Contribución del bloqueo del plano transverso abdominal guiado por ultrasonidos a la analgesia postoperatoria tras la cesárea

ObjectiveThe aim of this study was to evaluate the contribution made by ultrasound-guided transversus abdominis plane block (TAP) to the quality of the analgesia with intrathecal opioids obtained in patients undergoing elective caesarean delivery.Material and methodsA prospective, randomized study in patients submitted to elective caesarean section with spinal anaesthesia with 0.5% hyperbaric bupivacaine. The patients were randomized into 3 groups according to the added complementary drug for analgesia: group A morphine 0.1 mg; group B fentanyl 10 μg; group C 10 μg fentanyl + bilateral TAP block. The TAP block with 20 ml of 0.5% levobupivacaine on each side, after surgery. Groups A and B, were injected with 20 ml of saline. Postoperative analgesia was performed with morphine bolus through a system of patient-controlled analgesia (PCA). We studied the pain on a visual analogue scale at 12 and 24 h at rest and movement, the time elapsed to require the first bolus, and morphine bolus in 24 h. Secondary effects such as nausea, vomiting, pruritus, and drowsiness, were also evaluated. The level of patient satisfaction was also recorded.ResultsA total of 90 patients were included. At rest the 12/24 h VAS score was: group A, at 12 h 2.1 ± 1.2, at 24 h 4.7 ± 1.6; group B at 12 h 4.3 ± 2.9, at 24 h 4.8 ± 2; group C at 12 h 1.9 ± 1.09, at 24 h 2.3 ± 1.2 (P<.05). Walking improved analgesia more in group C (P≤.02). The time of asking for the first bolus was lower in group B: group A 9.3 ± 4.9 h (P=.02 compared to group C), in group B 2 ± 1.8 h (P<.001 compared to group C) and group C 13.2 ± 2.1 h. The number of bolus in 24 h in group B was 38 ± 5, in group A 10 ± 2 (P<.05), group C 5 ± 2 (P<.001). Delayed nausea was increased in group B (36.6%) and pruritus was greater in group A (36.6%).ConclusionsUltrasound (US)-guided TAP block improves spinal opioid analgesia, with a decrease in VAS scores in the first 24 h, and reduces opioid requirement and secondary effects after caesarean delivery.     

Epidemiology of acute kidney injury in surgical intensive care at University Hospital in Egypt. A prospective observational study

IntroductionThe acute kidney injury (AKI) incidence in ICU patients varies widely from 3% to 30%, with mortality ranging from 36% to 90%, depending on the type of ICU, study population, the period during which the study is conducted, and the criteria used to define AKI.There have been many studies about the epidemiology and risk factors of AKI in critically ill patients in the different regions of the world. However, little data on the epidemiology of AKI in critically ill patients are available in Egypt.ObjectivesThe aim of this study was to assess the incidence of AKI among critical ill patients using RIFEL [risk (R), injury (I), failure (F), loss (L), and end-stage kidney disease (E)] classification and to determine the risk factors and outcome of patients who developed AKI in our surgical ICU.MethodsWe conducted a 6-month prospective observational study in the surgical ICU. Patients were classified daily using the RIFLE criteria. Patients were considered as having new AKI if they did not have AKI on ICU admission and subsequently reached at least class risk during their follow-up. Deterioration of AKI was diagnosed if the patient had increased in RIFLE class compared to the initial classification.ResultsOne hundred and twelve patients were studied. AKI occurred in 40 (35.7%) of patients. The most common risk factors for AKI are APACHE II score (acute physiology and chronic health evaluation score, version II.) and sepsis. APACHEII was lower in non-AKI group than AKI group (17.3 ± 7.5 versus 22.4 ± 7.4, p = 0.001), and sepsis was more common in AKI patients than non-AKI patients (77.5% versus 49% p = 0.004). Patients with AKI had a mortality rate of 67.5% which was more in patients with failure compared with risk patients. APACHEII, AKI, and needs for mechanical ventilation were independent risks for mortality.     

