Electrical impedance to detect accidental nerve puncture during ultrasound-guided peripheral nerve blocks

Purpose

The objective of this study was to assess if an increase in electrical impedance was associated with intraneural (sub-epineural) needle tip placement.

Methods

Two electrical impedance measurements were carried out in each of 140 peripheral nerve blocks. The first measurement was performed at a distance of 0.5-1 cm from the nerve trunk (reference value), and the second measurement was performed close to the nerve, either immediately before local anesthetic injection if no nerve puncture was suspected, or immediately before repositioning the needle if nerve puncture was suspected. Nerve puncture was suspected if any one of the following indications was present: pain or paresthesia; motor responses with a minimal stimulating current < 0.4 mA; needle tip observed inside the nerve using ultrasound; nerve swelling after injection of local anesthetic. Electrical impedance variations were compared between the no puncture and the suspected puncture groups.

Results

Nerve puncture was suspected in 21 cases. The median variation [quartiles] of electrical impedance was +6.6% [?20; 36%] in the suspected puncture group (n = 21) and ?10.0% [?28; 0%] in the no puncture group (n = 119) (P = 0.02). Absolute values of electrical impedance close to the nerve were greater in the suspected puncture group (15.5 kΩ [12.0; 18.0 kΩ]) vs the no puncture group (12.0 kΩ [8.9; 15.1% kΩ]) (P = 0.013). A receiver operating characteristic (ROC) curve was constructed, and the optimal cut-off for impedance was +4.3%.

Conclusion

A > 4.3% increase in electrical impedance may indicate accidental nerve puncture during peripheral nerve block.     

Comparative efficacy of ultrasound-guided and stimulating popliteal-sciatic perineural catheters for postoperative analgesia

Purpose

Perineural catheter insertion using ultrasound guidance alone is a relatively new approach. Previous studies have shown that ultrasound-guided catheters take less time to place with high placement success rates, but the analgesic efficacy compared with the established stimulating catheter technique remains unknown. We tested the hypothesis that popliteal-sciatic perineural catheter insertion relying exclusively on ultrasound guidance results in superior postoperative analgesia compared with stimulating catheters.

Methods

Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot or ankle surgery were assigned randomly to either ultrasound guidance (bolus via needle with non-stimulating catheter insertion) or electrical stimulation (bolus via catheter). We used 1.5% mepivacaine 40 mL for the primary surgical nerve block and 0.2% ropivacaine (basal 8 mL·hr^?1; bolus 4 mL; 30 min lockout) was infused postoperatively. The primary outcome was average surgical pain on postoperative day one.

Results

Forty of the 80 subjects enrolled were randomized to each treatment group. One of 40 subjects (2.5%) in the ultrasound group failed catheter placement per protocol vs nine of 40 (22.5%) in the stimulating catheter group (P = 0.014). The difference in procedural duration (mean [95% confidence interval (CI)]) was ?6.48 (?9.90 - ?3.05) min, with ultrasound requiring 7.0 (4.0-14.1) min vs stimulation requiring 11.0 (5.0-30.0) min (P < 0.001). The average pain scores of subjects who provided data on postoperative day one were somewhat higher for the 33 ultrasound subjects than for the 26 stimulation subjects (5.0 [1.0-7.8] vs 3.0 [0.0-6.5], respectively; P = 0.032), a difference (mean [95%CI]) of 1.37 (0.03-2.71).

Conclusion

For popliteal-sciatic perineural catheters, ultrasound guidance takes less time and results in fewer placement failures compared with stimulating catheters. However, analgesia may be mildly improved with successfully placed stimulating catheters. Clinical trial registration number NCT00876681.     

Ultrasound-guided sciatic nerve block: a comparison between four different infragluteal probe and needle alignment approaches

Purpose

Our aim was compare onset time of sciatic nerve blockade (SNB) performed distal to the subgluteal fold using four different ultrasound (US)-guided approaches in patients undergoing foot or ankle surgery.

Methods

Patients were assigned to one of four groups: SI patients received SNB using short-axis (SA) view of the SN and in-plane (IP) placement of block needle (SA-IP approach); LI patients received SNB using long-axis (LA) view of the SN and IP needle placement (LA-IP approach); SO patients received the block using SA view of the SN and out-of-plane (OP) needle placement (SA-OP approach); LO patients received SNB using LA view of the SN and OP needle placement (LA-OP). Primary outcome included onset time of sensory and motor SNB. Patient satisfaction concerning the postoperative analgesia was noted.

