Single-Center, Double-Blind, Randomized Study to Evaluate the Efficacy of 4% Lidocaine Cream versus Vehicle Cream During Botulinum Toxin Type A Treatments

BACKGROUND: Botulinum toxin type A (BTX-A) injections are overwhelmingly safe and effective treatment in cosmetic treatment, but some patients are apprehensive about pain associated with injection. OBJECTIVE: To determine whether preprocedural application of lidocaine 4% topical anesthetic cream to the injection site will reduce pain on injection of BTX-A for the treatment of crow's feet. METHODS: Twenty-four participants receiving bilateral injections for crow's feet were enrolled. Subjects were randomized to one of four study groups. Prior to BTX-A injection, group 1 (n = 6) received lidocaine 4% cream on the right side of the face and vehicle cream on the left side of the face; group 2 (n = 6) received vehicle cream on the right side and lidocaine 4% on the left side; group 3 (n = 6) received lidocaine 4% on both sides; and group 4 (n = 6) received vehicle cream on both sides. RESULTS: We observed a statistically significant reduction in subject-reported procedural pain in participants pretreated with lidocaine 4% on both sides of the face compared with controls. CONCLUSION: Lidocaine 4% cream is effective in reducing the pain associated with BTX-A injection for crow's feet. We encourage further study to clarify the optimal use of topical anesthetics in the practice of cosmetic dermatology.     

氯普鲁卡因、利多卡因、丁卡因剖宫产腰麻比较

目的：比较三种局麻药蛛网膜下腔麻醉用于剖宫产。方法：90例足月妊娠孕产妇拟剖宫产随机分成氯普鲁卡因（CP），利多卡因（Li）、丁卡因（Di）三组．每组30例。在腰2-3脊间隙做腰硬联合穿刺，腰麻分别给予CP30mg，Li40mg和Di7．7mg。然后硬膜外置管留作备用。分别观察和记录病人麻醉情况。结果：CP、Li和Di三组麻醉起效时间分别是23．85±6．89s、34．29±8．94s和28．32±9．84s。取得切口无痛、平面最高时间和下肢不能运动时间（min）以及取得的最高阻滞点三组均相似。麻醉完全消退时间CP、Li和Di三组分别是78．45±16．83min．160．74±56．89min和471．54±99．24min。三组腰麻效果均非常满意，未行硬膜外麻醉。CP组从麻醉中恢复最快。均未发现麻醉后神经并发症。新生儿评分均正常。结论：剖宫产用氯普鲁卡因腰麻相对合理。     

Evaluation of the Efficacy and Safety of a Lidocaine and Tetracaine (7%/7%) Cream for Induction of Local Dermal Anesthesia for Facial Soft Tissue Augmentation with Hyaluronic Acid