Étude comparative de l’insuffisance rénale aiguë communautaire chez le sujet VIH positif et le sujet VIH négatif : expérience d’un service de médecine interne à Abidjan (Côte d’Ivoire)

BackgroundAcute kidney injury (AKI) is commonly associated with HIV infection.ObjectivesTo describe the profile of AKI in HIV infected versus non-infected persons.Patients and methodsThis is a prospective study that was carried out during the study period from January 2010 to December 2015 in the department of nephrology-internal medicine D of Treichville University Hospital (Côte d’Ivoire).ResultsThe prevalence of HIV infection was 35.2% in the population of AKI. The average age of patients was 42 ± 18 years in the HIV positive group against 51 ± 18 years in the HIV negative group (P = 0.0001). Etiologies were infections in 65.1% in the HIV positive group against 38.8% in the HIV negative group (P = 0.0001) and water loss in 24.7% in the HIV positive group against 7.8% in the HIV negative group (P = 0.0001). Factors such as the AIDS stage (P = 0.002), severe sepsis (P = 0.002) and acute pyelonephritis (P = 0.001) were associated with mortality in HIV positive patients against severe anemia (P = 0.0001) and severe sepsis (P = 0.0001) in the HIV-negative group.ConclusionHIV positive patients are younger with a female predominance. The mortality rate is identical in both groups.     

Safety of rituximab in rheumatoid arthritis patients with a history of severe or recurrent bacterial infection: Observational study of 30 cases in everyday practice

ObjectivesTo report our experience with rituximab therapy in patients with rheumatoid arthritis (RA) and a history of severe or recurrent bacterial infections.Patients and methodsRetrospective observational study in five rheumatology departments experienced in the use of biotherapies. Patients were included if they had RA and a history of severe or recurrent bacterial infection (requiring admission and/or intravenous antimicrobial therapy) that contraindicated the introduction or continuation of TNFα antagonist therapy.ResultsOf 161 RA patients given rituximab in the five study centers, 30 met the inclusion criteria, 23 females and seven males with a mean age of 58.4 ± 11.8 years and a mean disease duration of 11.4 ± 13.9 years. Among them, 22 had rheumatoid factors and 21 had received TNFα antagonist therapy (one agent in 15 patients, two in five patients and three in one patient). Prior infections were as follows: septicemia, n = 2; lower respiratory tract infection or lung abscess, n = 12; prosthesis infection, n = 3; septic arthritis, n = 3; endocarditis, n = 1; pyelonephritis, n = 2; osteitis, n = 4; and various skin infections (erysipelas, cellulitis or skin abscess), n = 6. Of these 33 infections, 21 occurred during TNFα antagonist therapy. During rituximab therapy, all patients received concomitant glucocorticoid therapy (mean dosage, 12 ± 7.9 mg/day). The number of rituximab cycles was one in 13 patients, two in seven patients and three or more in 10 patients. Mean time from the single or last serious infection and the first rituximab infusion was 20.1 ± 18.7 months. Mean follow-up since the first rituximab infusion was 19.3 ± 7.4 months. During follow-up, six (20%) patients experienced one infection each. Immunoglobulin levels after rituximab therapy were within the normal range.ConclusionRituximab therapy was well tolerated in 24 (80%) of 30 patients with RA and a history of severe or recurrent bacterial infection. In everyday practice, rituximab therapy seems safe with regard to the recurrence of infectious episodes. However, longer follow-ups are needed.     

L’insuffisance rénale aiguë après chirurgie cardiaque : évaluation des critères RIFLE

IntroductionAcute renal failure is a common complication is a common complication in cardiac surgery under cardiopulmonary bypass. It is associated with increased morbidity and mortality. Acute kidney injury (AKI) is a clinical entity encompassing the entire spectrum of acute renal failure, since minor alterations to the need for renal replacement therapy. The RIFLE criteria have been proposed for defining and classifying AKI. The aim of our study was to apply the RIFLE to a population of patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and to assess its relevance in terms of risk factor for hospital mortality compared to other risk factors.MethodsIn this prospective observational study, we included patients who were operated for programmed cardiac surgery. The assay of blood creatinine was performed at admission, after surgery and daily for 5 days post-surgery. The AKI was evaluated according to the criteria of classification RIFLE. The patients were divided into three levels of severity based on plasmatic creatinine (R: Risk = creatinine × 1.5; I: Injury = creatinine × 2; F: Failure = creatinine × 3). We have analyzed the different perioperative parameters and we sought associations with the occurrence of AKI. We also studied the impact of AKI on length of stay in ICU and mortality early and late.ResultsOne hundred and thirty-six patients were included. AKI was diagnosed in 17.6% of patients (RIFLE-R: 8.8%, RIFLE-I: 5.9% and RIFLE-F: 2.9%). AKI significantly prolongs the duration of ICU stay (7 ± 3.8 versus 5 ± 2.3 days; P = 0.02). RIFLE-R patients had a mortality of 8.3%, compared to 12.5% for I and 50% for F. Patients without PORD had a mortality of 1.8%. In univariate analysis, age, the EURO score, preoperative renal dysfunction, duration of aortic clamping, duration of CPB and C-reactive protein (CRP) were significantly associated with the occurrence of AKI. In multivariate analysis only preoperative renal dysfunction (clearance less than 63 mL/min) and CRP greater than 158 mg/L were found as independent factors of occurrence of AKI.ConclusionRIFLE classification seems to be a reliable way to detect acute renal failure and to classify its severity. The AKI is a common complication and is associated with increased morbidity and mortality. Identifying the risk factors allows a better prevention strategy.     