Results

The LI group had significantly faster onset of sensory blockade on the distribution of tibial nerve (16.0 ± 5.6 vs. 23.5 ± 3.6) and common peroneal nerve (12.5 ± 4.3 vs. 19.1 ± 5.4 min) in comparison with the LO group. The LI group had significantly faster onset of motor blockade on the distribution of tibial nerve (21.1 ± 6.2 vs. 26 ± 3.1) and common peroneal nerve (17.7 ± 4.8 vs. 23.7 ± 5.8 min.) in comparison with the LO group. The LI group had the highest rate of patient satisfaction for postoperative analgesia and the LO group had the lowest.

Conclusion

The LA-IP approach resulted in a rapid onset of SNB and was associated with the best satisfaction for postoperative analgesia in comparison with LA-OP, SA-IP, and SA-OP approaches for patients undergoing foot and ankle surgery.     

Ultrasound-guided versus computed tomography-controlled periradicular injections in the middle and lower cervical spine: a prospective randomized clinical trial

Purpose

We conducted this study to evaluate accuracy, time saving, radiation doses, safety, and pain relief of ultrasound (US)-guided periradicular injections versus computed tomography (CT)-controlled interventions in the cervical spine in a prospective randomized clinical trial.

Methods

Forty adult patients were consecutively enrolled and randomly assigned to either a US or a CT group. US-guided periradicular injections were performed on a standard ultrasound device using a broadband linear array transducer. By basically following the osseous landmarks for level definition in “in-plane techniques”, a spinal needle was advanced as near as possible to the intended, US-depicted nerve root. The respective needle tip positioning was then verified by CT. The control group underwent CT-guided injections, which were performed under standardized procedures using the CT-positioning laser function.

Results

The accuracy of US-guided interventions was 100 %. The mean time to final needle placement in the US group was 02:21 ± 01:43 min:s versus 10:33 ± 02:30 min:s in the CT group. The mean dose-length product radiation dose, including CT confirmation for study purposes only, was 25.1 ± 16.8 mGy cm for the US group and 132.5 ± 78.4 mGy cm for the CT group. Both groups showed the same significant visual analog scale decay (p < 0.05) without “inter-methodic” differences of pain relief (p > 0.05).

Conclusions

US-guided periradicular injections are accurate, result in a significant reduction of procedure expenditure under the avoidance of radiation and show the same therapeutic effect as CT-guided periradicular injections.     

No change in calcium absorption in adult Pakistani population before and after vitamin D administration using strontium as surrogate

Summary

Vitamin D, parathyroid hormone levels and calcium absorption was assessed before and after cholecalciferol using Strontium as a surrogate. Increase in 25OHD, lowering of iPTH with no effect on Sr absorption was seen, suggesting the possibility that maximal Ca absorption had already been achieved in these volunteers.

Introduction

This paper discusses the determination of calcium (Ca) absorption, using strontium (Sr) as a surrogate, before and after a single IM injection of vitamin D₃ (600,000 IU).

Methods

Baseline serum 25-hydroxyvitamin D (25OHD), Sr, Ca, P, and intact parathyroid hormone (iPTH) were determined in 53 fasting volunteers, followed by administrating (PO) 0.03 mM (4.8 mg/kg) SrCl₂ and collecting blood at 0.5, 1 and 4 h to determine the absorption (AUC_0→t ) of Sr. Following the initial absorption test, volunteers received a single IM injection of 600,000 IU vitamin D₃. Two months later, the fasting serum and the Sr absorption test were repeated, as described above.

Results

The IM injection of vitamin D₃ caused a significant increase in fasting 25OHD (from 43.5?±?19 to 66.1?±?19.1 nmol/L (p?<?0.001)) and a trend toward lower serum iPTH (from 59.8?±?27.8 to 53?±?31 ng/L). Fasting serum Ca and P remained unchanged. A higher 25OHD level failed (p?=?0.32) to translate into a higher rate of Sr absorption. AUC_0→4 h were almost identical before and after the IM injection of vitamin D₃.

Conclusion

A single vitamin D₃ injection of 600,000 IU significantly increase mean 25OHD concentration and tended to lower iPTH concentrations in volunteers with initially low 25OHD status, suggesting to utilize this simple form of treatment to improve vitamin D status and to have a possible biological effect on Ca homeostasis. However, we found no obvious effect on Sr absorption, suggesting the possibility that maximal vitamin D-dependent Ca absorption had already been achieved in these volunteers at a lower vitamin D status.     

