity (Wassermann et al., 2008). TMS is based on the fundamental principles of electromagnetic induction: a brief current in the stimulating coil induces a magnetic field that in turn induces an electric current in brain regions underneath the stimulating coil. In motor cortex, this leads to action potentials in corticospinal cells and multiple descending corticospinal volleys that synapse in spinal gray matter onto alpha-motoneurons, causing in turn action potentials and, finally, activation of muscles which can be recorded as motor evoked potentials (MEPs) by surface electromyography (Hallett, 2007; Kobayashi and Pascual-Leone, 2003) (Fig.
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Diminished kinesthetic and visual motor imagery ability in adults with chronic low back pain
Low back pain (LBP) is the most prevalent musculoskeletal problem among adults. It has been observed that patients with chronic pain have maladaptive neuroplastic changes and difficulty in imagination processes.
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Diagnosing Neuropathy in an Obese Patient
Source:Clinical Neurophysiology
Author(s): Elliot B. Bodofsky, Gregory T. Carter
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Diagnostic Value of Somatosensory Evoked Potential Changes During Carotid Endarterectomy for 30-Day Perioperative Stroke
Source:Clinical Neurophysiology
Author(s): Rajiv P. Reddy, Indraneel S. Brahme, Tejas Karnati, Jeffrey Balzer, Donald J. Crammond, Katherine Anetakis, Parthasarathy D. Thirumala
ObjectivesSomatosensory evoked potentials (SSEPs) have proven useful as an intraoperative modality to predict perioperative stroke during carotid endarterectomy (CEA). However, the predictive value of SSEPs for predicting stroke 30 days postoperatively remains unclear. The primary objective is to evaluate the efficacy of intraoperative SSEP change in predicting the risk of stroke in the postoperative period beyond 24 hours but within 30 days. Our secondary aim is to evaluate the predictive value of each subcategory of SSEP change.MethodsWe performed a meta-analysis of 25 prospective/retrospective studies from PubMed, Web of Science, and Embase regarding SSEP monitoring for postoperative outcomes in symptomatic and asymptomatic CEA patients.ResultsA 8307-patient cohort composed the total sample population, of which 54.17% had symptomatic CS. For SSEP change and stroke greater than 24 hours but within 30 days, the diagnostic odds ratio was 8.68. The diagnostic odds ratio was 3.88 for transient SSEP change and stroke; 49.29 for persistent SSEP change and stroke; 36.45 for transient SSEP loss and stroke; and 281.35 for persistent SSEP loss and stroke.ConclusionsPatients with SSEP changes are at increased risk of perioperative stroke within the entire 30-day period. There is a noticeable step-wise increase in the predicted risk of stroke with the severity of SSEP changes.SignificanceSSEP changes can serve as a predictor for 30-day perioperative stroke during CEA.
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Reply to “Diagnosing Neuropathy in an Obese Patient”: Measuring neuropathy in obese populations: Nerve conduction studies
Source:Clinical Neurophysiology
Author(s): Brian C. Callaghan, Eva L. Feldman
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Characterization and Transcriptome Analysis of Acinetobacter baumannii Persister Cells
Microbial Drug Resistance, Ahead of Print.
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The mechanical leg response to vibration stimuli in cave crickets and implications for vibrosensory organ functions
Abstract
We investigate the influence of leg mechanics on the vibration input and function of vibrosensitive organs in the legs of the cave cricket Troglophilus neglectus, using laser Doppler vibrometry. By varying leg attachment, leg flexion, and body posture, we identify important influences on the amplitude and frequency parameters of transmitted vibrations. The legs respond best to relatively high-frequency vibration (200–2000 Hz), but in strong dependence on the leg position; the response peak shifts progressively over 500–1400 Hz towards higher frequencies following leg flexion. The response is amplified most strongly on the tibia, where specialised vibrosensory organs occur, and the response amplitude increases with the increasing frequency. Leg responses peaking at 800 and 1400 Hz closely resemble the tuning of the intermediate organ receptors in the proximal tibia of T. neglectus, which may be highly sensitive to positional change. The legs of free-standing animals with the abdomen touching the vibrating substrate show a secondary response peak below 150 Hz, induced by body vibration. Such responses may significantly increase the sensitivity of low-frequency receptors in the tibial accessory organ and the femoral chordotonal organ. The cave cricket legs appear suitable especially for detection of high-frequency vibration.