Preoperative portal vein embolization with a combination of trisacryl microspheres,gelfoam and coils

PurposeTo evaluate the safety and efficiency of preoperative portal vein embolization (PVE) with a combination of trisacryl microspheres, gelfoam and coils for inducing lobar hypertrophy in hepatobiliary malignancy patients.Materials and methodsPVE was performed by a percutaneous left approach in 63 patients with hepatic malignancy (hepatocarcinoma = 38, colorectal metastasis = 14, cholangiocarcinoma = 11). The indication of PVE and surgery was evaluated by hepatic tumor board take into consideration to the tumor extension and the hepatic volume on initial and post-embolization CT-scans. The total functional liver volume (TELV) and future liver remnant (FLR) volume were measured before and 24 ± 5 days after PVE to assess FLR, TELV and FLR/TELV ratios. Efficiency evaluation was based on FLR increase, the ability to perform the hepatectomy and the hepatic function after surgery. Safety evaluation was determined by clinical and biological follow-up after embolization and surgery.ResultsPVE was successful in all the patients. The mean FLR volume increases by 57 ± 56% after embolization (449 ± 180 cm³ to 663 ± 254cm³) (P < 0.0001). The FLR/TELV ratio increases by 11% after PVE (25 ± 8% to 36 ± 12%). Three minors’ complications were registered without impact on surgery, and four patients developed portal hypertension. Forty-nine patients underwent hepatectomy; none of them developed liver failure. Surgery was not performed in 14 patients due to tumor progression (n = 9), inadequate hypertrophy of FLR (n = 1) and portal hypertension (n = 4).ConclusionPreoperative PVE with a combination of trisacryl microspheres, gelfoam and coils is a safe and effective method for inducing contralateral hypertrophy before right hepatectomy in patients with advanced hepatobiliary malignancy.     

Patterns of Physical Activity Progression in Patients With COPD

IntroductionAlthough mean physical activity in COPD patients declines by 400?500 steps/day annually, it is unknown whether the natural progression is the same for all patients. We aimed to identify distinct physical activity progression patterns using a hypothesis-free approach and to assess their determinants.MethodsWe pooled data from two cohorts (usual care arm of Urban Training [NCT01897298] and PROactive initial validation [NCT01388218] studies) measuring physical activity at baseline and 12 months (Dynaport MoveMonitor). We identified clusters (patterns) of physical activity progression (based on levels and changes of steps/day) using k-means, and compared baseline sociodemographic, interpersonal, environmental, clinical and psychological characteristics across patterns.ResultsIn 291 COPD patients (mean ± SD 68 ± 8 years, 81% male, FEV₁ 59 ± 19%_pred) we identified three distinct physical activity progression patterns: Inactive (n = 173 [59%], baseline: 4621 ± 1757 steps/day, 12-month change (?): ∧487 ± 1201 steps/day), Active Improvers (n = 49 [17%], baseline: 7727 ± 3275 steps/day, ?: + 3378 ± 2203 steps/day) and Active Decliners (n = 69 [24%], baseline: 11 267 ± 3009 steps/day, ?: ∧2217 ± 2085 steps/day). After adjustment in a mixed multinomial logistic regression model using Active Decliners as reference pattern, a lower 6-min walking distance (RRR [95% CI] 0.94 [0.90?0.98] per 10 m, P = .001) and a higher mMRC dyspnea score (1.71 [1.12?2.60] per 1 point, P = .012) were independently related with being Inactive. No baseline variable was independently associated with being an Active Improver.ConclusionsThe natural progression in physical activity over time in COPD patients is heterogeneous. While Inactive patients relate to worse scores for clinical COPD characteristics, Active Improvers and Decliners cannot be predicted at baseline.     

