Intercostal nerve blockade with liposomal bupivacaine reduces length of stay after video assisted thoracic surgery (VATS) lobectomy

BackgroundIntercostal nerve blockade (INB) for thoracic surgery analgesia has gained popularity in practice, but evidence demonstrating its efficacy remains sparse and inconsistent. We investigated the effect of INB with standard bupivacaine (SB) with epinephrine versus liposomal bupivacaine (LB) versus a mixed solution of the two on postoperative pain control and outcomes in video assisted thoracoscopic lobectomy patients.MethodsSince 2014, our practice has shifted from using INBs with SB with epinephrine, to LB, to a mix of the two as the central component of multimodal analgesia after video assisted thoracoscopic surgery. The blocks are performed in a standardized fashion under thoracoscopic visualization consecutively from two rib spaces above to two below the outermost incisions. We retrospectively compared all minimally invasive lobectomies performed at our institution between January 2014 and July 2018 by type of local anesthetic used for INB. We examined median length of stay (LOS), opioid utilization, and subjective pain scores [0–10].ResultsOut of 302 minimally invasive lobectomy patients, 34 received SB with epinephrine, 222 received LB alone, and 46 received the mixed solution. LOS was almost a full day shorter in the LB group than in the SB group (34.8 vs. 56.5 hours, P=0.01). There was nearly 25% lower median total morphine equivalent utilization in the mixed solution cohort compared to the LB cohort (−7.1 mg, P=0.02). Additionally, IV morphine equivalent utilization was over 50% lower in the mixed solution group than in the SB with epinephrine group (−10.0 mg, P=0.03).ConclusionsOur study is by far the largest (N=302) to compare types of local anesthetic used for INB within a uniform case population. The reductions in LOS and opiate utilization observed in our study among patients receiving LB-based formulations were both statistically and clinically significant.     

Mediation of serotonin-induced analgesia by the 5HT2 receptor in the pentobarbital anesthetized mouse model

Serotonin can induce analgesia when injected directly into the brain, but analgesia after peripheral administration has been more difficult to show. The pentobarbital anesthetized mouse (PAM) model, developed to alleviate some of the problems involved in the measurement of tail flick latency, was used to assess the action of peripherally administered serotonin. Mice were anesthetized with about 65 mg/kg of sodium pentobarbital IP and their tail flick latencies measured while they were in stage III anesthesia. In these anesthetized mice, IP serotonin induced a significant analgesia that was much more robust than that found in awake mice. The analgesic effect was dose-dependent from 0.25 mg/kg to 10 mg/kg but was not blocked by the antiopiate naltrexone. Of several psychotropic agents tested, only amitriptyline, mianserin, and trazodone had significant effects on analgesia in the PAM model. The analgesic effect of serotonin was reproduced by the 5HT2 agonist DOI and totally blocked by the 5HT2 antagonist NPP. These results show the utility of the PAM model in studying nonopiate analgesia and suggest that the analgesic action of serotonin is mediated primarily through the 5HT2 receptor.     

小儿淋巴管瘤的MRI诊断

目的分析小儿淋巴管瘤的磁共振表现及其病理基础。方法对６例经手术病理证实的、年龄７天至７岁的小儿淋巴管瘤患者的磁共振表现进行回顾性分析。结果淋巴管瘤磁共振表现为Ｔ１ＷＩ上呈与肌肉相似或稍高的信号，Ｔ２ＷＩ上高于脂肪信号。５例瘤内可见低信号分隔，１例瘤内见血管流空影，３例见明显包膜，３例边界不清。２例病理诊断为海绵状淋巴管瘤，４例诊断为囊状淋巴管瘤。结论磁共振成像可较好地显示肿瘤的大小、形态及范围，从而指导手术治疗。     