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The complete mitochondrial genome of Vanessa indica and phylogenetic analyses of the family Nymphalidae
Abstract
Vanessa indica is a small butterfly lacking historical molecular and biological research. Vanessa indica belongs to the family Nymphalidae (Lepidoptera: Papilionoidea), which is the largest group of butterflies and are nearly ubiquitous. However, after more than a century of taxonomic and molecular studies, there is no consensus for family classification, and the phylogenetic relationships within Nymphalidae are controversial. The first objective was to sequence and characterize the complete mitochondrial genome of V. indica. The most important objective was to completely reconstruct the phylogenetic relationships for family members within Nymphalidae. The mitochondrial genomic DNA (mtDNA) of V. indica was extracted and amplified by polymerase chain reaction. The complete mitochondrial sequence was annotated and characterized by analyzing sequences with SeqMan program. The phylogenetic analyses were conducted on thirteen protein coding genes (PCGs) in 95 mtDNA of Nymphalidae downloaded from GenBank for reference using the maximum likelihood method and Bayesian inference to ensure the validity of the results. The complete mitogenome was a circular molecule with 15,191 bp consisting of 13 protein coding genes, two ribosomal RNA genes (16S rRNA and 12S rRNA), 22 transfer RNA (tRNA) genes, and an A + T-rich region (D-loop). The nucleotide composition of the genome was highly biased for A + T content, which accounts for 80.0% of the nucleotides. All the tRNAs have putative secondary structures that are characteristic of mitochondrial tRNAs, except tRNASer(AGN) . All the PCGs started with ATN codons, except cytochrome c oxidase subunit 1 (COX1), which was found to start with an unusual CGA codon. Four genes were observed to have unusual codons: COX1 terminated with atypical TT and the other three genes terminated with a single T. The A + T rich region of 327 bp consisted of repetitive sequences, including a ATAGA motif, a 19-bp poly-T stretch, and two microsatellite-like regions (TA)8. The phylogenetic analyses consistently placed Biblidinae as a sister cluster to Heliconiinae and Calinaginae as a sister clade to Satyrinae. Moreover, the phylogenetic tree identified Libytheinae as a monophyletic group within Nymphalidae. The complete mitogenome of V. indica was 15,191 bp with mitochondrial characterizations common for lepidopteran species, which enriched the mitochondria data of Nymphalid species. And the phylogenetic analysis revealed different classifications and relationships than those previously described. Our results are significant because they would be useful in further understanding of the evolutionary biology of Nymphalidae.
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Rehabilitation for cancer survivors: How we can reduce the healthcare service inequality in low- and middle income countries
Cancer diagnosis often substantially affects patient's physical, psychological, and emotional status. The majority of cancer patients experience declining of energy, activity levels, social-cultural participation and relationships. In addition, cancer progression and side effects of aggressive cancer treatment often cause debilitating pain, fatigue, weakness, joint stiffness, depression, emotional instability, limited mobility, poor nutritional status, skin breakdown, bowel dysfunction, swallowing difficulty, and lymphedema leading into functional impairment and disability that can be addressed through rehabilitation care. Comprehensive care models by involving cancer rehabilitation have resulted in significant improvement of patient's quality of life. Although cancer rehabilitation has been implemented in many high income countries, it is either not yet or sub-optimally delivered in most low and middle income countries. In this review, we discussed gaps regarding cancer rehabilitation services and identified opportunities to improve quality of cancer care in developing countries. Future collaborations among international organizations and stakeholders of health care delivery systems are required to initiate and improve high quality cancer rehabilitation in the developing countries No funding to declare. Corresponding author: Boya Nugraha, Department of Rehabilitation Medicine, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, Hannover 30625, Germany, Tel.: +49-511-532-9197, Fax: +49-511-532-4293. Email: Nugraha.Boya@MH-Hannover.de Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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When the injury’s healing process meets the needs of a top-level volleyball player: A non-conventional treatment of a Mallet fracture re-injury