Injection of dermal fillers for soft tissue augmentation is a minimally invasive cosmetic procedure with growing popularity. However, patients often express concern about pain with such procedures. A topical anesthetic cream formulated with lidocaine/tetracaine 7%7% was approved by the United States Food and Drug Administration in 2006 and recently reintroduced to the market for use during superficial dermatological procedures. A Phase 3 study was conducted to assess the efficacy and safety of lidocaine/tetracaine 7%7% cream versus placebo cream when used to induce local dermal anesthesia during injections with hyaluronic acid. Mean visual analog scale scores significantly favored lidocaine/tetracaine 7%7% cream. A significant percent of subjects also indicated that lidocaine/tetracaine 7%7% cream provided adequate pain relief and that they would use lidocaine/tetracaine 7%7% cream again. Investigators also rated lidocaine/tetracaine 7%7% cream significantly better than placebo cream for providing adequate pain relief and on the assessment of pain scale. Lidocaine/tetracaine 7%7% cream was safe and well tolerated with most subjects reporting no erythema, edema, or blanching. No related adverse events were reported with lidocaine/tetracaine 7%7% cream; one related adverse event of erythema was reported with placebo cream. The results of this study indicate that lidocaine/tetracaine 7%7% cream is efficacious and safe at providing pain relief for soft tissue augmentation with hyaluronic acid.Soft tissue augmentation with dermal fillers is a popular, minimally invasive cosmetic procedure with an increasing number of procedures performed each year.1 Despite the popularity of dermal filler procedures and other cosmetic procedures, most patients are concerned about the pain associated with these procedures.2 Seventy-four percent of surveyed subjects expressed concern about associated pain with cosmetic procedures, and 42 percent of subjects who had a cosmetic procedure would consider not having other procedures due to concerns about pain.2 These results suggest that a sizeable number of subjects are given inadequate measures to control pain during cosmetic procedures.Various types of topical anesthetics are available to manage pain and provide relief during cosmetic procedures and contain ingredients such as lidocaine, tetracaine, and prilocaine.3 Many physicians use compounded formulations of anesthetics to provide dermal anesthesia before a procedure. However, these products have been found to not be standardized and frequently have higher concentrations of anesthetics than United States Food and Drug Administration (FDA)-approved products.3 This resulted in the FDA issuing a warning in 2006 to multiple pharmacies to stop compounding topical anesthetic creams.4 And in 2007, a public health advisory was issued by the FDA when two women died after using compounded high-concentration topical anesthetics under occlusion before a procedure.5 Therefore, it is recommended that only FDA-approved topical anesthetics be used as they have demonstrated efficacy as well as safety.5An anesthetic cream formulated with lidocaine and tetracaine 7%/7% (LT cream; Pliaglis® Cream; Galderma Laboratories, LP) was approved by the FDA in 2006 and recently reintroduced to the market. LT cream is indicated for use on intact skin in adults to provide topical analgesia for superficial dermatological procedures.6 In addition to being formulated with the maximum allowable FDA-approved concentrations of lidocaine and tetracaine, LT cream also dries to a flexible membrane that functions as a self-occlusive barrier. Multiple studies have demonstrated the efficacy and safety of LT cream in various dermatological cosmetic procedures including ablative and nonablative laser resurfacing, laser tattoo removal, laser hair removal, and CO₂ laser resurfacing.7-10A Phase 3 study was conducted to investigate the efficacy and safety of LT cream when used as a topical anesthetic for facial soft tissue augmentation with hyaluronic acid. The results of this study indicate that LT cream provided significantly better pain relief than vehicle cream, was well tolerated, and is an ideal choice to provide topical anesthesia before dermal filler injections.     

The Use of a Contact Cooling Device to Reduce Pain and Ecchymosis Associated With Dermal Filler Injections

