Diffusion tensor MR imaging in spinal cord injury

BackgroundThe ability of diffusion tensor imaging (DTI) to complement conventional MR imaging by diagnosing subtle injuries to the spinal cord is a subject of intense research. We attempted to study change in the DTI indices, namely fractional anisotropy (FA) and mean diffusivity (MD) after traumatic cervical spinal cord injury and compared these with corresponding data from a control group of individuals with no injury. The correlation of these quantitative indices to the neurological profile of the patients was assessed.Material and methods20 cases of acute cervical trauma and 30 age and sex matched healthy controls were enrolled. Scoring of extent of clinical severity was done based on the Frankel grading system. MRI was performed on a 3T system. Following the qualitative tractographic evaluation of white matter tracts, quantitative datametrics were calculated.ResultsIn patients, the Mean FA value at the level of injury (0.43+/−0.08) was less than in controls (0.62+/−0.06), which was statistically significant (p value <0.001). Further, the Mean MD value at the level of injury (1.30+/−0.24) in cases was higher than in controls (1.07+/−0.12, p value <0.001). Statistically significant positive correlation was found between clinical grading (Frankel grade) and FA values at the level of injury (r value = 0.86). Negative correlation was found between clinical grade and Mean MD at the level of injury (r value = −0.38) which was however statistically not significant.ConclusionQuantitative DTI indices are a useful parameter for detection of spinal cord injury. FA value was significantly decreased while MD value was significantly increased at the level of injury in cases as compared to controls. Further, FA showed significant correlation with clinical grade. DTI could thus serve as a reliable objective imaging tool for assessment of white matter integrity and prognostication of functional outcome.     

Is gabapentin effective and safe in open hysterectomy? A PRISMA compliant meta-analysis of randomized controlled trials

BackgroundPain management after open hysterectomy has been investigated for years. Owing to the effect of significant analgesic, gabapentin was often administrated for pre-emptive analgesia. However, the relationship between gabapentin and postoperative pain after open hysterectomy is still controversial. This meta-analysis was applied to assess the efficacy of pre-emptive use of gabapentin in open hysterectomy.MethodsThis meta-analysis of randomized controlled trials (RCTs) was performed to compare the use of gabapentin with placebo in open hysterectomy regarding (1) the mean difference (MD) of postoperative opioid requirements; (2) the changes of visual analogue scale (VAS) scores in two groups; and (3) incidence rate of adverse effects. Systematic searches of all related literatures was conducted using the following databases: MEDLINE, EMBASE, ClinicalTrials.gov and Web of Science. Only randomized controlled trials (RCTs) for open hysterectomy were included. The MD of postoperative opioid requirements and VAS scores, relative risk (RR) of incidence rate of adverse effects in the gabapentin group versus placebo group were extracted throughout the study.ResultsFourteen trials were included in this meta-analysis. The total opioid consumption at 24 h was a less in gabapentin group. (MD = − 11.61, 95% CI: − 16.71 to − 6.51, P = 0.00) The visual analogue scale (VAS) score at 4, 12 and 24 h were less in the gabapentin group. (MD = − 16.83, 95% CI: − 22.88 to − 10.77, P = 0.00), (MD = − 17.45, 95% CI: − 21.83 to − 13.08, P = 0.00), (MD = − 9.83, 95% CI: − 13.31 to − 6.35, P = 0.00) The incidence rate of vomiting and nausea were significantly less in gabapentin groups. (RR 0.13, 95% CI 0.45 to 0.73, P = 0.00), (RR 0.67, 95% CI 0.49 to 0.93, P = 0.02). Compared with placebo, gabapentin achieved higher patient satisfaction. (MD = 20.43, 95% CI: 12.42 to 28.44, P < 0.00).ConclusionThis meta-analysis suggested that the employment of gabapentin was efficacious in reduction of postoperative opioid consumption, VAS score and some side effects after open hysterectomy.     