Myocardial deformation assessment in patients with precapillary pulmonary hypertension: A cardiac magnetic resonance study

PurposeThe purpose of this study was to investigate right atrial and ventricular strain parameters on cardiac magnetic resonance (CMR) in patients with precapillary pulmonary hypertension (PPH) and whether they can aid in the assessment of PPH prognosis.Materials and methodsAdult patients with groups 1 and 4 PPH were invited to participate in the study. Age- and sex-matched healthy volunteers were also recruited as controls. At baseline, patients underwent clinical examination, N-terminal pro-B-type natriuretic peptide measurement and CMR with feature tracking post-processing (CMR-FT). Healthy controls underwent only CMR-FT. The study's primary endpoint was clinical failure, defined as death, hospitalization or demonstrable clinical deterioration during follow-up. Patients who were unable to perform 6-minute walking test due to musculoskeletal disorders were excluded from the study.ResultsThirty-six patients (8 men, 28 women; mean age, 50.6 ± 13.8 [SD] years [range: 18.6–78.5 years]) and 12 healthy control subjects (5 mean, 7 women; mean age, 40.6 ± 13.5 [SD] years [range: 23.1–64.4 years]) were recruited. Right ventricular global longitudinal strain (GLS) was significantly impaired in PPH patients (?20.2 ± 5.3 [SD] % [range: ?28.8 to ?9.1%] vs. ?28.4 ± 3.1% [?33.7 to ?22.7%] respectively, P < 0.001). The right atrial GLS was significantly impaired in PPH compared to healthy controls (?19.9 ± 4.5% [range: ?28.6 to ?3.6%] vs. ?26.5 ± 4.2% [range: ?32.8 to ?15.8%] respectively) (P < 0.001). Clinical failure occurred in 19 (19/36, 53%) of patients. Right ventricular GLS predicted clinical failure most reliably among CMR parameters (?22.6 ± 3.8 [SD] % [range: ?27.6 to ?12.7%] for patients without clinical failure vs. ?18 ± 5.6 [SD] % [range: ?28.8 to ?9.1%] for patients with clinical failure; hazard ratio [HR] = 1.85; P = 0.007; area under the AUC curve = 0.75). Lower absolute right atrial GLS was significantly associated with clinical failure (?22.7 ± 3.0 [SD] % [range: ?28.6 to ?17.7%] for patients without clinical failure vs. ?16.9 ± 5.8 [SD] % [range: ?24.2 to ?3.6%] for patients with clinical failure) (HR = 1.53; P = 0.035).ConclusionCMR feature tracking-derived myocardial strain parameters of both the right atrium and ventricle can assist clinicians in the prognosis of PPH.     

A randomized study of maternal serum cytokine levels following cesarean section under general or neuraxial anesthesia

BackgroundCytokines are significant mediators of the immune response to surgery and also play a role in parturition. The aim of the study was to investigate the impact of the anesthetic technique for cesarean section on plasma levels of cytokines IL-6 and TNF-α.MethodsThirty-five parturients scheduled for elective cesarean section were randomly assigned to general (n = 18) or neuraxial (n = 17) anesthesia. The general anesthesia group received thiopental 4 mg/kg, succinylcholine 1–1.5 mg/kg and 1% end-tidal concentration of sevoflurane in nitrous oxide and 50% oxygen. The neuraxial anesthesia group received intrathecal 0.5% levobupivacaine 1.8–2.2 mL and epidural fentanyl 1 μg/kg. Blood samples were taken for IL-6 and TNF-α immediately after positioning the parturient on the operating table, after uterine incision and before the umbilical cord clamping and 24 h after surgery (T₁, T₂ and T₃ respectively).ResultsThe two groups did not differ in IL-6 (P = 0.15) or TNF-α (P = 0.73) serum concentrations at any time point. In the general and neuraxial anesthesia groups, IL-6 serum concentrations were significantly higher in the third blood sample, T₃ (12.2 ± 5.0 and 15.2 ± 4.3 pg/mL), than in T₁ (0.41 ± 0.38 and 0.29 ± 0.10 pg/mL) and T₂ (0.37 ± 0.47 and 0.24 ± 0.05) respectively (P < 0.001). Within each group, serum TNF-α concentrations did not differ significantly over time (P = 0.44).ConclusionsUnder the present study design anesthetic technique did not affect IL-6 or TNF-α concentrations in parturients undergoing elective cesarean section. Serum IL-6 levels increased 24 h postoperatively independently of anesthetic technique.     