Objectives. Consensus guidelines developed for the use of hyaluronic acid dermal fillers describe the use of cooling the skin to reduce patient discomfort during injection. The vasoconstrictive effects of cold may provide reduced ecchymosis and swelling at the site. However, the effect of applying ice or cooled air is unpredictable because these modalities do not deliver precise temperature, which may result in cold burn or insufficient effect to targeted areas. This open-label, randomized, single-blinded, split-face trial was conducted to measure the extent to which applying a spot cooling device reduces patient discomfort and ecchymoses in the clinical setting in patients undergoing a dermal filler procedure. Subjects. Twenty male and female subjects of any race, ages 35 to 65 years, with moderate and severe nasolabial folds were included in this study. Seven (35%) subjects had received previous small gel particle hyaluronic acid injections. Methods. Prior to injection, the topical cooling system was set at 35°F and a cooled applicator was applied for 20 seconds on one nasolabial fold. A control using a noncooled applicator was applied for 20 seconds on the other nasolabial fold. Postprocedure ice packs were prohibited so as not to confound the subject''s perception of procedure-related pain. Subjects (using visual analog pain scales) and blinded investigators rated pain and ecchymosis using predetermined scales and satisfaction surveys. Results. Use of the cooling system was associated with mean pain reduction of 61, 70, and 42 percent compared to control, as measured by visual analog pain scales, immediately following and one hour and three hours post small gel particle hyaluronic acid injection. Additionally, use of the cooling system was associated with mean ecchymosis reduction of 88, 89, 80, and 66 percent compared to control immediately following injection, one hour, three hours, and next-day postinjection. Conclusion. The cooling system provided adequate pain management (both subjectively and objectively through blinded evaluations) during and after small gel particle hyaluronic acid dermal filler injections for the correction of moderate nasolabial folds. Furthermore, results demonstrate that the cooling system is associated with decreased ecchymosis. Future studies are needed comparing the use of topical anesthetics to a cooling system for the reduction of pain and ecchymosis associated with the use of dermal filler injections.The number of aesthetic procedures requiring the use of needle-based injections is progressively increasing due to their widely successful and effective results.¹ Of these injections, botulinum toxins and injectable hyaluronic acid dermal fillers are most often used. According to the American Society for Aesthetic Plastic Surgery, hyaluronic acid gels account for approximately 80 percent of the nearly two million soft tissue filler injections performed in 2006.¹ The most commonly utilized soft tissue filler is Restylane^® (Medicis Aesthetics Inc., Scottsdale, Arizona), a small gel particle hyaluronic acid (SGP-HA) that is indicated for mid-to-deep dermal implantation for the correction of moderate-to-severe facial wrinkles and folds, such as nasolabial folds.² All injections may cause some discomfort to the patient as well as postinjection ecchymosis and swelling. Topical anesthetics and ice are the most often employed methods for limiting the degree of pain, ecchymoses, or swelling.Much research has been devoted to the development of effective topical anesthetics of the skin to minimize or eliminate the discomfort experienced by the patient during the procedure.³ Many studies exist that scrutinize the efficacy of topical anesthetics for dermatological procedures,⁴ and several studies specifically have investigated mixing 2% lidocaine with HA prior to injection.^5,6 Effective anesthesia via topical administration is difficult to achieve on keratinized or nontraumatized skin due to limited transepidermal absorption. Various creams, ointments, and gels have been used for this; however, their efficacy has been less than ideal and complications have occurred. While a variety of topical anesthetics are currently available, their use is limited by variable efficacy, lengthy application times, and often elaborate and time-consuming techniques for occlusion and removal of the anesthetic. Consequently, there has been an increased need for safe, more effective, and expedient topical anesthesia.Recently, research has turned toward alternative methods of topical anesthesia when injecting dermal fillers, such as skin cooling through the use of ice or cooled air. The use of cold to relieve pain has been employed since Hippocrates in the 4th century BC.⁷ Cooling the tissue also induces vasoconstriction, which may decrease swelling and ecchymosis.⁸ The Restylane Consensus Group published its proceedings, which included the use of patient comfort techniques, such as the use of icing before, during, and after treatment with HA.⁸ Half of the panel members assert that icing after treatment achieves the most benefit, yet another 40 percent of members use ice before, during, and after treatment. The American Society for Dermatologic Surgery (ASDS) Guidelines recommend several mechanisms to diminish dermal filler injection pain including preinjection application of ice.⁹ Unfortunately, the effect of applying ice or cooled air is often unpredictable because these modalities cannot be delivered accurately and precisely to targeted areas. Also, applying ice and cooled air directly to the site of injection may be associated with risks to the patient because the temperature is imprecise and cannot be controlled.The ArTek Spot^® (ThermoTek, Inc., Flower Mound, Texas), a commercially available spot contact cooling system, has been used to control pain associated with hair and tattoo removal procedures. It also has been used to prevent pain and discomfort associated with dermal fillers and other injectables as an alternative to ice cubes, ointments, and chemical sprays.¹⁰ To date, however, no randomized, controlled trials have assessed its safety and efficacy for prevention of pain and ecchymosis in subjects receiving dermal filler injections.The purpose of this study was to assess the efficacy, safety, and subject satisfaction of a contact topical cooling system on the reduction of subjective and objective pain and ecchymosis when applied prior to HA gel injections for correction of nasolabial folds.     

Merkel Cell Carcinoma of the Skin and Mucosa: Report of 12 Cutaneous Cases with 2 Cases Arising from the Nasal Mucosa