Biomechanical comparison of conventional versus modified technique in distal chevron osteotomies of the first metatarsal: A cadaver study

BackgroundDistal chevron osteotomy can be performed using a conventional or a modified technique. The aim of this biomechanical study was to compare the stability of the two techniques.MethodsEighteen first metatarsals from nine pairs of fresh frozen human cadaver feet were used. A distal chevron osteotomy was performed using the conventional technique in group 1 (n = 9) and using the modified technique in group 2 (n = 9). The head of the first metatarsals was loaded in two different configurations (cantilever and physiological), using a materials testing machine.ResultsIn the cantilever configuration, the relative stiffness of the osteosynthesis in comparison with intact bone was 60% (±21%) in group 1 and 65% (±25%) in group 2 (p = 0.61). In the physiological configuration, it was 47% (±29%) in group 1 and 47% (±21%) in group 2 (p = 0.98). The failure strength in the cantilever configuration was 235 N (±128 N) in group 1 and 210 N (±107 N) in group 2 (p = 0.47).ConclusionsThe conventional and the modified technique for distal chevron osteotomy in the treatment of hallux valgus show a comparable biomechanical loading capacity in this cadaver study.     

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.     

Systematic assessment of heart valves and cardiac function by echocardiography in axial spondyloarthritis: A systematic review and meta-analysis

ObjectivesAxial Spondyloarthritis (ax-SpA) is associated with increased risk of cardiovascular disease (CVD)-specific deaths. We aimed to assess the prevalence of left ventricular (LV) systolic and diastolic dysfunction and valvular heart disease (VHD) by transthoracic echocardiography (TTE) in ax-SpA patients without history of CVD.MethodsA systematic literature review was performed in PUBMED, Embase, Cochrane Library databases published before April 2020. We included all controlled studies assessing myocardial function and heart valve by TTE in ax-SpA without history of CVD. A meta-analysis was performed with random or fixed effects model estimating mean differences (MD) and odds ratio (OR).ResultsLiterature search selected 189 abstracts and 28 articles were included (1471 ax-SpA and 1115 controls). ax-SpA had a statistically slight alteration of LV ejection fraction (MD = 0.64%, 95%CI: 0.14–1.14). ax-SpA had more frequently LV diastolic dysfunction (OR = 3.43, 95%CI: 1.78–6.59) and an alteration of E/A ratio (MD = 0.15, 95%CI: 0.08–0.21), deceleration time (MD = 13.07ms, 95%CI: 7.75–18.40), isovolumetric relaxation time (MD = 7.90ms, 95%CI: 4.50–11.30), left-ventricular end diastolic (MD = 0.57 mm, 95%CI: 0.19–0.95) and systolic (MD = 0.77 mm, 95%CI: 0.36–1.17) diameters. Three studies (15%) used a combination of TTE parameters to diagnose LV diastolic dysfunction. Prevalence of mitral regurgitation and aortic regurgitation were similar in ax-SpA patients and healthy individuals.Conclusionax-SpA have a non-clinically relevant alteration of LV ejection fraction and similar prevalence of VHD compared to healthy individuals. LV diastolic TTE parameters are altered in ax-SpA. However, most studies do not combine set of parameters to recognize diastolic dysfunction. The clinical relevance of diastolic dysfunction observed by TTE remains to be determined in future longitudinal studies.     

Effects of 14 weeks of TNF alpha blockade treatment on lipid profile in ankylosing spondylitis