Accuracy of lower cervical pedicle screw placement with assistance of distinct navigation systems: a human cadaveric study

Purpose

Evaluate the accuracy of five different techniques for lower cervical pedicle screw placement.

Methods

Forty human cadaveric cervical spines were equally divided into five groups, and each group had eight specimens. Pedicle screws with dia. 3.5 mm were used. Group 1 was blind screw placement without any assistance; Group 2–5 was assisted by the X-ray fluoroscopy, virtual fluoroscopy navigation system, CT-based navigation system, and Iso-C 3D navigation system, respectively. Thereafter, cortical integrity of each pedicle was evaluated by anatomic dissection of the specimens.

Results

A total of 398 pedicle screws were inserted. In the Group 1–5, the average operation time per sample was 27 ± 3.0, 112 ± 10.3, 69 ± 6.4, 98 ± 11.0, and 91 ± 6.0 min, respectively. The outcome for excellent, fair and poor were 29 (36.3 %), 21 (26.2 %) and 30 (37.5 %) in Group 1; 35 (44.9 %), 29 (37.2 %) and 14 (17.9 %) in Group 2; 34 (42.5 %), 36 (45.0 %) and 10 (12.5 %) in Group 3; 70 (87.5 %), 10 (12.5 %) and 0 (0.0 %) in Group 4; 72 (90.0 %), 8 (10.0 %) and 0 (0.0 %) in Group 5.

Conclusions

Blind screw placement was surely unsafe. Lower cervical pedicle screw placement assisted by the CT-based navigation system or the Iso-C 3D navigation system significantly improved the accuracy compared to the fluoroscopy assistance and the virtual fluoroscopy navigation assistance.     

Evaluación del área de sección del nervio mediano tras la inyección intraneural o perineural

Introduction

To recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage. However, signs of intraneural injection are not clearly established. The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1 ml of solution.

Supratentorial Glioblastoma Multiforme: The Role of Surgical Resection Versus Biopsy Among Older Patients

Background

The peak incidence of glioblastoma multiforme (GBM) occurs in those aged 65 years and older. However, studies on this patient group remain limited. The goal of this study is to evaluate the efficacy of surgery versus biopsy for older patients with these lesions.

Methods

133 and 72 consecutive patients aged 65 years and older who underwent surgery and needle biopsy for intracranial primary (de novo) GBM between 1997 and 2007 were retrospectively reviewed. Among these patients, 40 who underwent surgical resection were matched with 40 who underwent needle biopsy alone for factors consistently shown to be associated with survival [age, Karnofsky Performance Scale (KPS) indexing, eloquent involvement, radiation, temozolomide]. Survival was expressed as estimated Kaplan–Meier plots, and log-rank analysis was used to compare survival curves.

Results

Mean ± standard deviation age was 73 ± 5 years, and median survival was 4.9 months. There were no significant differences in perioperative outcomes among patients who underwent surgical resection versus needle biopsy. Patients who underwent resection had median survival of 5.7 months as compared with 4.0 months for patients who underwent needle biopsy (P = 0.02). Likewise, for patients aged 70 years and older, median survival was 4.5 months for 26 patients who underwent surgical resection as compared with 3.0 months for 26 patients who underwent needle biopsy (P = 0.03).

Conclusion

This study demonstrates that older patients tolerate aggressive surgery without increased surgery-related morbidity and have prolonged survival as compared with similar patients undergoing needle biopsy. These findings may help guide treatment decisions for patients, their families, and their physicians.     

Perineural Invasion in Extrahepatic Cholangiocarcinoma: Prognostic Impact and Treatment Strategies

Background

The significance of perineural invasion in extrahepatic cholangiocarcinoma has not been fully elucidated. This study aims to determine the prognostic impact of and optimal treatment strategy for perineural invasion in patients with extrahepatic cholangiocarcinoma.

Methods

Medical records of 133 patients with extrahepatic cholangiocarcinoma who underwent curative resection were reviewed retrospectively. Ninety-eight patients had perineural invasion and 35 patients did not. Univariate and multivariate survival analyses were performed to clarify the prognostic impact of and optimal treatment strategy for perineural invasion.