BACKGROUND: Merkel cell carcinoma (MCC) is an uncommon skin tumor that most frequently arises on sun-exposed facial sites. It rarely occurs on mucous membranes of the head region. The primary MCC is usually treated by wide excision followed by radiation to the primary site and regional lymph nodes. Using traditional surgery the local recurrence rate ranges from 20 to 50%. In our clinic, Mohs surgery is used to excise the primary MCC completely, followed by radiation. Here we present our treatment experiences and outcomes. OBJECTIVE: To document our experience of MCC treated by Mohs surgery. We present our series of 12 cases of MCC, 2 cases of which arose from mucosal sites of the nasal cavity. METHODS: We reviewed 12 cases of MCC from the Mohs clinic database. We also reviewed the literature for cutaneous and mucosal MCC. RESULTS: There were 12 cases of MCC: 10 cutaneous and 2 mucous. The site distribution of cutaneous MCC was eight on the head, one on the neck, and one on the groin. Of these, nine were treated by Mohs excision. Two patients developed local recurrence following Mohs treatment. The local recurrence rate was 22% (2 of 9). The sites of mucosal MCC were the nasal septum and nasopharynx. One case had a history of previous radiation and developed an MCC 40 years later. This case also demonstrated epidermotropic spread of Merkel cells to the overlying mucous epithelium. This patient required extensive intranasal and cranial surgery to remove the tumor. Both patients with mucosal MCCs died of their disease. The overall mucocutaneous survival of MCC at 1 year was 80% and at 2 years was 50%. CONCLUSION: In our series, local control of the primary MCC was achieved in 70% of patients (7 of 10) using combined Mohs excision and radiation. Two recurrences had primary tumors larger than 3.5 cm in diameter, while the other case was nonresectable by Mohs surgery. Tumor size appeared to determine the degree of local control. When the postoperative Mohs defect was less than 3.0 cm in diameter, local and regional control appeared to be more favorable. When the primary facial MCC is relatively small, removal by Mohs surgery followed by radiation was effective, therapeutic, and less disfiguring. Mucosal MCC is rare and may occur as a long-term sequelae after radiation therapy to the skin.     

Q-Switched Alexandrite Laser Therapy for Pigmentation of the Lips Owing to Laugier-Hunziker Syndrome

BACKGROUND: Laugier-Hunziker (LH) syndrome is a rare benign condition in which hyperpigmentation of the lips and buccal mucosa occurs with no systemic associations. OBJECTIVE: We report the response to treatment with the Q-switched alexandrite laser (QSAL) because there are few reports on therapy for LH syndrome. METHODS: The QSAL was used for pigmentation of the lips in a 63-year-old woman with LH syndrome. Laser irradiation was done at 5.0 J/cm2 with a 3 mm spot size. RESULTS: There was 100% clearance of pigmentation of the lips with a single laser treatment, and recurrence was not observed after 6 months. CONCLUSION: The QSAL is very effective for pigmentation owing to LH syndrome.     

Relative Contribution of Skin and Core Temperatures to Vasoconstriction and Shivering Thresholds during Isoflurane Anesthesia

Background: Thermoregulatory control is based on both skin and core temperatures. Skin temperature contributes [approximate] 20% to control of vasoconstriction and shivering in unanesthetized humans. However, this value has been used to arithmetically compensate for the cutaneous contribution to thermoregulatory control during anesthesia-although there was little basis for assuming that the relation was unchanged by anesthesia. It even remains unknown whether the relation between skin and core temperatures remains linear during anesthesia. We therefore tested the hypothesis that mean skin temperature contributes [approximate] 20% to control of vasoconstriction and shivering, and that the contribution is linear during general anesthesia.

Methods: Eight healthy male volunteers each participated on 3 separate days. On each day, they were anesthetized with 0.6 minimum alveolar concentrations of isoflurane. They then were assigned in random order to a mean skin temperature of 29, 31.5, or 34 [degree sign]C. Their cores were subsequently cooled by central-venous administration of fluid at [almost equal to] 3 [degree sign]C until vasoconstriction and shivering were detected. The relation between skin and core temperatures at the threshold for each response in each volunteer was determined by linear regression. The proportionality constant was then determined from the slope of this regression. These values were compared with those reported previously in similar but unanesthetized subjects.

Results: There was a linear relation between mean skin and core temperatures at the vasoconstriction and shivering thresholds in each volunteer: r2 = 0.98 +/- 0.02 for vasoconstriction, and 0.96 +/- 0.04 for shivering. The cutaneous contribution to thermoregulatory control, however, differed among the volunteers and was not necessarily the same for vasoconstriction and shivering in individual subjects. Overall, skin temperature contributed 21 +/- 8% to vasoconstriction, and 18 +/- 10% to shivering. These values did not differ significantly from those identified previously in unanesthetized volunteers: 20 +/- 6% and 19 +/- 8%, respectively.     

Five Percent Weight Lost in the First Month of Intragastric Balloon Treatment May Be a Predictor for Long-Term Weight Maintenance

Background

Most of the weight loss with the BioEnterics intragastric balloon (BIB) has occurred during the first 3–4 months. This study aimed to evaluate the effect of initial weight loss on long-term weight maintenance.