ObjectiveCardiovascular morbidity and mortality seem to be increased in ankylosing spondylitis, perhaps as the result of biological inflammation and consecutive dyslipidemia. This study aims to investigate the impact of TNF alpha-inhibitors, an effective treatment, on lipid profile.MethodsThirty-four ankylosing spondylitis (AS) patients with active disease undergoing anti-TNF alpha therapy (n = 20, infliximab; n = 7, etanercept; n = 7, adalimumab) were recruited. Disease activity parameters, total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were assessed at baseline and after 14 weeks of treatment.ResultsAfter 14 weeks of TNF alpha blockade treatment, there was a significant increase in levels of total cholesterol (5.08 ± 1.20 vs. 4.73 ± 1.12 mmol/l; p = 0.01) and HDL-cholesterol (1.61 ± 0.47 vs. 1.47 ± 0.35 mmol/l; p = 0.008), but no resulting change in the atherogenic index (3.43 ± 1.13 vs. 3.35 ± 0.93; p = 0.87). There was also no change in concentrations of triglycerides (1.33 ± 1.22 vs. 1.27 ± 0.98 mmol/l; p = 0.794) and LDL-cholesterol (3.15 ± 0.99 vs. 2.91 ± 0.93 mmol/l; p = 0.24). TNF alpha inhibitor treatment was followed by a significant improvement in all disease activity parameters: VAS pain or VAS disease activity, BASDAI or BASFI and systemic inflammation. Sub-group analysis showed that monoclonal antibodies increased total and LDL-cholesterol levels but did not change the atherogenic index. Conversely, 14 weeks of etanercept treatment was followed by no change in lipid profile.ConclusionTNF alpha inhibitors may be successful in reducing cardiovascular risk in AS, as in RA, but not by affecting lipid profile. However, there is insufficient documented evidence, and long-term investigations are needed to define the possible protective mechanisms of TNFalpha inhibitor treatment in spondylarthropathies.     

Sciatic nerve block made easy for resident trainers

BackgroundThe infragluteal parabiceps approach to sciatic nerve might be easier to be learnt by trainees with reasonable success rate and performance time and less incidence of complications.MethodsAfter ethical approval, infragluteal and Labat approaches for sciatic nerve block (n = 50 for each) were performed by five trainees at 3rd grade of anesthesia training program. We recorded the changes in the times to performance of the block, and onset of sensory block, the patients' satisfaction and difficulty of the technique for the trainees.ResultsPerformance time was 3–3.5 min with Labat approach and 2–2.75 min with infra-gluteal approach (P < 0.001). Sciatic nerve stimulation was observed at a depth of 70 ± 8 mm after (2–10) needle redirection in group Labat, and at a depth of 58 ± 13 mm after (2–7) needle redirection in infragluteal group (P < 0.001). Failed nerve block was reported in 5 cases in group Labat and 2 cases in infra-gluteal group (P = 0.13). Thirty cases in Labat group would refuse the same anesthetic if required in the future for another surgery, while only twenty five cases in infragluteal group would refuse the same technique in the future (P = 0.13). Three resident trainer described the infragluteal approach as a simple approach and easy to perform by a beginner, whereas only two trainers accepted the Labat approach (P = 0.52).ConclusionInfragluteal approach for the sciatic nerve block was considered rapidly and easy to use and the preferred approach regardless of previous experience compared with Labat approach.     

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.     

The contribution of periapical nerve block in transrectal ultrasound-guided prostate biopsy: Results from a prospective randomized trial

ObjectivePeriprostatic nerve block has been shown to be the most effective method to reduce pain during transrectal ultrasound (TRUS) guided prostate biopsy, but the ideal technique remains controversial. The aim of this study was to compare pain control between bilateral basal block (BBB) alone and BBB combined with periapical nerve block (PNB).Patients and methodsFrom November 2007 to May 2009, 182 consecutive patients with abnormally elevated serum prostate-specific antigen (PSA) or suspicious digital rectal examination (DRE) underwent TRUS-guided needle biopsy of the prostate. The patients were prospectively randomized after informed consent had been obtained. Group 1 (n = 90) underwent bilateral basal block (BBB) with periprostatic infiltration of 8 ml 1% lidocaine into the neurovascular bundle at the prostate-seminal vesicle junction on each side. Group 2 (n = 92) underwent BBB with the addition of periapical nerve block (PNB) using 2 ml 1% lidocaine per side. A visual analog scale (VAS) was used to evaluate the patient's perception of pain during the biopsy.ResultsThe mean patient age was 64.6 ± 8.2 years and the average VAS was 1.9 ± 2.0. The mean VAS was lower in Group 2 compared with Group 1, 1.6 ± 1.9 versus 2.2 ± 2.0 (p = 0.026). In the subgroup aged 56–65 years the mean VAS was 1.26 ± 0.6 in Group 1 versus 2.46 ± 0.5 in Group 2 (p = 0.001), and in the subgroup aged 66–87 years it was 1.41 ± 0.5 in Group 1 versus 1.66 ± 0.75 in Group 2 (p = 0.554).ConclusionsBBB combined with PNB seems to be more effective to BBB alone to reduce pain during TRUS-guided prostate biopsy and may be of maximum benefit for younger patients.     