Results

Only tumor differentiation (P?=?0.024) was independently associated with perineural invasion in the multivariate logistic regression model. Multivariate survival analysis revealed that perineural invasion (P?=?0.002), resection margin status (P?=?0.016), and International Union Against Cancer (UICC) pT factor (P?=?0.015) were independent prognostic factors of overall survival. Overall 5-year survival rates for patients with and without perineural invasion were 28 and 74 %, respectively. Among 98 patients with perineural invasion, the use of adjuvant chemotherapy (P?=?0.003), lymph node status (P?=?0.015), resection margin status (P?=?0.008), and UICC pT factor (P?=?0.016) were independently associated with overall survival by multivariate analysis. Overall 5-year survival rates for patients with perineural invasion who did and did not receive adjuvant chemotherapy were 33 and 21 %, respectively (P?=?0.023).

Conclusions

Perineural invasion is a potent prognostic factor in extrahepatic cholangiocarcinoma. Adjuvant chemotherapy may improve the overall survival of patients with perineural invasion.     

Elektrische Nervenstimulation bei peripheren Nervenblockaden

Background

The use of nerve stimulation is a common standard procedure for peripheral nerve blocks. However, ultrasound guidance is increasingly being used as an alternative. This study explored the relationship between needle positioning defined by ultrasound guidance and the electrical nerve stimulation before and after injection of 5% glucose solution (G5%).

Patients and methods

After obtaining permission from the ethics committee, 60 patients were enrolled in the study and the results from 51 patients could be analyzed. For sonographically defined correct needle placement the lowest electrical threshold of the elicited motor responses before and after injection of 1 ml G5% was determined.

Results

In 76% of cases nerve structures could be visualized with high quality and 90% of the blocks were successful. Only 29% of patients with a successful block showed a motor response with a stimulation current ≤0.5 mA. There was a relationship only between the quality of the visualization and the success of the blockade. Addition of G5% did not result in significant changes in stimulation thresholds.

Conclusion

With the protocol used the success of a blockade depends only on the quality of visualization. With correct ultrasound-guided needle tip positioning the electrical information seems to be skewed and doubtful.     

Effect of vitamin D supplementation on bone health parameters of healthy young Indian women

Summary

There is a huge prevalence of hypovitaminosis D in the Indian population. We studied the efficacy and safety of oral vitamin D supplementation in apparently healthy adult women. Monthly cholecalciferol given orally, 60,000 IU/month during summers and 120,000 IU/month during winters, safely increases 25-hydroxyvitamin D (25(OH)D) levels to near normal levels.

Introduction

There is a huge burden of hypovitaminosis D in the Indian population. The current recommendation for vitamin D supplementation is not supported by sufficient evidence.

Methods

Study subjects included 100 healthy adult women of reproductive age group from hospital staff. They were randomized into group A (control) and group B (supplement) by simple randomization. Group B received 60,000 IU of cholecalciferol/month administered orally for 3 months, and then group A received 60,000 IU and group B 120,000 IU/month for 6 months.

Results

Mean baseline 25(OH)D level was 4.5?±?3.1 ng/ml and parathyroid hormone level was 50?±?25 pg/ml. In group B, 25(OH)D levels increased from 4.8?±?3.5 to 31.6?±?15.5 ng/ml (P?<?0.001) in 3 months. Interestingly, the increase, although of lower magnitude, was also observed in control group A, from 4.5?±?3.4 ng/ml (in spring) to 10.8?±?7.2 ng/ml (in summer; P?<?0.001). In group A (60,000 IU/month), mean 25(OH)D level had increased to 22.3?±?12.4 ng/ml (P?<?0.001) at 9 months (winter). In group B (120,000 IU/month), 25(OH)D levels were maintained at 30.7?±?12.8 ng/ml at 9 months (winter).

Conclusion

Our data show that monthly administration of 60,000 IU cholecalciferol in healthy subjects with hypovitaminosis D may suffice in summer months, but higher doses may be more appropriate during winter months.     

Management of Papillary Lesions of the Breast: Can Larger Core Needle Biopsy Samples Identify Patients Who May Avoid Surgical Excision?

Background

The ability to distinguish benign from atypical/malignant papillary lesions on core needle biopsy is limited by the representative nature of the biopsy method, thus follow-up excision is usually recommended. We aimed to determine if larger samples of tissue obtained by core needle biopsy can more reliably predict the true benign nature of a papilloma.