Abstract: Managing top-level athlete's recovery after an injury is very complicated because it requires a challenging combination of clinical and social/professional aspects with the need to return as soon as possible to sports play. Herein, we report a top-level volleyball player for whom a finger splint combined with a custom made thermoplastic protection was used for the conservative management of a Mallet fracture re-injury. This way our player continued training and competitions in contrast to conventional rehabilitation protocols which suggest to avoid new traumas until the healing phase is completed. After 8 weeks, we obtained the fracture healing and a complete functional recovery without major medical complications. From our results we suggest that novel treatment strategies or modification of conventional rehabilitation protocols are worth consideration for the management of high-level sports players'injuries. However new clinical studies with a larger sample can compare these results to those resulting from both surgical procedures, and from immobilization and rest as well. Correspondence: Daniele Checcarelli, Department of Rehabilitation, Foligno Hospital, Via Arcamone - 06034 Foligno (PG) - Italy. Tel +390742339840, Fax +390742339816. Email daniele.checcarelli@libero.it No funding was received for this manuscript. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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Huge Bursitis and Bursal Synovial Osteochondromatosis associated with Scapular Osteochondroma Mimicking a Giant Calcific Mass of the Chest Wall: A Case Report
Osteochondroma is the most common benign bone tumor but it rarely arises from the scapula. Scapulothoracic bursitis is quite rare and osteochondroma is one of the unusual causes of this condition. Synovial chondromatosis may occur extremely uncommonly in this bursa. We reported an unusual case of scapulothoracic bursitis with synovial chondromatosis which is caused by osteochondroma. To the best of our knowledge, there is no defined chondromatosis in the scapulothoracic bursa secondary to scapular osteochondroma in the literature. An osteochondroma originating from the inner surface of the scapula can irritate this bursa and scapulothoracic bursitis may develop.1-2 Clinical manifestations are usually pain and swelling on the posterior chest wall. Patients may also declare crepitation by shoulder rotation. Ultrasonography can reveal a fluid collection between the serratus anterior muscle and chest wall. On computed tomography (CT) a hypodense, well-demarcated cystic mass may be seen at this location. Its magnetic resonance (MR) imaging features are similar to other cystic lesions. It is hypointense on T1-weighted images and hyperintense on T2-weighted images.3 Synovial chondromatosis or osteochondromatosis is a benign synovial metaplastic proliferation that occurs extremely uncommonly in bursae. When we searched "large scapulothoracic bursa chondromatosis" phrases in lliterature review of Chochran Database and Web of Science, we could not find any case reports of synovial chondromatosis in large scapulothoracic bursa. The bursal chondroid bodies appear hypointense on T1-weighted images and hyperintense on T2-weighted images but the signal intensity decreases in all sequences as the calcific or ossific component of these nodules increases. We here report an unusual case of scapulothoracic bursitis with synovial osteochondromatosis which is caused by osteochondroma. A written informed consent was taken from the patient. Corresponding author: Hayri Ogul M.D., Address: Kazim Karabekir Mah. Terminal Cad. Site Polat Apt. B Blok, Kat 1, No 2, Erzurum, Turkey, Telephone: +90 442 2361212-1521 (work), Fax: +90(442) 2361301. E-mail: drhogul@gmail.com The authors received no financial support for the research and/or authorship of this article. The authors declare that they have no conflict of interest to the publication of this article. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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In Response
No abstract available
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Comparing Anesthesia Durations Among Hospitals Based on Statistical Methods Described in Previous Publications in Anesthesia & Analgesia
No abstract available
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In Response
No abstract available
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Implementation of Perioperative Music Using the Consolidated Framework for Implementation Research
BACKGROUND: Complementary integrative health therapies have a perioperative role in the reduction of pain, analgesic use, and anxiety, and increasing patient satisfaction. However, long implementation lags have been quantified. The Consolidated Framework for Implementation Research (CFIR) can help mitigate this translational problem. METHODS: We reviewed evidence for several nonpharmacological treatments (CFIR domain: characteristics of interventions) and studied external context and organizational readiness for change by surveying providers at 11 Veterans Affairs (VA) hospitals (domains: outer and inner settings). We asked patients about their willingness to receive music and studied the association between this and known risk factors for opioid use (domain: characteristics of individuals). We implemented a protocol for the perioperative use of digital music players loaded with veteran-preferred playlists and evaluated its penetration in a subgroup of patients undergoing joint replacements over a 6-month period (domain: process of implementation). We then extracted data on postoperative recovery time and other outcomes, comparing them with historic and contemporary cohorts. RESULTS: Evidence varied from strong and direct for perioperative music and acupuncture, to modest or weak and indirect for mindfulness, yoga, and tai chi, respectively. Readiness for change surveys completed by 97 perioperative providers showed overall positive scores (mean >0 on a scale from −2 to +2, equivalent to >2.5 on the 5-point Likert scale). Readiness was higher at Durham (+0.47) versus most other VA hospitals (range +0.05 to +0.63). Of 3307 veterans asked about willingness to receive music, approximately 68% (n = 2252) answered "yes." In multivariable analyses, a positive response (acceptability) was independently predicted by younger age and higher mean preoperative pain scores (>4 out of 10 over 90 days before admission), factors associated with opioid overuse. Penetration was modest in the targeted subset (39 received music out of a possible 81 recipients), potentially reduced by device nonavailability due to diffusion into nontargeted populations. Postoperative recovery time was not changed, suggesting smooth integration into workflow. CONCLUSIONS: CFIR-guided implementation of perioperative music was feasible at a tertiary VA hospital, with moderate penetration in a high-risk subset of patients. Use of digital music players with preferred playlists was supported by strong evidence, tension for change, modest readiness among providers, good acceptability among patients (especially those at risk for opioid overuse), and a protocolized approach. Further study is needed to identify similar frameworks for effective knowledge-translation activities. Accepted for publication May 8, 2018. Funding: The Patient Safety Center of Inquiry was funded by the VA National Center for Patient Safety Field Office 10A4E (during fiscal years 2016–2018). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website. The institutional review board at Durham VA Healthcare System provided approval: protocol MIRB #1968. Reprints will not be available from the authors. Address correspondence to Karthik Raghunathan, MD, MPH, Duke University Medical Center 3094, Durham, NC 27710. Address e-mail to karthik.raghunathan@duke.edu. © 2018 International Anesthesia Research Society
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Impact of Clinical Guidelines on Revisits After Ambulatory Pediatric Adenotonsillectomy
BACKGROUND: Pediatric adenotonsillectomies are common and carry known risks of potentially severe complications. Complications that require a revisit, to either the emergency department or hospital readmission, increase costs and may be tied to lower reimbursements by federal programs. In 2011 and 2012, recommendations by pediatric and surgical organizations regarding selection of candidates for ambulatory procedures were issued. We hypothesized that guideline-associated changes in practice patterns would lower the odds of revisits. The primary objective of this study was to assess whether the odds of a complication-related revisit decreased after publication of guidelines after accounting for preintervention temporal trends and levels. The secondary objective was to determine whether temporal associations existed between guideline publication and characteristics of the ambulatory surgical population. METHODS: This study employs an interrupted time series design to evaluate the longitudinal effects of clinical guidelines on revisits. The outcome was defined as revisits after ambulatory tonsillectomy for privately insured patients. Data were sourced from the Truven Health Analytics MarketScan database, 2008–2015. Revisits were defined by the most prevalent complication types: hemorrhage, dehydration, pain, nausea, respiratory problem, infection, and fever. Time periods were defined by surgeries before, between, and after guidelines publication. Unadjusted odds ratios estimated associations between revisits and clinical covariates. Multivariable logistic regression was used to estimate the impact of guidelines on revisits. Differences in revisit trends among pre-, peri-, and postguideline periods were tested using the Wald test. Results were statistically significant at P
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Repeated Measures Designs and Analysis of Longitudinal Data: If at First You Do Not Succeed—Try, Try Again