Methods

From 2008 to 2011, 50 patients who had mean body mass index (BMI) of 44.7?±?12.4 kg/m² underwent BIB therapy for 6 months. All patients were given a diet of 1,100 kcal/day. Weight loss parameters [absolute weight loss, BMI loss, percentage of body weight loss (BWL%), and percentage of excess BMI loss] were recorded at the baseline, 1 month, 6 months (time of BIB removal), 12 months, and 18 months from the baseline. Successful weight loss was defined as ≥10 % weight loss after 6, 12, and 18 months.

Results

Twenty-seven patients (54 %) achieved a percentage of BWL?≥?10 at the time of removal. Eighteen (36 %) and 12 (24 %) patients were able to maintain weight loss of 10 % at 12 and 18 months. Percentage of BWL after 1 month was positively correlated with BWL% after 6, 12, and 18 months (r?=?0.77, 0.65, and 0.62, p?<?0.001, respectively). Twenty-four patients who lost 5 % of the BWL after 1 month of treatment succeeded in maintaining a lasting percentage of BWL ≥10 after the BIB removal: more precisely, this cutoff point was achieved in 96 % at the time of removal and in 71 %, 50 % at 12 months, and 18 months of follow-up.

Conclusions

Five percent BWL after 1 month of treatment may be a predictor for long-term weight maintenance.     

An Approach to Heparin and Lidocaine Hypersensitivity for the Interventional Nephrologist

The general and interventional nephrologist may occasionally encounter a situation where the patient may state that he/she has an allergy to lidocaine or heparin. Heparin hypersensitivity is usually either a delayed type hypersensitivity reaction or an immune‐mediated thrombocytopenia. While a number of alternative drugs are available, many of them are subject to local availability, food and drug administration indications, and the patient's hepatic and renal function. Many of these drugs do not have antidotes in case of bleeding. Lidocaine hypersensitivity is usually a delayed type reaction, although adverse reactions, which are much more common, are wrongly labeled as an allergy. 1% diphenhydramine and benzyl alcohol may be used as alternatives.     

Interaction of Propofol and Sevoflurane on Loss of Consciousness and Movement to Skin Incision during General Anesthesia

Background: Loss of consciousness (LOC) and immobility to surgical incision seem to be mediated at different levels of the central nervous system. Pharmacologic studies of hypnotic agents have previously focused on combinations of either volatile or intravenous anesthetics. This study examined the combination of inhaled sevoflurane and intravenous propofol at these two clinically relevant anesthetic end points.

Methods: Thirty-six elective surgical patients were initially enrolled. Conditions approximating steady state were obtained for sevoflurane and target-controlled propofol infusions. Patients were sequentially evaluated for LOC (loud voice plus mild prodding) and immobility to surgical incision. The study was designed using the Dixon up-down method.

Results: The observed propofol effect target with 50% response plus sevoflurane (0.46% end-tidal concentration) was 1.2 [mu]g/ml (95% confidence interval, 1.1-1.3 [mu]g/ml). It was not significantly different from that predicted (1.5 [mu]g/ml; 95% confidence interval, 1.2-1.7 [mu]g/ml) by simple additivity. The effective plasma concentration of propofol that suppressed movement to skin incision in 50% of patients was 5.4 [mu]g/ml (95% confidence interval, 4.8-6.0 [mu]g/ml) plus sevoflurane (0.86%) and was not significantly different from that predicted by additivity (5.4 [mu]g/ml; 95% confidence interval, 4.8-5.9 [mu]g/ml). Both analyses had adequate power (90%) to detect a significant change (+/-19 to 25%) from predicted value. Repeated-measures analysis of variance identified a Bispectral Index value of 70 as the break point between those who responded at LOC or did not.     