Methods

We reviewed the pathology slides and medical records of 51 patients who were diagnosed with benign papillomas on core needle biopsy from 2000 to 2010, who subsequently underwent surgical excision. The characteristics of the core needle biopsy that were associated with retention of benign histology on excision were determined and analyzed.

Results

Atypical ductal hyperplasia and carcinoma were identified in 5.8 % (3/51) and 5.8 % (3/51) of papillary lesions, respectively, when excised. Patients whose lesions were diagnosed as benign on excision were significantly distinguished by the area (mm²) of tissue sampled by core needle biopsy (mean ± standard deviation (SD): 101.5 ± 106.5) compared with those with atypia or carcinoma on excision (mean ± SD: 41.7 ± 24.0, P = 0.003). All biopsies performed with 12-gauge or larger needles retained benign features on excision. Core needle biopsy tissue samples consisting of ≥7 cores, or measuring >96 mm² in aggregate, had a negative predictive value for atypia/malignancy of 100 %.

Conclusions

Larger tissue samples significantly improved the predictive value of benign histology on core needle biopsy. A papilloma sampled by a 12-gauge or larger needle, ≥7 cores, or >96 mm² retained its benign features upon excision.     

Changes in Body Composition Secondary to Neoadjuvant Chemotherapy for Advanced Esophageal Cancer are Related to the Occurrence of Postoperative Complications After Esophagectomy

Background

Although a survival benefit of neoadjuvant treatment for patients with esophageal cancer has been highlighted, the influence of neoadjuvant treatment on the nutritional status of patients with esophageal cancer is not well understood.

Methods

Changes in body composition parameters were assessed in 30 patients who underwent neoadjuvant chemotherapy (NAC) comprising docetaxel, cisplatin, and 5-fluorouracil followed by esophagectomy from August 2009 to April 2013. Body composition was evaluated before and after NAC using multifrequency bioelectrical impedance analysis (InBody 720; Biospace, Tokyo, Japan). Postoperative complications were graded according to the Clavien-Dindo classification.

Results

Twenty-three postoperative events occurred in 16 patients. A decrease in body protein was observed in 13 patients (43.3 %), while skeletal muscle (SM), body cell mass (BCM), and fat-free mass (FFM) declined in 11 patients (36.7 %) during NAC. Changes in these four parameters during chemotherapy significantly differed between patients with postoperative complications and those without: protein, ?1.6 ± 0.9 versus +4.4 ± 2.1 kg (P = 0.01); SM, ?1.3 ± 1.1 versus +4.7 ± 2.4 kg (P = 0.02); BCM, ?2.4 ± 1.6 versus +3.8 ± 2.2 kg (P = 0.03); and FFM, ?1.4 ± 1.4 versus +4.3 ± 2.3 kg (P = 0.04).

Conclusions

Changes in body composition parameters are possible predictive markers of postoperative complications after esophagectomy after NAC. Further analysis is needed to clarify whether nutritional intervention improves such parameters and thus contributes to reduced postoperative morbidity.     

Long-Term Results of Seton Placement for Fistula-in-ano in Infants

Background

The present study aimed to assess the long-term results of seton placement for fistula-in-ano (FIA) in infants.

Methods

Data of patients aged <1 year who presented to our department with perianal abscess (PA) between January 2006 and February 2010 were retrospectively reviewed. Our standard initial treatment for PA was incision and drainage. Patients with systemic diseases and inflammatory bowel diseases were excluded.

Results

Ninety-five patients were treated for PA and/or FIA during the 5-year period, and follow-up data were available for 90 patients. The mean follow-up duration in these patients was 49.8?±?11.4 months, and mean age at presentation was 3.1?±?2.7 months. Of the 90 patients, 36 (40 %) developed FIA (39 lesions) and underwent seton placement. The condition healed in a mean period of 6.3?±?4.0 weeks after the placement of a cutting seton. Healing of the fistula was achieved in 35 (97.2 %) of 36 patients after the initial seton procedure, and one patient who showed recurrence underwent a second seton placement, resulting in successful healing of the FIA after 5 weeks.

Conclusions

The long-term success of seton placement indicates that this procedure should be a treatment option for FIA in infants.     

Metallic Stent Placement in Patients with Recurrent Malignant Obstruction in the Surgically Altered Stomach

Purpose

The purpose of this study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in 196 patients with recurrent malignant obstruction in their surgically altered stomach.