“Anterior subcutaneous pelvic internal fixator (INFIX), Is it safe?” A cadaveric study

IntroductionAnterior pelvic internal fixator (INFIX) is used to treat unstable pelvic ring injuries. Nerve injury complications with this procedure have been reported.ObjectivesThis anatomic study attempted to identify structures at risk after application of INFIX.Materials and methodsINFIX was applied in fifteen fresh, frozen, anatomical specimens using polyaxial pedicular screws and subcutaneous rods. Surgical dissection was done to identify the structures at risk including the femoral nerve (FN), femoral artery (FA), femoral vein (FV) and the lateral femoral cutaneous nerve (LFCN) related to which are potentially affected by the implant.ResultsAll structures at risk were closer to the rod than to the pedicular screw. Measurements were made between the rod and the structures at risk. The LFCN was an average of 13.49 ± 1.65 mm (95% CI 12.871–14.103) from the lateral end of the rod. The FN was an average of 12.43 ± 3.42 mm (95% CI 11.151–13.709), the FA was an average of 12.80 ± 3.67 (95% CI 11.430–14.173) and the FV was an average of 13.48 ± 3.73 (95% CI 12.082–14.871) below the rod. No direct compression of the rod to the structure at risk was observed.ConclusionsThe femoral nerve is the structure most at risk of compression by the INFIX rod. Careful surgical technique is required in every step of this surgery. We suggest using polyaxial screws and recommend that during screw insertion the surgeon should leave some space between the screw and rectus fascia. The the rod should be trimmed as short as possible to reduce LFCN irritation.     

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.     

Development and evaluation of a low-cost part-task trainer for laparoscopic repair of inguinal hernia in boys and the acquisition of basic laparoscopy skills

PurposeTo examine the fidelity of our model of laparoscopic inguinal hernia repair (LIHR) in boys and evaluate its value in resident training programs and the learning of basic laparoscopy skills.MethodsWe created a simulation model with inexpensive, easy-to-obtain equipment. Study participants from 34 university hospital departments received a user manual and an evaluation questionnaire (11 items rated on a 5-point Likert scale). We considered that the evaluation was positive when the median overall score was 4 or over. We compared the results for residents (n = 26) vs. expert surgeons (n = 29) (t tests).ResultsThe duration of the procedure was significantly longer among the residents (30.0 ± 16.8 min) than among the expert surgeons (20.5 ± 11.7 min; p = 0.01). In both groups, the participants rated the model favorably with regard to the overall impression (median score: 4.0 ± 1.0), realism (4.0 ± 0.9), ease of access to the required equipment (5.0 ± 0.6), the quality of the user manual (5.0 ± 0.6), ease of assembly (5.0 ± 0.8), ease of the procedure (5.0 ± 0.8), value in resident training programs (4.0 ± 0.9), and value in learning basic laparoscopy skills (5.0 ± 0.8)). The evaluation was positive (4.0 ± 0.9).ConclusionOur low-cost model was an effective teaching and training tool for LIHR and basic laparoscopy skills.Level of EvidenceLevel IV.     