Randomized, Double-Blind, Placebo-Controlled Study Evaluating the Lidocaine/Tetracaine Patch for Induction of Local Anesthesia prior to Minor Dermatologic Procedures in Geriatric Patients

BACKGROUND: Topical anesthetics offer a noninvasive method of anesthesia. OBJECTIVE: To evaluate the efficacy and safety of the lidocaine/tetracaine patch, a 1:1 (wt:wt) eutectic mixture of lidocaine and tetracaine, for local anesthesia before minor dermatologic procedures in geriatric patients. METHODS: In a multicenter, randomized, double-blind, placebo-controlled study, 79 patients over the age of 65 years received a 30-minute application of either the lidocaine/tetracaine patch or placebo immediately before a shave biopsy or superficial excision. The primary measure of efficacy was patient assessment of procedural pain using the visual analog scale (VAS). Secondary efficacy end points included patient, investigator, and independent observer assessments. RESULTS: There was a statistically significant difference (p = .041) in patient ratings of pain by VAS score in the active group (9.5 mm) compared with the placebo group (22.5 mm). None of the secondary end points showed a statistically significant difference between groups. No adverse events were reported. CONCLUSION: The lidocaine/tetracaine patch is a safe and effective method for noninvasive induction of local anesthesia for minor dermatologic procedures in patients over the age of 65 years.     

Auditory Evoked Potential Index Predicts the Depth of Sedation and Movement in Response to Skin Incision during Sevoflurane Anesthesia

Background: The auditory evoked potential (AEP) index, which is a single numerical parameter derived from the AEP in real time and which describes the underlying morphology of the AEP, has been studied as a monitor of anesthetic depth. The current study was designed to evaluate the accuracy of AEPindex for predicting depth of sedation and anesthesia during sevoflurane anesthesia.

Methods: In the first phase of the study, a single end-tidal sevoflurane concentration ranging from 0.5 to 0.9% was assigned randomly and administered to each of 50 patients. The AEPindex and the Bispectral Index (BIS) were obtained simultaneously. Sedation was assessed using the responsiveness portion of the observer's assessment of alertness-sedation scale. In the second phase of the study, 10 additional patients were included, and the 60 patients who were scheduled to have skin incisions were observed for movement in response to skin incision at the end-tidal sevoflurane concentrations between 1.6 and 2.6%. The relation among AEPindex, BIS, sevoflurane concentration, sedation score, and movement or absence of movement after skin incision was determined. Prediction probability values for AEPindex, BIS, and sevoflurane concentration to predict depth of sedation and anesthesia were also calculated.

Results: The AEPindex, BIS, and sevoflurane concentration correlated closely with the sedation score. The prediction probability values for AEPindex, BIS, and sevoflurane concentration for sedation score were 0.820, 0.805, and 0.870, respectively, indicating a high predictive performance for depth of sedation. AEPindex and sevoflurane concentration successfully predicted movement after skin (prediction probability = 0.910 and 0.857, respectively), whereas BIS could not (prediction probability = 0.537).     

Comparison of Ropivacaine and Lidocaine for Intravenous Regional Anesthesia in Volunteers: A Preliminary Study on Anesthetic Efficacy and Blood Level

Background: Ropivacaine may be useful for intravenous regional anesthesia, but its anesthetic effectiveness and toxicity have not been evaluated.

Methods: Two doses of ropivacaine (1.2 and 1.8 mg/kg) and one dose of lidocaine (3 mg/kg) were compared for intravenous regional anesthesia in 15 volunteers. An arm tourniquet was inflated for 30 min after injection and then deflated in two cycles. Sensory block was measured by response to touch, cold, pinprick, and transcutaneous electric stimulation, and motor function was measured by hand grip strength and muscle power. Median, ulnar, radial, and musculocutaneous nerve functions were tested before local anesthetic injection and then at 5-min intervals until blocks resolved. The plasma ropivacaine and lidocaine concentrations were determined from arterial and venous blood samples drawn from the unanesthetized arm.

Results: Sensory and motor blocks were complete within 25 min and 30 min, respectively, in all three treatment groups. However, recovery of sensory and motor block after tourniquet release was slowest in the high-dose ropivacaine group. Anesthesia to pinprick and transcutaneous electric stimulation was sustained in all the volunteers in the high-dose ropivacaine group for 55 min and 85 min, respectively, whereas complete recovery was observed in the lidocaine group (P = 0.008) and partial recovery in the low-dose ropivacaine group (P < 0.05) during the same period. Motor block also was sustained in the high-dose ropivacaine group for 70 min, which was significantly longer than in the lidocaine group (P < 0.05). All volunteers (five of five) given lidocaine and one volunteer given high-dose ropivacaine reported light-headedness and hearing disturbance during tourniquet release when the arterial plasma lidocaine and ropivacaine concentrations were 4.7 +/- 2.1 [micro sign]g/ml (mean) and 2.7 [micro sign]/ml, respectively.     