Preincisional peritonsillar vs. intravenous lornoxicam for posttonsillectomy analgesia: A clinical and platelet aggregometry comparative study

BackgroundLornoxicam is a fairly new short-half oxicam with an improved tolerability profile. Our objective was to investigate the safety and efficacy of intravenous and peritonsillar infiltration of 8 mg lornoxicam on pain relief in children undergoing tonsillectomy.MethodsIn a double-blinded, placebo-controlled trial, 60 children were randomized into three groups; intravenous group (n = 20), received lornoxicam 8 mg iv., infiltration group (n = 20) received lornoxicam 8 mg peritonsillar infiltration, and placebo controls (n = 20). The verbal rating pain scale, time to first postoperative analgesic request, total analgesic consumption during 1st 24 h postoperative, platelet aggregometry before, 15 min, 2 and 24 h after study drug administration, intraoperative blood loss, postoperative bleeding, and adverse effects were evaluated.ResultsThe time to first postoperative analgesic request was significantly prolonged in intravenous (318.75 ± 67.37 min) and infiltration (214.50 ± 43.06 min) groups compared with placebo group (66.75 ± 26.95 min). A significantly lower mean postoperative VRS scores and significantly reduced 1st day postoperative diclofenac consumption were recorded in iv. group (44.73 ± 9.31 mg), compared with infiltration (69.80 ± 38.71 mg) and placebo (87.8 ± 24.40 mg) groups. An increased intraoperative blood volume losses and intraoperative bleeding complains were observed in infiltration group (34.25 ± 11.93 ml), rather than in iv. (28.85 ± 10.01 ml) and placebo (24.75 ± 8.70 ml) groups. The (%) of platelet aggregation with ADP, collagen, and arachidonic acid was significantly reduced 15 min and 2 h after study drug administration with highest decreases in iv. group compared with infiltration and placebo groups. No patients reported postoperative bleeding or GIT adverse effects in the study.ConclusionIntraoperative preincisional intravenous lornoxicam enhanced postoperative analgesia after tonsillectomy in children. In comparison, the analgesic efficacy of locally applied lornoxicam was inferior to intravenous administration and was associated with increased incidence of intraoperative bleeding.     

Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind,dose-comparison,placebo-controlled randomized trial

BackgroundThe analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery.MethodsSixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3 mg/kg), low-dose ropivacaine (1.5 mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10–12 mg, fentanyl 10 μg and morphine 150 μg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24 h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48 h and at 6 and 12 weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction.ResultsThere were no differences between groups in the primary outcome. Mean ± SD pain scores (0–10) with movement at 24 h were: high-dose ropivacaine 3.6 ± 1.5, low-dose ropivacaine 4.6 ± 2.1 and placebo 4.1 ± 1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6 h were lower in the high-dose group 2.0 ± 1.8 compared to the low-dose 3.4 ± 2.7 and placebo groups 4.2 ± 2.0 (P = 0.009). Pain scores at 12 h were also lower in the high-dose group 2.2 ± 2.0 compared to the low-dose group 4.1 ± 2.7 and placebo group 4.0 ± 1.3 (P = 0.011). There was no difference in other outcomes between groups.ConclusionsNeither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24 h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12 h after cesarean delivery.     

Dexmedetomidine versus nimodipine for controlled hypotension during spine surgery

BackgroundControlled hypotension is a technique that is used to limit intraoperative blood loss, improve operative field, decrease duration of surgery, and thus decrease the amount of blood transfused.ObjectiveThe aim of this double-blind, randomized, controlled study is to compare the effects of sevoflurane combined with dexmedetomidine (DEX) or nimodipine (NIMO) on blood loss in the surgical field, recovery time, and patient tolerability in spine surgery.MethodsForty-eight (48) patients, 20–50 years of age, ASA I-II, randomly divided into DEX group (n = 24) and NIMO group (n = 24). In the DEX group, a loading dose of DEX infused over 10 min at a rate of 1 μg/kg/h, followed by a maintenance rate of 0.4–0.8 μg/kg/h. In the NIMO group, the dose infused at 15 μg/kg/h for 2 h (approximately 1 mg/h). The infusion rates were titrated to maintain mean arterial pressure (MAP) of 60–65 mm. Hg. We recorded MAP, intraoperative blood loss, total recovery time, total fentanyl consumption, incidence of arrhythmia or ischemia, and postoperative nausea and vomiting.ResultsNo significant difference in the amount of blood loss between the two groups was observed. Total fentanyl consumption was significantly higher in the NIMO group (350 ± 8.9 μg) versus (200 ± 5.5 μg) in the DEX group (p = 0.002). Recovery time was shorter in the NIMO group (6.8 min) versus (8.9 min) in the DEX group (p = 0.001).ConclusionsDexmedetomidine and Nimodipine provided effective method of controlled hypotension limiting the blood loss, and NIMO was associated with significantly shorter extubation and recovery times compared with DEX.     