Methods

The 196 patients were treated using five different types of gastric surgery performed for gastric cancer: total gastrectomy (type 1) in 73 patients; distal gastrectomy with gastroduodenostomy (type 2) in 39 patients; distal gastrectomy with a Roux-en-Y gastrojejunostomy (type 3) in 21 patients; distal gastrectomy with a gastrojejunostomy (type 4) in 49 patients; and palliative gastrojejunostomy for unresectable gastric cancer (type 5) in 14 patients. The technical and clinical success rates, complications, dysphagia score, and influence of chemotherapy were evaluated and the complications compared between the two stent types. The overall survival and stent patency were calculated using the Kaplan–Meier method.

Results

Stent placement was technically successful in 192 of 196 patients (97.9 %), with 184 of the 192 patients (95.8 %) showing symptomatic improvement. The mean dysphagia score improved from 3.24 ± 0.64 to 1.48 ± 0.82 (p < 0.001). The complication rate was 25 %. The incidence of stent migration was significantly higher in fully covered stents and in patients who underwent chemotherapy (p < 0.001 and p = 0.005, respectively). Chemotherapy was significantly associated with an increase of survival (p < 0.001). The median survival and stent patency were 131 and 90 days, respectively.

Conclusion

Placement of expandable metallic stents in patients with recurrent cancer after a surgically altered stomach is technically feasible and clinically effective. Chemotherapy was associated with increased stent migration and prolonged survival.     

How does reverse shoulder replacement change the range of motion in activities of daily living in patients with cuff tear arthropathy? A prospective optical 3D motion analysis study

Background

Reverse total shoulder arthroplasty (RSA) can improve function in cuff tear arthropathy (CTA) shoulders, but limited exact data are available about the maximum values in 3D motion analysis, and as to how improvements translate into the normal range of motion (ROM) in activities of daily living (ADLs).

Methods

This study included nine consecutive patients (n = 9) who received RSA for CTA without muscle transfers. We measured shoulder movement by a novel 3D motion analysis using the Heidelberg upper extremity model (HUX) which can eliminate compensatory movements of the scapula, and the trunk. The measurement included active maximum values, and four ADLs.

Results

Comparing the pre- to the 1-year postoperative status, RSA was associated with a significant increase in the mean maximum values for active flexion of about 43° (SD ± 31) from 66° to 109° (p = 0.001), for active abduction of about 37° (SD ± 26) from 57° to 94° (p = 0.001), and for the active adduction of about 28° (SD ± 10) from 5° to 33° (p = 0.002). Comparing the preoperative to the postoperative ROM in the ADLs in flexion/extension, ROM improved significantly in all ADLs, in abduction/adduction in three of four ADLs. No significant changes were observed in internal/external rotation in any ADLs.

Conclusion

RSA improves the active maximum ROM for flexion, abduction, and adduction. The patients are able to take advantage of this ROM increase in ADLs in flexion and in most ADL in abduction, but only in trend in internal and external rotation.

Level of evidence

Level IV, Case Series with no comparison group.     

Intracutaneous sterile water injection versus oral paracetamol for renal colic during pregnancy: a randomized controlled trial

Purpose

The aim of this study was to assess the analgesic efficacy of intracutaneous sterile water injection compared with oral paracetamol in pregnant women with acute renal colic caused by urolithiasis.

Methods

The study included 45 patients randomized into two different groups: Group A (n = 24) received paracetamol (1,000 mg, oral), while group B (n = 21) received sterile water injections. The severity of pain was assessed by a visual analogue scale (VAS) system at baseline and at 15, 30 min, and 1 h after administering the treatments. Subjects with inadequate pain relief at 1 h received rescue analgesia.

Results

The VAS values prior to the start of therapy and 15, 30 min, and 1 h after therapy were 85.42 ± 10.62, 69.17 ± 8.3, 45.42 ± 12.5, and 32.08 ± 14.44 for the paracetamol group, while for the sterile water injection group, the VAS values were 90.48 ± 11.17, 30.95 ± 16.7, 14.76 ± 11.23, and 10.48 ± 8.65, respectively. There was no statistically significant difference between the starting VAS values of the two groups, but the VAS values 15, 30 min, and 1 h after paracetamol administration were statistically less in the group that received sterile water injections. Rescue analgesics at 1 h were required by eight subjects (33 %) receiving paracetamol and one subject (5 %) receiving sterile water injection.

Conclusions

Intracutaneous injection of sterile water is an efficacious treatment for renal colic caused by urolithiasis in pregnant women. It was significantly superior to oral administration of paracetamol.     