Anesthesia, critical care, perioperative, and pain research often involves study designs in which the same outcome variable is repeatedly measured or observed over time on the same patients. Such repeatedly measured data are referred to as longitudinal data, and longitudinal study designs are commonly used to investigate changes in an outcome over time and to compare these changes among treatment groups. From a statistical perspective, longitudinal studies usually increase the precision of estimated treatment effects, thus increasing the power to detect such effects. Commonly used statistical techniques mostly assume independence of the observations or measurements. However, values repeatedly measured in the same individual will usually be more similar to each other than values of different individuals and ignoring the correlation between repeated measurements may lead to biased estimates as well as invalid P values and confidence intervals. Therefore, appropriate analysis of repeated-measures data requires specific statistical techniques. This tutorial reviews 3 classes of commonly used approaches for the analysis of longitudinal data. The first class uses summary statistics to condense the repeatedly measured information to a single number per subject, thus basically eliminating within-subject repeated measurements and allowing for a straightforward comparison of groups using standard statistical hypothesis tests. The second class is historically popular and comprises the repeated-measures analysis of variance type of analyses. However, strong assumptions that are seldom met in practice and low flexibility limit the usefulness of this approach. The third class comprises modern and flexible regression-based techniques that can be generalized to accommodate a wide range of outcome data including continuous, categorical, and count data. Such methods can be further divided into so-called "population-average statistical models" that focus on the specification of the mean response of the outcome estimated by generalized estimating equations, and "subject-specific models" that allow a full specification of the distribution of the outcome by using random effects to capture within-subject correlations. The choice as to which approach to choose partly depends on the aim of the research and the desired interpretation of the estimated effects (population-average versus subject-specific interpretation). This tutorial discusses aspects of the theoretical background for each technique, and with specific examples of studies published in Anesthesia & Analgesia, demonstrates how these techniques are used in practice. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Accepted for publication April 30, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Patrick Schober, MD, PhD, MMedStat, Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands. Address e-mail to p.schober@vumc.nl. © 2018 International Anesthesia Research Society
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Adductor Canal Versus Femoral Triangle: Let Us All Get on the Same Page
No abstract available
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Local Vancomycin Effectively Reduces Surgical Site Infection at Implant Site in Rodents
Background and Objectives Infected implantable devices represent a clinical challenge, because the customary option is to surgically remove the device, and that is associated with substantial cost and morbidity to the patient, along with patient dissatisfaction with the physician. Although prophylactic systemic antibiotics and sterile technique are the mainstay of prevention of surgical site infection (SSI) after implant, the incidence of SSI remains relatively high. Although some surgeons add local antibiotic at implant site during surgery, there is no scientific research to demonstrate if there is a benefit. Methods Rats and mice were randomly assigned to 4 treatment groups: systemic vancomycin alone, local vancomycin alone, combined systemic and local vancomycin, and untreated. After systemic vancomycin or saline preinjection, a surgical incision was performed for placement of a metal disc, and local vancomycin or saline was injected in the superficial tissue pocket created. The metal disc (implant) was placed in that space, followed by local injection of Staphylococcus aureus bacteria and wound closure. After 1 and 6 days, samples of the tissue surrounding the disc implant, the disc itself, and the spleen (systemic infection marker) were processed, and bacterial levels assayed. Results In both mice and rats, local vancomycin was more potent in reducing tissue SSI, implant infection, and spleen infection than systemic vancomycin at 1 day after induction of bacteria to a surgical wound. At 6 days, in both mice and rats, local vancomycin was again more potent in reducing tissue SSI than systemic vancomycin. Conclusions This study suggests that local vancomycin should be added to systemic vancomycin to reduce SSI with cardiac pacemaker, defibrillator, implantable pulse generator of neurostimulator, or intrathecal pump implants. Accepted for publication April 7, 2018. Address correspondence to: Asokumar Buvanendran, MD, Department of Anesthesiology, Rush University Medical Center, 600 S Paulina, Chicago, IL 60612 (e-mail: asokumar@aol.com). This work was supported by University Anesthesiologists, SC, Chicago, IL. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.