Clinical results of acetabular fracture management with the Pararectus approach

IntroductionTo present the accuracy of reduction, complications and results two years after open reduction and internal fixation of displaced acetabular fractures involving the anterior column (AC) through the Pararectus approach. Frequencies for conversion to total hip replacement in the early follow up, the clinical outcome in preserved hips, and the need for an extension of the approach (1st window of the ilioinguinal approach) are compared to the literature about the modified Stoppa approach.MethodsForty-eight patients (mean age 62 years, range: 16–98; 41 male) with displaced acetabular fractures involving the AC (AC: n = 9; transverse fracture: n = 2; AC and hemitransverse: n = 24; both column: n = 13) were treated between 12/2009 and 12/2011 using the Pararectus approach. Surgical data and accuracy of reduction (using computed tomography) were assessed. Patients were routinely followed up at eight weeks, 6, 12 and 24 months postoperatively. Failure was defined as the need for total hip arthroplasty. Twenty-four months postoperatively the outcome was rated according to Matta.ResultsIn four patients there were four intraoperative complications (minor vascular damage in two, small perforations of the peritoneum in two) which were managed intraoperatively. Fracture reduction showed statistically significant decreases (mean ± SD, pre- vs. postoperative, in mm) in “step-offs”: 2.6 ± 1.9 vs. 0.1 ± 0.3, p < 0.001 and “gaps”: 11.2 ± 6.8 vs. 0.7 ± 0.9, p < 0.001. Accuracy of reduction was “anatomical” in 45, “imperfect” in three. Five (13%) from 38 available patients required a total hip arthroplasty. Of 33 patients with a preserved hip the clinical outcome was graded as “excellent” in 13 or “good” in 20; radiographically, 27 were graded as “excellent”, four as “good” and two as “fair”. An extension of the approach was infrequently used (1st window ilioinguinal approach in 2%, mini-incision at the iliac crest in 21%).ConclusionIn the treatment of acetabular fractures involving the anterior column the Pararectus approach allowed for anatomic restoration with minimal access morbidity. Results obtained by means of the Pararectus approach after two years at least parallel those reported after utilisation of the modified Stoppa approach. In contrast to the modified Stoppa approach, a relevant extension of the Pararectus approach was almost not necessary.     

Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study

BackgroundEpisiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia.MethodsIn this double-blind randomized prospective study, infiltration with 15 mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24 h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded.ResultsA total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9 h with 0.75% ropivacaine, 17.0 h with 1% lidocaine, and 16.6 h with saline (P = 0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P = 0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8 ± 11.6, lidocaine 12.4 ± 9.7; and saline 16.2 ± 11.5, P = 0.08).ConclusionFor the first 24 h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia.     

Clinical relevance of diffusion tensor imaging parameters in lumbar disco-radicular conflict

PurposeTo measure the fractional anisotropy (FA) and the mean diffusivity (MD) values of L4, L5 and S1 nerve roots using diffusion tensor imaging (DTI) and to correlate them with four different clinical patterns.Patients and methodsFifty-six human participants were prospectively included and divided between four groups: healthy subjects, patients with clinical symptomatic nerve root pain with and without anatomical discoradicular conflict and patients with incidental anatomical discoradicular conflict seen on magnetic resonance imaging (MRI). MRI protocol included anatomical sequences (sagittal T1- and T2-weighted, axial T2-weighted) and a 25 directions DTI sequence. FA and MD values were measured in consensus by two readers and compared between the four groups.ResultsMean FA and MD values were significantly different for patients with clinically symptomatic nerve root pain (n = 27) both with (n = 16) (FA = 0.187 ± 0.015; MD = 510 ± 40) and without (n = 11) (FA = 0.193 ± 0.011; MD = 490 ± 30.5) anatomical discoradicular conflict compared to healthy subjects (n = 29) (FA = 0.221 ± 0.011; MD = 460.9 ± 35.5) including 2 subjects with incidental anatomical discoradicular conflict (FA = 0.211 ± 0.013; MD = 450.8 ± 41.2) on MRI (P = 0.003).ConclusionMeasurement of FA and MD values of L4, L5 and S1 nerve roots using DTI could be useful in lumbar nerve root pain assessment. Further studies with different image processing methods are needed.     