Ethnic differences in 25-hydroxyvitamin D levels and response to treatment in CKD

Aim

Nutritional vitamin D [25(OH)D] deficiency is common in patients with chronic kidney disease (CKD). No studies have specifically examined the differences between ethnic groups in response to ergocalciferol (“D2”) therapy.

Methods

A retrospective analysis was performed to evaluate the effectiveness of D2 therapy as recommended by the KDOQI guidelines in 184 Hispanic and Caucasian nondialysis CKD patients.

Results

Low 25(OH)D levels (<75 nmol/L) were found in 89.4 % of Hispanics versus 61.4 % of Caucasians, despite similar degrees of CKD. Treatment per KDOQI guidelines resulted in 85.5 % of treated Hispanics and 66.7 % of treated Caucasians remaining vitamin D-deficient. Although both Hispanics and Caucasians had significant (P < 0.0001) changes in 25(OH)D levels, absolute changes were modest (12.5 ± 2.0 nmol/mL in Hispanics, 20.0 ± 3.5 nmol/L in Caucasians). The increase seen in Caucasians was significantly greater than in Hispanics (P < 0.0001). In multiple logistic regression modeling, Hispanic ethnicity remained independently associated with poorer response to therapy (P = 0.0055), even after adjustment for other factors.

Conclusions

While both Hispanics and Caucasians demonstrated suboptimal response to the KDOQI-guided vitamin D repletion strategy, Hispanic ethnicity was significantly associated with poorer response. Our findings may have implications for other darker-skinned populations, even in solar-rich environments.     

Is Perineural Invasion More Accurate Than Other Factors to Predict Early Recurrence after Pancreatoduodenectomy for Pancreatic Head Adenocarcinoma?

Background

Some patients operated by pancreaticoduodenectomy for resectable pancreatic head adenocarcinoma will present with a recurrence during the first year (early recurrence).

Objective

The aim of this study was to determine prognostic factors associated with early recurrence in a large retrospective study.

Methods

From January 1995 to November 2010, all patients operated by pancreaticoduodenectomy for pancreatic head adenocarcinoma in our institution were retrospectively included. Univariate and multivariate analyses were performed to determine factors associated with early recurrence.

Results

A total of 166 patients were included; 57 patients (34 %) developed early recurrence. In univariate analysis, factors associated with early recurrence were perineural invasion (p = 0.0002), preoperative bilirubin (p = 0.01), lymph node ratio (LNR) ≥0.2 (p = 0.009), and T stage (p = 0.02). In multivariate analysis, perineural invasion (odds ratio [OR] 3.31; 95 % confidence interval [CI] 1.42–7.72; p = 0.005), LNR ≥0.2 (OR 2.55; 95 % CI 1.17–5.52; p = 0.02), and preoperative bilirubin (OR 1.04; 95 % CI 1.01–1.07; p = 0.03) were independent factors associated with early recurrence. Perineural invasion was also associated with poor overall survival (p = 0.001) and poor disease-free survival (p = 0.07).

Conclusion

In our study, perineural invasion (OR 3.31) is more accurate than T stage and lymph node status (OR 2.55) to predict early recurrence after pancreatoduodenectomy for pancreatic head adenocarcinoma.     

Rat model of spinal cord injury preserving dura mater integrity and allowing measurements of cerebrospinal fluid pressure and spinal cord blood flow

Purposes

Cerebrospinal fluid (CSF) pressure elevation may worsen spinal cord ischaemia after spinal cord injury (SCI). We developed a rat model to investigate relationships between CSF pressure and spinal cord blood flow (SCBF).

Methods

Male Wistar rats had SCI induced at Th10 (n = 7) or a sham operation (n = 10). SCBF was measured using laser-Doppler and CSF pressure via a sacral catheter. Dural integrity was assessed using subdural methylene-blue injection (n = 5) and myelography (n = 5).

Results

The SCI group had significantly lower SCBF (p < 0.0001) and higher CSF pressure (p < 0.0001) values compared to the sham-operated group. Sixty minutes after SCI or sham operation, CSF pressure was 8.6 ± 0.4 mmHg in the SCI group versus 5.5 ± 0.5 mmHg in the sham-operated group. No dural tears were found after SCI.

Conclusion

Our rat model allows SCBF and CSF pressure measurements after induced SCI. After SCI, CSF pressure significantly increases.