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Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia Following Ambulatory Foot Surgery, a Proof-of-Concept Study
Background and Objectives Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect. Methods Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28. Results During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal. Conclusions This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns. Clinical Trial Registration This study was registered at Clinicaltrials.gov, identifier NCT02898103. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Accepted for publication April 14, 2018. Address correspondence to: Brian M. Ilfeld, MD, MS, Department of Anesthesiology, 200 W Arbor Dr, MC 8770, San Diego, CA 92103 (e-mail: bilfeld@ucsd.edu). Conflict of interest: The institution of Drs. Ilfeld, Gabriel, Said, Sztain, Abramson, Khatibi, and Finneran–the University California San Diego (San Diego, CA)–has received funding and/or product for other research studies from SPR Therapeutics (Cleveland, OH). Funding for this project provided by the University California Academic Senate (San Diego, CA) and the Department of Anesthesiology, University of California San Diego (San Diego, CA). SPR Therapeutics, Inc (Cleveland, OH), also provided the stimulators and leads used in this investigation. This company was given the opportunity to review the protocol and initial manuscript (minor revisions were suggested for each), but the investigators retained full control of the investigation, including study design, protocol implementation, data analysis, results interpretation, and manuscript preparation. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the funding entities. None of the authors has a personal financial interest in this research. This work was presented, in part, as a scientific abstract for the Annual Meeting of the American Society of Regional Anesthesia in New York, NY, April 19 to 21, 2018. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.
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Ultrasound-Guided Selective Versus Conventional Block of the Medial Brachial Cutaneous and the Intercostobrachial Nerves: A Randomized Clinical Trial
Background and Objectives For superficial surgery of anteromedial and posteromedial surfaces of the upper arm, the medial brachial cutaneous nerve (MBCN) and the intercostobrachial nerve (ICBN) must be selectively blocked, in addition to an axillary brachial plexus block. We compared efficacy of ultrasound-guided (USG) versus conventional block of the MBCN and the ICBN. Methods Eighty-four patients, undergoing upper limb surgery, were randomized to receive either USG (n = 42) or conventional (n = 42) block of the MBCN and the ICBN with 1% mepivacaine. Sensory block was evaluated using light-touch on the upper and lower half of the anteromedial and posteromedial surfaces of the upper arm at 5, 10, 15, 20 minutes after nerve blocks. The primary outcome was the proportion of patients who had no sensation in all 4 regions innervated by the MBCN and the ICBN at 20 minutes. Secondary outcomes were onset time of complete anesthesia, volume of local anesthetic, tourniquet tolerance, and quality of ultrasound images. Results In the USG group, 37 patients (88%) had no sensation at 20 minutes in any of the 4 areas tested versus 8 patients (19%) in the conventional group (P
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Pharmacokinetics of 400 mg Locally Infiltrated Ropivacaine After Total Knee Arthroplasty Without Perioperative Tourniquet Use
Background and Objectives Local infiltration analgesia (LIA) with ropivacaine for total knee arthroplasty (TKA) is increasingly used. Despite the high doses of ropivacaine, LIA is considered safe, and this perception is sustained by pharmacokinetic data demonstrating that maximum concentrations of ropivacaine stay well below the toxic threshold in plasma. These pharmacokinetic studies all involve TKA procedures with the use of a tourniquet. Recently, performing TKA without the use of a tourniquet is gaining popularity, but no pharmacokinetic data exist when LIA is administered for TKA without the use of a tourniquet. The purpose of this study was to describe the pharmacokinetic profile of a single-shot ropivacaine (200 mL 0.2%) and 0.75 mg epinephrine (1000 μg/mL) when used for LIA in patients for TKA without a tourniquet. Methods In this prospective cohort study, 20 patients treated with LIA for TKA without a tourniquet were studied. Plasma samples were taken at 20, 40, 60, 90, 120, 240, 360, 480, 600, 720, and 1440 minutes after local anesthetic infiltration, in which total and unbound ropivacaine concentrations were determined. Results Results are given as median (interquartile range [IQR]). Median peak ropivacaine concentration was 1.16 μg/mL (IQR, 0.46); median peak unbound ropivacaine concentration was 0.05 μg/mL (IQR, 0.02). The corresponding times to reach the maximum concentration for total and unbound ropivacaine were 360 (IQR, 240) and 360 (IQR, 360) minutes, respectively. Conclusions Although great interindividual variability in ropivacaine concentration was found, both total and unbound maximum serum concentrations remained below the assumed systemic toxic thresholds in all samples. Clinical Trial Registration This study was registered at Netherlands Trial Registry (https://ift.tt/13oTAKm), trial ID NTR6306. Accepted for publication February 11, 2018. Address correspondence to: Rudolf Stienstra, MD, PhD, Department of Anesthesiology, Sint Maartenskliniek, Post Box 9011, 6500 GM Nijmegen, the Netherlands (e-mail: r.stienstra@maartenskliniek.nl). This study was entirely funded by the Department of Anesthesiology, Sint Maartenskliniek, Nijmegen, the Netherlands. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.
