Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures

Study ObjectiveTo compare isobaric lidocaine and mepivacaine in outpatient arthroscopic surgery.DesignProspective, randomized, double-blinded study.SettingAmbulatory surgery center affiliated with an academic tertiary-care hospital.Patients84 adult, ASA physical status 1, 2, and 3 ambulatory patients, age 18-70 years, undergoing arthroscopic knee surgery.InterventionPatients were randomized to receive a combination spinal-epidural anesthetic using 80 mg of either isobaric 2% mepivacaine or isobaric 2% lidocaine. Patients also received a femoral 3-in-1 block with 0.5% bupivacaine applied to the affected extremity.MeasurementsDemographic data and level and duration of the block were recorded. The use of supplemental epidural anesthesia was noted along with frequency of bradycardia, hypotension, and episodes of nausea and vomiting. Duration of block and times to ambulation and voiding were recorded. Delayed variables, including fatigue, difficulty urinating, back pain, and transient neurologic symptoms (TNS) were obtained.Main ResultsNo demographic differences were noted between groups, and surgical duration was similar. Satisfactory anesthesia was achieved in all cases, with no differences noted in hypotension, bradycardia, nausea, or vomiting. Onset of sensory and motor block was similar. Duration of block before epidural supplementation was 94 ± 21 minutes with lidocaine versus 122 ± 23 minutes for mepivacaine (P < 0.011). Times to ambulation and voiding were longer in patients receiving mepivacaine but did not affect PACU stay. Twenty-four and 48-hour recovery was similar with no TNS symptoms reported.ConclusionNo major differences were noted between lidocaine and mepivacaine spinal anesthesia. Time to ambulation and voiding were longer in patients who received mepivacaine as was time to first dose of epidural catheter. Neither group had TNS symptoms. Lidocaine and mepivacaine are both appropriate spinal anesthetics for ambulatory orthopedic lower extremity procedures.     

Effects of N-acetylcysteine on myoglobinuric-acute renal failure in rats

Oxygen metabolites play an important role in renal injury during myoglobinuric acute renal failure (ARF). This study was designed to determine the protective influence of N-acetylcysteine (NAC), a hydroxyl radical scavenger, and treatment in an experimental model of myoglobinuric-ARF induced by intramuscular injection of hypertonic glycerol in rats. The rats were randomly distributed into five groups: Group 0 (n = 10), was assigned to receive 2mL saline (0,9%) intraperitoneally (ip); Group 1 (n = 10), NAC ip in a dose of 0 mg/100 g of body weight 30 min before the intramuscular (im) injection of 50% glycerol (10 mg/kg); Group 2 (n = 10), received saline 0,9% ip in a equivalent volume of NAC in Group I before the im injection of glycerol; Group 3 (n = 10), received NAC ip in a dose of 10 mg/100 g after im injection of glycerol; Group 4 (n = 10), saline 0,9% ip in a equivalent volume of NAC of the Group 3 after im administration of glycerol. After 24 h rats were sacrificed and kidney morphology and renal function were determined. A severe renal failure was produced by glycerol injection in the Groups 1, 2, 3, and 4, with significant tubular proximal necrosis and cast formation, and creatinine and urea concentrations were elevated in these groups without significant differences among groups, but Group 0 where the values were significantly lower. The results of this study suggests that ip administration of NAC in rats before or after glycerol injection do not confer protection against impairment of renal function under these conditions in this model of myoglobinuric-ARF.     

Nutritional-inflammation status and resistance to erythropoietin therapy in haemodialysis patients.

BACKGROUND: Chronic kidney disease patients who are resistant to erythropoietin (EPO) treatment may suffer from malnutrition and/or inflammation. METHODS: In a cross-sectional study of haemodialysis patients, we investigated the relationship between the natural logarithm of the weekly EPO dose normalized for post-dialysis body weight and outcome measures of nutrition and/or inflammation [BMI, albumin and C reactive protein (CRP)] by means of multiple linear regression analysis. On the basis of the decile distribution of weekly EPO doses, we also evaluated four groups of patients: untreated, hyper-responders, normo-responders and hypo-responders. RESULTS: Six hundred and seventy-seven adult haemodialysis patients were recruited from five Italian centres. BMI and albumin were lower in the hypo-responders than in the other groups (21.3+/-3.8 vs 24.4+/-4.7 kg/m(2), P<0.001; and 3.8+/-0.6 vs 4.1+/-0.4 g/dl, P<0.001), whereas the median CRP level was higher (1.9 vs 0.8 mg/dl, P = 0.004). The median weekly EPO dose ranged from 30 IU/kg/week in the hyper-responsive group to 263 IU/kg/week in the hypo-responsive group. Transferrin saturation linearly decreased from the hyper- to hypo-responsive group (37+/-15 to 25+/-10%, P = 0.003), without any differences in transferrin levels. Ferritin levels were lower in the hypo-responsive than in the other patients (median 318 vs 445 ng/ml, P = 0.01). At multiple linear regression analysis, haemoglobin, BMI, albumin, CRP and serum iron levels were independently associated with the natural logarithm of the weekly EPO dose (R(2) = 0.22). CONCLUSIONS: Our findings support a clear association between EPO responsiveness and nutritional and inflammation variables in haemodialysis patients; iron deficiency is still a major cause of hypo-responsiveness.     