Percutaneous Endovascular Treatment of Innominate Artery Lesions: A Single-centre Experience on 77 Lesions

PurposeTo assess primary success and safety of percutaneous transluminal angioplasty and/or stenting of innominate artery lesions and to compare its 30-day stroke/mortality level with the literature data.MethodsA total of 72 patients (77 stenoses, five recurrent, 58 symptomatic and 39 female) with seven innominate vessel occlusions, nine subocclusive lesions and 61 significant (>60%) stenoses of innominate artery treated between 2000 and 2009 were retrospectively reviewed. With the exception of seven, all procedures were performed using a transfemoral approach. A stent was implanted in 49 (63.6%) cases. Follow-up included neurological examination, carotid duplex scan and office/telephone interview.ResultsPrimary technical success was 93.5% (72/77). There was neither periprocedural (<48 h) death, nor major neurological complication. Minor periprocedural neurological complications consisted of 2/72 (2.6%) ipsilateral TIAs. Access site complications included 4 (5.2%) access site bleedings. Follow-up was achieved in 65/72 (90.3%) of all patients and 68 (88.3%) of all procedures for a mean of 42.3 months and revealed neither major neurological complication, nor additional TIA.The cumulative primary patency rate was 100% at 12 months, 98 ± 1.6% at 24 months, and 69.9 ± 8.5% at 96 months. The cumulative secondary patency rate was 100% at 12 and at 24 months, and 81.5 ± 7.7% at 96 months. Log-rank test showed no significant difference (p = 0.79) in primary cumulative patencies between PTA alone (n = 28) or PTA/stent (n = 49).ConclusionTransfemoral PTA with or without stent appears to be a safe treatment option for innominate artery lesions.     

Impairment of two types of circulating endothelial progenitor cells in patients with glucocorticoid-induced avascular osteonecrosis of the femoral head

ObjectivesThis study examined whether abnormalities of early EPCs and endothelial colony forming cells (ECFCs) are present and compared their functions in glucocorticoid (GC)-induced avascular osteonecrosis of the femoral head (ANFH).MethodsEarly EPCs and endothelial colony forming cells (ECFCs) were obtained from 33 patients with glucocorticoid-induced ANFH and 33 age- and sex-matched control subjects. Cells were isolated, in vitro cultured and studied by Flow Cytometry and Immunofluorescence. Colony-forming unit counts were observed from 33 patients and 33 healthy controls. Growth kinetics, migratory capacity to multiple chemo-attractants, in vitro tube formation capacity and cytokine (vascular endothelial growth factor and stromal cell-derived factor-1) levels in supernatants of two types of EPCs were assayed in ANFH patients and matched controls (n = 4).ResultsMean numbers of colonies formed by both types of EPCs were decreased in ANFH patients (Early EPCs: 2.42 ± 1.46 versus 4.52 ± 2.00, p < 0.05; ECFCs: 0.62 ± 0.55 versus 1.12 ± 0.82, p < 0.05,). Early EPCs from ANFH patients showed impaired migratory capacity (63.8 ± 11.7 versus 152.3 ± 12.4, p < 0.001) and VEGF secretion (50.8 ± 7.2 pg/ml versus 62.8 ± 10.1 pg/ml, p < 0.05). ECFCs from ANFH patients showed decreased tube formation capacity (7.1 ± 2.7 versus 23.8 ± 4.3, p < 0.001) and proliferation.DiscussionEarly EPCs and ECFCs were impaired in number and function in GC-induced ANFH, and their distinct reduced capacity profiles might reflect different roles they played in endothelial dysfunction of GC-induced ANFH.     