Balo病同心圆硬化的MRI分析

目的：探讨Balo病同心圆硬化（BCS）的磁共振表现特征及其病理基础.方法：回顾性分析4例Balo病同心圆硬化患者的MRI表现,均经激素治疗临床症状好转后行MRI复查.结果：4例患者中,1例单发,3例多发,最多者病灶5个.病变主要累及大脑半球皮层下和深部白质区,共发现11个病灶,其中顶叶半卵圆中心和颞叶的发病比例高.典型同心圆样病灶8个,直径1～2.3cm,同心圆层数为3～5个.在T1WI加权像呈等、低信号相间;T2WI,FLAIR像上呈等、高信号交替环,病灶周围有轻度水肿表现,上述表现与镜下脱髓鞘区与髓鞘保留区相间相对应.其余3个不典型的病灶呈斑片状或煎蛋样改变;增强后1例病灶呈点状或边缘线状强化.结论：Balo病同心圆性硬化的MRI及其增强扫描具有特征性表现,可作为本病诊断的主要方法,并可用于疗效的观察.     

From the Cover: Exploiting olfactory learning in alien rats to protect birds’ eggs

Predators must ignore unhelpful background “noise” within information-rich environments and focus on useful cues of prey activity to forage efficiently. Learning to disregard unrewarding cues should happen quickly, weakening future interest in the cue. Prey odor, which is rapidly investigated by predators, may be particularly appropriate for testing whether consistently unrewarded cues are ignored, and whether such behavior can be exploited to benefit prey. Using wild free-ranging populations of black rats, Rattus rattus, an alien predator of global concern, we tested whether the application of bird-nesting odors before the introduction of artificial nests (odor preexposure), enhanced the survival of birds eggs (prey) compared with areas where prey and nesting odors were introduced concurrently. In areas where predators had encountered prey odor before prey being available, the subsequently introduced eggs showed 62% greater survival than in areas where prey and odor were introduced together. We suggest that black rats preexposed to prey odor learned to ignore the unrewarding cue, leading to a significant improvement in prey survival that held for the 7-d monitoring period. Exploiting rapid learning that underpins foraging decisions by manipulating sensory contexts offers a nonlethal, but effective approach to reducing undesirable predatory impacts. Techniques based on olfactory preexposure may provide prey with protection during critical periods of vulnerability, such as immediately following a prey reintroduction. These results also highlight the potential benefits to species conservation to be gained from a greater understanding of the cognitive mechanisms driving alien predator behavior within ecological contexts.     

Nutritional status of elderly trauma patients presenting to a South Dublin Teaching Hospital

BackgroundIt has been hypothesised that elderly orthopaedic trauma patients may be malnourished when compared to the general population. We conducted an observational study to identify if this was the case.MethodsThirty elderly trauma patients (≥ 65 years) admitted to the orthopaedic unit were recruited. Serum markers (albumin, urea, creatinine, sodium, potassium, haemoglobin, white cell count, platelets, lymphocytes, C-reactive protein, magnesium, calcium) anthropometric measurements (triceps skin-fold thickness, mid-arm circumference, body mass index) and short form mini-nutritional assessment (MNA-SF^®) were carried out at presentation and at 3 months postoperation. Serum markers were also repeated at day 1 and day 3 postoperation.ResultsSixty percent had an initial mini-nutritional assessment (MNA-SF^®) score of less or equal to 11 points indicating that they were at risk from possible malnutrition. However, median BMI at presentation was normal at 22.79 kg/m² (WHO guidelines) (Interquartile range [IQR] 19.8–28). Interestingly, a higher proportion of the group (67%) were below the 50th centile for age related BMI centiles. At follow-up (15 patients), there was no significant difference in anthropometric measures. The mean MNA-SF^® had increased, but not significantly (P = 0.121).ConclusionsIt could be extrapolated from this study that elderly trauma patients may be at risk of malnutrition regardless of their BMI at presentation and should be screened using validated nutrition screening tools and monitored. The use of age specific centiles is also recommended. Further research is needed using larger sample sizes to confirm these findings.