Retroclavicular vs supraclavicular brachial plexus block for distal upper limb surgery: a randomised,controlled, single-blinded trial

Background

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.

Making colonoscopy-based screening more efficient: A “gateopener” approach

Screening colonoscopy for early detection and prevention of colorectal cancer (CRC) is mostly used inefficiently. Here, we assessed the potential of an innovative approach to colonoscopy-based screening, by use of a single, low threshold fecal immunochemical test (FIT) as a “gateopener” for screening colonoscopy. Using COSIMO, a validated simulation model, we modeled scenarios including either direct invitation to screening colonoscopy or an alternative approach involving mailing a single (“gateopener”) FIT along with an invitation to colonoscopy contingent on a FIT value above a low threshold yielding a 50% positivity rate (ie, every other pretest will be positive). Under plausible assumptions on screening offer adherence, we found that such “gateopener screening” (use of screening colonoscopy contingent on a positive, low threshold gateopener FIT) approximately doubled cancer detection rates vs conventional screening. In those spared from screening colonoscopy due to a negative gateopener FIT pretest, numbers needed to screen were 10-times higher vs those for individuals with a positive FIT, peaking in >2000 and >3800 (hypothetically) needed colonoscopies to detect one case of cancer in men and women, respectively. Gateopener screening resulted in 42%-51% and 59%-65% more prevented CRC cases and deaths, respectively. In summary, by directing colonoscopy capacities to those most likely to benefit, offering screening colonoscopy contingent on a “gateopener” low-threshold FIT would substantially enhance efficiency of colonoscopy screening.     

A randomised controlled trial of intravenous dexmedetomidine added to dexamethasone for arthroscopic rotator cuff repair and duration of interscalene block

Prolongation of peripheral nerve blockade by intravenous dexamethasone may be extended by intravenous dexmedetomidine. We randomly allocated 122 participants who had intravenous dexamethasone 0.15 mg.kg⁻¹ before interscalene brachial plexus block for day-case arthroscopic rotator cuff repair to intravenous saline (62 participants) or intravenous dexmedetomidine 1 μg.kg⁻¹ (60 participants). The primary outcome was time from block to first oral morphine intake during the first 48 postoperative hours. Fifty-nine participants reported taking oral morphine, 25/62 after placebo and 34/60 after dexmedetomidine, p = 0.10. The time to morphine intake was shorter after dexmedetomidine, hazard ratio (95%CI) 1.68 (1.00–2.82), p = 0.049. Median (IQR [range]) morphine doses were 0 (0–12.5 [0–50]) mg after control vs. 10 (0–30 [0–50]) after dexmedetomidine, a difference (95%CI) of 7 (0–10) mg, p = 0.056. There was no effect of dexmedetomidine on pain at rest or on movement. Intra-operative hypotension was recorded for 27/62 and 50/60 participants after placebo vs. dexmedetomidine, respectively, p < 0.001. Other outcomes were similar, including durations of sensory and motor block. In conclusion, dexmedetomidine shortened the time to oral morphine consumption after interscalene block combined with dexamethasone and caused intra-operative hypotension.     

A systematic review and meta‐analysis of perineural dexamethasone for peripheral nerve blocks

We systematically reviewed the safety and efficacy of perineural dexamethasone as an adjunct for peripheral nerve blockade in 29 controlled trials of 1695 participants. We grouped trials by the duration of local anaesthetic action (short‐ or medium‐ vs long‐term). Dexamethasone increased the mean (95% CI) duration of analgesia by 233 (172–295) min when injected with short‐ or medium‐term action local anaesthetics and by 488 (419–557) min when injected with long‐term action local anaesthetics, p < 0.00001 for both. However, these results should be interpreted with caution due to the extreme heterogeneity of results, with I² exceeding 90% for both analyses. Meta‐regression did not show an interaction between dose of perineural dexamethasone (4–10 mg) and duration of analgesia (r² = 0.02, p = 0.54). There were no differences between 4 and 8 mg dexamethasone on subgroup analysis.     

Reconstruction of the temporal contour for traumatic tissue loss using a CAD/CAM-prefabricated titanium implant-case report

INTRODUCTION: A 16-year-old Arab boy had suffered from a severe head injury including an intracranial haematoma. Despite replantation of the bone flap later on, the cosmetic result was very unfavourable due to partial resorption of the reinserted bone and atrophy of the right temporalis muscle. AIM: For contour reconstruction of both soft and hard tissues the boy was transferred from Saudi Arabia. METHOD: A spiral CT was obtained and the contour was reconstructed using a new algorithm for surface generation. RESULT: The resulting titanium implant was inserted without complications or the need for revision. The cosmetic result was good and corresponded to the preoperative digital planning. CONCLUSION: Techniques of computer-assisted implant prefabrication and surgery may include special algorithms for considering soft tissues including contour deficits of the temporalis muscle.