Incidence and risk factors of acute kidney injury in the Japanese trauma population: A prospective cohort study

IntroductionPrevious studies have reported the prevalence and risk factors of acute kidney injury (AKI) in relatively young trauma patients. The aims of this study were to identify the prevalence and risk factors of AKI among older Japanese trauma patients.MethodsWe conducted a prospective observational study in the 8-bed intensive care unit (ICU) of a Japanese tertiary-care hospital. Participants comprised trauma patients aged 18 years or older admitted to the ICU. Our primary outcome was the incidence of AKI within 10 days of admission, according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.ResultsAmong 333 patients, 66 (19.8%) developed AKI (Stage 1, n = 54; Stages 2, n = 5; and Stage 3, n = 7). Multivariate logistic regression analysis revealed that the incidence of AKI was associated with increased age (odds ratio (OR), 1.38; 95% confidence interval (CI), 1.15–1.65), male sex (OR, 2.06; 95%CI, 1.04–4.07), greater amount of red blood cell transfusions (OR, 1.61; 95%CI, 1.04–1.17), and presence of underlying chronic kidney disease (CKD) (OR, 3.97; 95%CI, 1.78-8.83). Length of stay in the ICU was significantly longer in patients with AKI (6 days) than in those without (3 days; p < 0.001). Patients ≥65 years old were more likely to develop AKI (26.2% vs 11.6%; p < 0.001). No significant differences in ICU stay (median, 4 vs 4 days; p = 0.70), hospital stay (median, 24 vs 21 days; p = 0.45), or 28-day mortality (2.1% vs 1.4%; p = 0.19) were evident between age groups.ConclusionsApproximately 20% of trauma patients developed AKI, and the elderly were more likely to develop AKI. Older age, male, greater units of red blood cell transfusions, and underlying CKD were associated with incidence of AKI.     

Prosthetic Carotid Bypass Grafts for Atherosclerotic Lesions: A Prospective Study of 198 Consecutive Cases

ObjectivesCarotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. The goal of this study was to determine the outcome and durability of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to CEA.MethodsThis is a prospective series of 198 consecutive patients with PCB, representing 12.4% of 1595 patients with a carotid reconstruction procedure performed in our department between September 1986 and December 2006. Qualifying event was stroke in 67 patients (34%) and transient ischaemic attack (TIA) in 45 (23%), and 86 patients (43%) were asymptomatic. Primary indications for PCB were extensive atherosclerotic lesions (n = 71; 36%), carotid stenosis associated with kinking (n = 49; 25%), recurrent stenosis (n = 47; 23%), stenosis after radiation therapy (n = 18; 9%) and technical failure of CEA (n = 13; 7%), with excessive arterial wall thinning and perforation after endarterectomy (n = 10) or intimal flap on completion digital angiography (n = 3).ResultsThe combined stroke and death rate at 30 days were 0.5% (one stroke). Median follow-up was 9.5 years (interquartile range (IQR): 6.2–18.3 years). At 10 years, primary patency was 97.9 ± 3.4%. Six PCBs (3.0%) became occluded during follow-up; one patient had a restenosis greater than 50% and 18 patients (9.1%) had a restenosis of less than 50%. Five patients had an ipsilateral stroke (one postoperative stroke, one at 103 days with a patent PCB and three related to occlusion of the PCB at 4, 13 and 15 years after the procedure). At 10 years, cumulative stroke-free survival was 98.4 ± 3.2%, and cumulative survival was 78.8 ± 7.0%.ConclusionsPCB is a safe surgical alternative and is durable, with a low incidence of graft restenosis, when CEA seems hazardous.     

Ketamine/propofol versus fentanyl/propofol for sedating obese patients undergoing endoscopic retrograde cholangiopancreatography (ERCP)

ObjectiveThis study was conducted to compare two techniques of sedation for obese patients undergoing ERCP, using either ketofol or fentanyl–propofol as regards propofol consumption, recovery time, patients’ satisfaction, and sedation-related adverse events.Materials and methodsTwo hundred obese patients were randomly allocated to one of two groups; ketamine/propofol (ketofol) group KP (n = 100) or fentanyl/propofol group FP (n = 100). The level of sedation was adjusted to achieve a Ramsay Sedation Scale (RSS) score of 5.ResultsTotal dose of propofol consumed was significantly higher in group FP compared with group KP (97.08 ± 23.31 mg and 57.71 ± 16.97) mg. Recovery time was slightly longer in group KP compared with group FP (11.19 ± 2.59 min and 9.43 ± 1.23 min, respectively), time needed to achieve Aldrete Recovery Scale Score of 9 was comparable in both groups, and sedation-related side effects as hypotension, bradycardia, apnea, and reduction of SpO₂ were more significant in the FP group.In conclusionKetamine/propofol combination 1:4 provided better sedation quality than fentanyl/propofol combination with less side effects and can be safely used for sedating obese patients undergoing ERCP.