Recovery of Storage and Emptying Functions of the Urinary Bladder after Spinal Anesthesia with Lidocaine and with Bupivacaine in Men

Background: The aim of this study was to evaluate and compare the effects of spinal anesthesia with lidocaine and with bupivacaine on urinary bladder function in healthy men who were scheduled for minor orthopaedic surgical procedures.

Methods: Twenty men were randomly allocated to receive either bupivacaine or lidocaine. Before spinal anesthesia, filling cystometry was performed with the patient in the supine position and a pressure flow study was done with the patient in the standing position. After operation, cystometric measurements were continued until the patient could void urine spontaneously. The levels of analgesia and of motor blockade were recorded.

Results: The urge to void disappeared immediately after injection of the local anesthetics. There was no difference in the duration of lower extremity motor blockade between bupivacaine and lidocaine. Detrusor blockade lasted significantly longer in the bupivacaine group (means +/- SD, 460 +/- 60 min) than in the lidocaine group (235 +/- 30 min). Total fluid intake and urine volume accumulated during the detrusor blockade were significantly higher in the bupivacaine group than in the lidocaine group. In the bupivacaine group, the total volume of accumulated urine (875 +/-385 ml) was also significantly higher than cystometric bladder capacity (505 +/- 120 ml) with the risk of over distension of the bladder. Spontaneous voiding of urine did not occur until segmental sensory analgesia had regressed to the third sacral segment.     

Skin Surgery Under Local Anesthesia Leads to Stress-Induced Alterations of Psychological, Physical, and Immune Functions

BACKGROUND: Although excision of nevi under local anesthesia is a frequent and harmless operation, it apparently causes increased stress in many patients. However, thus far no studies have focused on the question of whether there are measurable effects on psychological, physiological, and immunological parameters. OBJECTIVE: To assess the perioperative stress reactions of patients undergoing skin surgery under local anesthesia for nevocellular nevi. METHODS: Fifty consecutive patients with pigmented nevi were examined at five points of measurement: 1 week and 30 minutes before the operation, during the operation, 30 minutes and 1 week after the operation. Somatic parameters included blood pressure, pulse, respiratory rate, and the level of pain. Lymphocyte subpopulations, white blood cell count, and cortisol in saliva were determined. Anxiety and general psychological distress were evaluated with validated questionnaires. RESULTS: There was a significant increase in anxiety at the time of surgery. In parallel, the physiological parameters as well as the CD56+ lymphocytes changed significantly. Preoperation anxiety and intraoperation pain were significantly higher in women (P <.001), but did not depend on age. CONCLUSION: There appears to be an interaction between physiological and emotional components in the operative stress reaction under local anesthesia. In patients with skin cancer, the perioperative stress may lead to transient impairment of immune function.     

Lidocaine for the prevention of pain due to injection of propofol.

Propofol has a high incidence of pain with injection, particularly into small veins. We sought to determine whether concomitant administration of lidocaine could prevent this pain. In a randomized double-blind trial, 368 women were allocated to one of four groups to receive 19 mL of propofol mixed with either 1 mL of 0.9% saline, 1 mL of 0.5% (5 mg) lidocaine, 1 mL of 1% (10 mg) lidocaine, or 1 mL of 2% (20 mg) lidocaine. The pain of injection was scored as none, mild, moderate, or severe. There was a significant reduction in the overall incidence of pain from 73% with saline to 32% with 20 mg lidocaine. A highly significant negative dose-response relationship between the dose of lidocaine and the severity of pain was demonstrable, both at induction of anesthesia and as recalled in the recovery room (P less than 0.001 for both). Lidocaine (20 mg IV) will significantly reduce the incidence and severity of pain with propofol injection, but about 6% of patients will still suffer unpleasant pain if the dorsum of the hand is used.     

An Aluminum Magnesium Hydroxide Stearate-based Skin Barrier Protection Cream Used for the Management of Eczematous Dermatitis: A Summary of Completed Studies

Eczematous dermatoses can often be very difficult to treat. An aluminum magnesium hydroxide stearate-based cream has recently become available for clinical use. Aluminum magnesium hydroxide stearate-based cream provides an alternative option in treating these dermatoses while providing barrier protection against external allergens and irritants. This article reviews various studies evaluating aluminum magnesium hydroxide stearate-based cream.