Use of Permacol in complicated incisional hernia

Polypropylene mesh repair is the gold standard for primary inguinal hernia and incisional hernia. Wound infection and small bowel fistulas are contraindications to polypropylene mesh repair. In addition, synthetic meshes are known to cause severe peritoneal adhesions and enteric fistulas if located close to the bowel. Porcine intestinal submucosa has been used successfully in experimental studies in dogs and rats to repair large abdominal wall defects. A new porcine dermal collagen graft has been used in man for groin hernia repair, incisional hernia repair and other surgical procedures without complications. We describe 6 cases of complicated incisional hernia operated in emergency using porcine dermal collagen grafts. In one woman the incisional hernia was associated with an enterovaginal fistula. Three cases presented severe wound infections, two of which related to a previous polypropylene mesh repair, while another had an irreducible recurrent incisional hernia and one woman presented complete evisceration. None of the patients had postoperative or porcine-graft-related complications. Over a follow-up period of 3-24 months we have had no recurrence or wound infection. The results of these few cases confirm the safety and efficacy of the porcine dermal collagen mesh also in incisional hernia repair.     

IgA glomerulonephritis: beyond angiotensin-converting enzyme inhibitors

IgA glomerulonephritis accounts for 25-50% of renal biopsy diagnoses. About 25-50% of patients progress to end-stage renal disease within 20 years of diagnosis. Angiotensin-converting enzyme inhibitors and angiotensin II type I receptor blockers slow progression of IgA nephropathy (IgAN); however, as drugs of this class are not IgAN specific and are therefore unlikely to alter significantly its natural course, many other therapeutic approaches have been proposed. Most have been tested in a relatively small number of patients and have not yet proven to be effective in the long term. Conflicting and variable data, and a lack of long-term prospective randomized studies, mean that most treatments cannot be recommended as standard therapy for IgAN. Steroids seem to be the best treatment for patients with proteinuria, as drugs in this class ameliorate this symptom and protect against deterioration of renal function. Combined treatment with corticosteroids and cytotoxic drugs has yielded interesting results in several studies, especially in progressive patients with severe IgAN. In this review, we critically analyze the data on these treatments.     

Cognitive processing in the aftermath of relationship dissolution: Associations with concurrent and prospective distress and posttraumatic growth

Non‐marital romantic relationship dissolution is amongst the most stressful life events experienced by young adults. Yet, some individuals experience posttraumatic growth following relationship dissolution. Little is known about the specific and differential contribution of trait‐like and event‐specific cognitive processing styles to each of these outcomes. A longitudinal design was employed in which trait‐like (brooding and reflection) and dissolution‐specific (intrusive and deliberate) cognitive processing was examined as predictors of growth (Posttraumatic Growth Inventory) and distress (Breakup Distress Scale) following a recent relationship dissolution. Initially, 148 participants completed measures of trait‐like and dissolution‐specific cognitive processing, growth, and distress (T1). A subsample completed a seven‐month follow‐up (T2). Higher frequency of relationship‐dissolution intrusive thoughts predicted concurrent distress after accounting for brooding and relationship characteristics. Further, higher brooding and lower reflection predicted higher distress prospectively. Concurrent growth was predicted by both higher brooding and more deliberate relationship‐dissolution thoughts. Prospectively, T1 dissolution intrusive thoughts predicted higher T2 deliberate thoughts, and the interaction between these two constructs predicted higher T2 growth. Therefore, deliberately thinking of the dissolution was related to positive psychological outcomes. In contrast, intrusive dissolution cognitions and a tendency for brooding had a mixed (paradoxical) association with psychological adjustment.     

Outcome and management of isolated moderate renal pelvis dilatation detected at postnatal screening

The aim of this study was to evaluate the incidence and outcome of isolated moderate renal pelvis dilatation (RPD) [anterior–posterior diameter (APD) 10–15 mm] in an unselected population of 2-month-old infants prospectively followed for up to 12–14 months of life. Isolated moderate renal pelvis dilatation was detected in 282 of the 11,801 (2.4%), infants screened; 240 infants with normal renal ultrasound were enrolled as the control group. Resolution of RPD was considered when an APD ≤ 5 mm was found on two consecutive sonograms. Urological investigations were initiated if the RPD persisted or if urinary tract infection (UTI) occurred during follow-up, and antibiotic therapy was administered only when UTI occurred. The events of interest were resolution of the RPD, presence of uropathy and UTI. At follow-up, RPD persisted only in 18 infants; of these, four infants were diagnosed with vesicoureteral reflux (grade 1–3) and 14 with ureteropelvic junction obstruction. Of the 223 infants with RPD and 230 control infants who completed follow-up, UTI occurred in 3.6 and 2.5%, respectively. The incidence rate of UTI per 1000 person-months was 5.98 episodes in the patient group and 5.22 episodes in the control group. The rate ratio was 1.146 (95% confidence interval 0.389–3.54, p = 0.8). Our data suggest that isolated moderate RPD is essentially a self-limiting condition and that antibiotic prophylaxis for the prevention of UTI should not be performed. A non-invasive ultrasound scan performed during the follow-up is sufficient to diagnose a potentially dangerous and persistent RPD.     

VAC therapy for the treatment of complex wounds after cardio‐thoracic surgery

The aim of this study is to report our experience about the treatment of complex sternal and thoracic wounds following cardiothoracic surgery, using vacuum‐assisted closure (VAC therapy. Twelve patients presenting with sternal (five cases) and thoracic (seven cases) wounds that were difficult to heal were treated through VAC therapy after the first surgical debridement. The duration of VAC application ranged from 12 to 36 days with an average hospital stay of 24·6 ± 11·4 days. During a mean follow‐up of 12 months, we observed complete wound healing in seven cases (58·3%), in an average period of 25·5 ± 14·3 days; one patient died during follow‐up, two patients were lost to follow‐up and two patients required definitive surgical closure of the wound cavity. In conclusion, VAC therapy promotes faster wound healing, with shorter hospital stay and subsequent lesser in‐hospital cost, reducing the mortality rate in the long run. It also promotes early rehabilitation and alleviates the need for a second procedure, thus improving patient satisfaction, with minimal discomfort or inconvenience.