Regional anaesthesia for upper limb surgery is routinely performed with brachial plexus blocks. A retroclavicular brachial plexus block has recently been described, but has not been adequately compared with another approach. This randomised controlled single-blinded trial tested the hypothesis that the retroclavicular approach, when compared with the supraclavicular approach, would increase the success rate.
Methods
One hundred and twenty ASA physical status 1–3 patients undergoing distal upper limb surgery were randomised to receive an ultrasound-guided retroclavicular or supraclavicular brachial plexus block with 30 mL of a 1:1 mixture of mepivacaine 1% and ropivacaine 0.5%, using a single-injection technique without needle tip repositioning. The primary outcome was block success rate 30 min after local anaesthetic injection, defined as a composite score of 14 of 16 points, inclusive of sensory and motor components. Secondary outcomes included needling time, time to first opioid request, oxycodone consumption, and pain scores (numeric rating scale, 0–10) at 24 h postoperatively.
Results
Success rates were 98.3% [95% confidence interval (CI): 90.8%, 99.9%] and 98.3% [95% CI: 90.9%, 99.9%] in the supraclavicular and retroclavicular groups, respectively (P=0.99). The mean needling time was reduced in the supraclavicular group [supraclavicular: 5.0 (95% CI: 4.7, 5.4) min; retroclavicular: 6.0 (95% CI: 5.4, 6.6) min; P=0.006]. The mean time to first opioid request was similar between groups [supraclavicular: 439 (95% CI: 399, 479) min; retroclavicular: 447 (95% CI: 397, 498) min; P=0.19] as were oxycodone consumption [supraclavicular: 10.0 (95% CI: 6.5, 13.5 mg; retroclavicular: 7.9 (95% CI: 4.8, 11.0) mg; P=0.80] and pain scores at 24 h postoperatively [supraclavicular: 1.2 (95% CI: 2.1, 2.7); retroclavicular: 1.5 (95% CI: 1.6, 2.4); P=0.09].
Conclusions
Ultrasound-guided retroclavicular and supraclavicular brachial plexus blocks share identical success rates, while providing similar pain relief. Reduced needling time in the supraclavicular approach is not clinically relevant.
To assay peripheral inter-ictal cytokine serum levels and possible relations with non-invasive vagus nerve stimulation (nVNS) responsiveness in migraineurs.
Methods
This double-blinded, sham-controlled study enrolled 48 subjects and measured headache severity, frequency [headache days/month, number of total and mild/moderate/severe classified attacks/month], functional state [sleep, mood, body weight, migraine-associated disability] and serum levels of inflammatory markers [inter-ictal] using enzyme-linked immunoassays at baseline and after 2 months of adjunctive nVNS compared to sham stimulation and suitably matched controls.
Results
No significant differences were observed at baseline and after 2 months for headache severity, total attacks/month, headache days/month and functional outcome [sleep, mood, disability] between verum and sham nVNS. However, the number of severe attacks/month significantly decreased in the verum nVNS group and circulating pro-inflammatory IL-1β was elevated significantly in the sham group compared to nVNS. Levels of anti-inflammatory IL-10 were significantly higher at baseline in both groups compared to healthy controls, but not at 2 months follow-up [p?<?0.05]. Concentrations of high-mobility group box-1 (HMGB-1), IL-6, tumor-necrosis factor-α (TNF-α), leptin, adiponectin, ghrelin remained unchanged [p?>?0.05]. No severe device-/stimulation-related adverse events occurred.
Conclusion
2 months of adjunctive cervical nVNS significantly declined the number of severe attacks/month. Pro-inflammatory IL-1β plasma levels [inter-ictal] were higher in sham-treated migraine patients compared to verum nVNS. However, pro- [IL-6, HMGB-1, TNF-α, leptin] and anti-inflammatory [IL-10, adiponectin, ghrelin] mediators did not differ statistically. Profiling of neuroinflammatory circuits in migraine to predict nVNS responsiveness remains an experimental approach, which may be biased by pre-analytic variables warranting large-scale biobank-based systematic investigations [omics]. 相似文献
The Lapidus bunionectomy is performed to treat hallux valgus. Recurrence of the deformity remains a concern. A transverse intermetatarsal screw spanning the base of the first metatarsal to the base of the second can increase stability. The neurovascular bundle is located within the proximity of this screw. In this study, we assessed the structures at risks with the use of this technique. In 10 specimens, a guide wire was placed, and a 4.0-mm cannulated screw was inserted. The neurovascular bundle was dissected and inspected for direct trauma to the neurovascular bundle, and the proximity of the screw was measured using a digital caliper. Ten cadaveric specimens were used. The dorsalis pedis artery and deep peroneal nerve were free from injury in 9 of 10 specimens. In those 9 specimens, the neurovascular bundle was located dorsal in relation to the screw. The mean distance of the screw to the neurovascular bundle was 7.1 ± 3.3 mm. The mean distance from the screw to the first tarsometatarsal joint (TMTJ) was 14.7 ± 4.3 mm. The mean distance from the screw as it entered the second metatarsal to the second TMTJ was 18.0 ± 7.2 mm. In 1 specimen, the screw was found to be traversing through the neurovascular bundle. The distance from the screw to the first TMTJ was 15.0 mm. The distance of the screw from where it entered the second metatarsal to the second TMTJ was 24.0 mm. Although the intermetatarsal screw avoided the neurovascular cases in most instances, there is some anatomic risk to the neurovascular bundle. Further study is warranted to evaluate clinical results using the intermetatarsal screw for the modified Lapidus procedure. 相似文献
Introduction: Tumor biology, as well as completeness of surgical resection, are two important prognostic factors when treating retroperitoneal sarcoma (RPS). A frontline extended surgical approach is associated with improved local control and possibly improved survival. However, this approach has to be tailored to each histological subtype, as the patterns of growth and recurrence risks vary significantly among them.
Areas covered: We provide a review of the literature in RPS, describing the behavior of each of the five main histologic subtypes: well-differentiated liposarcoma (WDLPS), dedifferentiated liposarcoma (DDLPS), leiomyosarcoma (LMS), solitary fibrous tumor (SFT) and malignant peripheral nerve sheath tumor (MPNST). The prognostic factors relevant to oncologic outcomes of RPS, the role of margins and the importance of local control are discussed. Finally, a histologic specific surgical approach to RPS is provided in detail.
Expert opinion: While tumor-related factors are paramount, the only intervenable predictive factor is extent and quality of surgery. The extended surgical approach has been advocated for previously and again we describe it in more detail, tailored specifically to the tumor subtype. The aim of this approach is to maximize the possibility of achieving a complete resection through a standardized approach based on histologic behavior and site of origin. 相似文献