Ultrasound guided injection inside the common sheath of the sciatic nerve at division level has a higher success rate than an injection outside the sheath

Background and objectiveThe recommendations for the level of injection and ideal placement of the needle tip required for successful ultrasound-guided sciatic popliteal block vary among authors. A hypothesis was made that, when the local anesthetic is injected at the division of the sciatic nerve within the common connective tissue sheath, the block has a higher success rate than an injection outside the sheath.MethodsThirty-four patients scheduled for hallux valgus repair surgery were randomized to receive either a sub-sheath block (n = 16) or a peri-sheath block (n = 18) at the level of the division of the sciatic nerve at the popliteal fossa. For the sub-sheath block, the needle was advanced out of plane until the tip was positioned between the tibial and peroneal nerves, and local anesthetic was then injected without moving the needle. For the peri-sheath block, the needle was advanced out of plane both sides of the sciatic nerve, to surround the sheath. Mepivacaine 1.5% and levobupivacaine 0.5% 30 mL were used in both groups. The progression of motor and sensory block was assessed at 5 min intervals. Duration of block was recorded.ResultsAdequate surgical block was achieved in all patients in the subsheath group (100%) compared to 12 patients (67%) in the peri-sheath group at 30 min. Sensory block was achieved faster in the subsheath than peri-sheath (9.1 ± 7.4 min vs. 19.0 ± 4.0; p < .001).ConclusionsOur study suggests that for successful sciatic popliteal block in less than 30 min, local anesthetic should be injected within the sheath.     

Role of sugammadex in accelerating postoperative discharge: A meta-analysis

Study objectiveSugammadex has been introduced for reversal of neuromuscular blockade (NMB) induced by rocuronium (or vecuronium). Although its efficacy and safety have been established, data are conflicting as to whether it accelerates discharge to the surgical ward compared with neostigmine, which is traditionally used for reversing NMB. The object of this systematic review and meta-analysis was to review the research comparing sugammadex and neostigmine in the context of patient discharge after general anesthesia.DesignSystematic review and meta-analysis.SettingUniversity medical hospital.PatientsFive-hundred eighteen patients from six studies were included.MethodsA comprehensive search was conducted using PubMed, Web of Science, Google Scholar, and Cochrane Library electronic databases to identify randomized controlled trials written in English. Two reviewers independently selected the studies, extracted data regarding postoperative discharge, and assessed the trials' methodological quality and evidence level. Postoperative discharge time was determined from the operating room (OR) to the postanesthesia care unit (PACU) and from the PACU to the surgical ward. This study was conducted using PRISMA methodology.MeasurementsTime to discharge after NMB reversal with sugammadex or neostigmine.Main resultsCompared with neostigmine, sugammadex was associated with a significantly faster discharge from the OR to the PACU (mean difference [MD] = 22.14 min, 95% CI (14.62, 29.67), P < 0.0001, I² = 0%) and from the PACU to the surgical ward (MD = 16.95 min, 95% CI (0.23, 33.67), P = 0.0469, I² = 98.4%). Similarly, discharge-readiness was shorter for sugammadex than for neostigmine from the OR to the PACU (MD = 5.58 min, 95% CI (3.03, 8.14), P ≤ 0.0001, I² = 0%). However, discharge-readiness was similar in both groups for patients moving from the PACU to the surgical ward (MD = − 1.10 min, 95% CI (− 5.69, 3.50), P = 0.6394, I² = 25.3%).ConclusionsResults from this meta-analysis suggest that sugammadex accelerates postoperative discharge of patients after general anesthesia compared with neostigmine.     

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.     

Positron emission tomography/computed tomography guided percutaneous biopsies of Ga-68 avid lesions using an automated robotic arm