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Influences of meteorological parameters on indoor radon concentrations (222Rn) excluding the effects of forced ventilation and radon exhalation from soil and building materials
Source:Journal of Environmental Radioactivity, Volume 192
Author(s): Michael Schubert, Andreas Musolff, Holger Weiss
Elevated indoor radon concentrations (222Rn) in dwellings pose generally a potential health risk to the inhabitants. During the last decades a considerable number of studies discussed both the different sources of indoor radon and the drivers for diurnal and multi day variations of its concentration. While the potential sources are undisputed, controversial opinions exist regarding their individual relevance and regarding the driving influences that control varying radon indoor concentrations. These drivers include (i) cyclic forced ventilation of dwellings, (ii) the temporal variance of the radon exhalation from soil and building materials due to e.g. a varying moisture content and (iii) diurnal and multi day temperature and pressure patterns. The presented study discusses the influences of last-mentioned temporal meteorological parameters by effectively excluding the influences of forced ventilation and undefined radon exhalation. The results reveal the continuous variation of the indoor/outdoor pressure gradient as key driver for a constant "breathing" of any interior space, which affects the indoor radon concentration with both diurnal and multi day patterns. The diurnally recurring variation of the pressure gradient is predominantly triggered by the day/night cycle of the indoor temperature that is associated with an expansion/contraction of the indoor air volume. Multi day patterns, on the other hand, are mainly due to periods of negative air pressure indoors that is triggered by periods of elevated wind speeds as a result of Bernoulli's principle.
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Iodine isotopes (129I and 127I) in the hydrosphere of Qinghai-Tibet region and South China Sea
Source:Journal of Environmental Radioactivity, Volume 192
Author(s): Peng Yi, Xuegao Chen, Zixia Wang, Ala Aldahan, Xiaolin Hou, Zhongbo Yu
The radioactive isotope 129I, with a half-life of 1.57 × 107 years, is widely used as a tracer to assess nuclear safety, to track environmental and geological events and to figure out the details of the stable iodine geochemical cycle. This work investigated the 129I and 127I distribution in water samples collected from the terrestrial (rivers, lakes and springs) and marine water systems (estuary and sea) in China. The measured 129I concentrations of (1–51) × 106 atoms/L and 129I/127I ratios of (0.03–21) × 10−10 shows the variability of 129I level in the water systems. The local permafrost and seasonal frozen environment play a key role in groundwater recharge in the Qinghai-Tibet region, which is reflected in the 129I distribution in surface water. The depth distribution of 129I in the water column of the South China Sea reflects the effluence of different currents. The results also indicate that the hydrosphere of China contains one to three orders of magnitude less 129I compared to those reported in Europe. Despite the large distance, the European nuclear fuel reprocessing facilities represent the major source of 129I in the hydrosphere of China through atmospheric transport. The contribution of the Fukushima nuclear accident to 129I levels in the hydrosphere of China was negligible.
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