PurposeThe purpose of this prospective study was to evaluate the feasibility of positron emission tomography/computed tomography (PET/CT)-guided biopsy of Ga-68 avid lesions using an automated robotic arm and determine the diagnostic yield of this technique.Material and methodsPatients who underwent Ga-68 labelled tracers imaging followed by PET/CT-guided biopsies of tracer-avid lesions were prospectively included. Biopsies were performed using a dedicated automated-robotic-arm assisted PET/CT-guided biopsy device on the same-day of diagnostic PET/CT-imaging. The tissue samples were retrieved after confirming the position of needle-tip in the target lesion. Procedure-related complications and radiation exposure of the interventionist were recorded. Histopathological reports were reviewed for diagnostic yield.ResultsA total of 25 patients (19 men, six women) with a mean age of 50.8 ± 17.3 (SD) years (range: 17-83 years) were included. The biopsies were performed after PET/CT using Ga-68 DOTANOC (n = 16) or Ga-68 PSMA (n = 8) and Ga-68 chemokine-analogue (n = 1). The biopsy samples were obtained from the liver (n = 9), bone (n = 8), lymph-nodes (n = 3), lung (n = 1), pancreas (n = 1), anterior mediastinal lesion (n = 1), peritoneal-deposit (n = 1) and thigh-lesion (n = 1). No immediate or delayed procedure-related complications were documented in any patient. PET/CT-guided molecular sampling was technically successful in all the patients. Histopathology revealed malignancies in all the biopsied specimens without the need for repeat sampling or further invasive-diagnostic workup, with a diagnostic yield of 100%. The estimated absorbed-radiation dose was 566.7 μSv/year for the interventionist.ConclusionPET/CT-guided molecular biopsy using Ga-68 labelled radiotracers is feasible and can be performed safely and accurately with a high-diagnostic yield. It is helpful in accurately staging the disease when tracer-avid isolated distant lesion evident on imaging and highly practical in patients with previous inconclusive sampling.     

Le traitement chirurgical des fractures de l’extrémité supérieure de l’humérus : plaque anatomique versus embrochage en palmier, à propos de 26 cas

BackgroundThe aim of this study is to compare functional and radiological results of two surgical techniques in treatment of proximal humeral fractures.Patients and methodsA prospective study was performed, which included 12 patients operated for a proximal humeral fracture by open reduction and internal fixation using an anatomical humeral plate, and another group of patient (14 patients) treated for the same lesion using a palm tree pinning technique of Kapandji. The comparison of results of the two techniques was based on three parameters: the time of healing, quality of reduction, and the functional result. The global mean age was 48.6 (±13,7), and the sex ratio (M/W) was 1.ResultsStatistical analysis of functional and radiological results showed no superiority of one technique over another; so the mean time of healing was 6.1 (± 0.7) weeks in the group treated by plate, and 6 (± 0.7) weeks in the group treated by pinning (P = 0.5), the mean absolute Constant score was respectively 86 (±10.4) and 90.92 (±2.5) (P = 0.09), and the mean measuring of cephalic angle was respectively 46.91 (±17.68) and 55.71 (±19.48) (P = 0.24).ConclusionUnivariate analysis showed no statistically significant association between endpoints and the two surgical techniques studied. Therefore the study showed no statistical superiority of one surgical technique over another.     

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

Chronic Mycobacterium abscessus infection and lung function decline in cystic fibrosis

BackgroundAlthough nontuberculous mycobacteria (NTM) are recognized pathogens in cystic fibrosis (CF), associations with clinical outcomes remain unclear.MethodsMicrobiological data was obtained from 1216 CF patients over 8 years (481 ± 55 patients/year). Relationships to clinical outcomes were examined in the subset (n = 271, 203 ± 23 patients/year) with longitudinal data.ResultsFive hundred thirty-six of 4862 (11%) acid-fast bacilli (AFB) cultures grew NTM, with Mycobacterium abscessus (n = 298, 55.6%) and Mycobacterium avium complex (n = 190, 35.4%) most common. Associated bacterial cultures grew Stenotrophomonas or Aspergillus species more often when NTM were isolated (18.2% vs. 8.4% and 13.9% vs. 7.2%, respectively, p < 0.01). After controlling for confounders, patients with chronic M. abscessus infection had greater rates of lung function decline than those with no NTM infection (− 2.52 vs. − 1.64% predicted FEV₁/year, p < 0.05).ConclusionsNTM infection is common in CF and associated with particular pathogens. Chronic M. abscessus infection is associated with increased lung function decline.