Brachial Plexus Nerve Block Exhibits Prolonged Duration in the Elderly

Background: Upper limb trauma occurs frequently in elderly patients for whom peripheral nerve blocks are often preferred for anesthesia. The characteristics of such regional blocks have, however, never been described in an elderly population. Therefore, the authors assessed prospectively the onset and duration of upper extremity peripheral nerve block (the mid-humeral block) in elderly and young patients undergoing emergency upper extremity surgery.

Methods: Consecutive patients aged > 70 yr or < 70 yr received a mid-humeral block with a small volume of ropivacaine, 0.75%. Five milliliters was injected onto each of the musculocutaneous, radial, ulnar, and median nerves. Time to complete sensory and motor block and durations of complete sensory and motor block were assessed. Results are shown as median and its 95% confidence interval.

Results: Median ages were 77 yr (95% CI, 72-81 yr) and 39 yr (95% CI, 27-46 yr) in the two groups. Both groups had similar times to complete sensory blockade. The elderly group had longer durations of complete sensory (390 min [range, 280-435 min]vs. 150 min [range, 105-160 min];P < 0.05) and motor (357 min [range, 270-475 min]vs. 150 min [range, 90-210 min];P < 0.05) blockade. Duration of complete sensory block was significantly correlated with age ([rho] = 0.56;P < 0.05).     

Emergency gum elastic bougie-assisted tracheal intubation in four patients with upper airway distortion

PURPOSE: The gum elastic bougie (GEB) has been in use for a long time and allows tracheal intubation in most cases of difficult direct laryngoscopy. Use of the GEB when anatomical landmarks of the upper airway are not recognizable has not been reported. We describe our experience of airway management with the GEB in cases of severe upper airway distortion. CLINICAL FEATURES: Four patients with severe respiratory distress caused by upper airway distortion secondary to various non-malignant causes were managed with the GEB. For these four patients, a rapid sequence induction of anesthesia was performed with a surgeon present during the procedure. The GEB was used as the initial intubating technique in all cases and allowed a rapid and successful tracheal intubation in spite of non-recognizable anatomical structures. The distal hold-up feeling after GEB insertion confirmed, in all cases, the correct intratracheal position of the GEB. CONCLUSION: The GEB can be a valuable tool in cases of difficult airway management caused by upper airway distortion. The lack of visualization of normal pharyngeal structures did not prevent the successful insertion of the GEB in the trachea in the four patients reported.     

Clinical reactivation after liver transplantation with an unusual minor strain of hepatitis B virus in an occult carrier.

Hepatitis B virus (HBV) DNA is detectable in a number of liver transplant candidates who are negative for hepatitis B surface antigen (HBsAg). After liver transplantation (LT), such patients may have molecular and/or serologic evidence of HBV replication. However, clinical disease from reactivation of occult HBV infection after LT has not been described. We report a patient who underwent LT for cryptogenic cirrhosis and had to be retransplanted twice for hepatic artery thrombosis. The patient was negative for HBsAg and positive for anti-hepatitis B core (HBc) and anti-HBs before all LT procedures and developed acute hepatitis B shortly after receiving the third graft. The HBV strain isolated at that time exhibited an unusual in frame insertion of a CAG motif within the HBV polymerase (HBV(INS+)). HBV(INS+) was detected retrospectively as a minor species in pretransplantation sera and the explanted native liver by insertion-specific polymerase chain reaction. This case in an occult HBV carrier shows that clinically apparent, endogenous reinfection of the graft may occur with minor HBV variants that are not detectable in pretransplantation samples by standard diagnostic procedures. This has implications for the analysis of sources of acute hepatitis B in patients after LT and possibly for consideration of antiviral prophylaxis in anti-HBc/anti-HBs/HBV DNA-positive patients.     

Leakage of 4 resin-based root-canal sealers used with a single-cone technique.

OBJECTIVE: The aim of this study was to measure leakage of 4 resin-based sealers. STUDY DESIGN: Four groups of premolars (n = 60) were prepared using GT Rotary files and the crown-down technique and filled by the single-cone technique with AH26, AHPlus, EndoREZ, and an experimental MBP as sealer. Leakage was measured using the fluid filtration method after 15, 30, and 60 days and determined as microL/min(-1) x 10 psi. RESULTS: Statistical analysis by ANOVA and Tukey HSD test indicated that root fillings with AH Plus and the MBP showed lower leakage values after 15 days (P < .05). At 30 days, AH26 presented higher leakage values when compared to other sealers (P < .05). At 60 days, MBP and AH Plus presented the lower leakage values, differing significantly from EndoREZ (P < .05). CONCLUSION: It was observed that AH Plus and the experimental MBP showed lower leakage after 60 days than AH 26 and EndoREZ.     

Visualization of maturation of the corpus callosum during childhood and adolescence using T2 relaxometry

Previous studies have shown that maturation of the white matter in terms of its relative signal intensity changes on MRI is almost complete at 2-3 years of age. We hypothesized that quantitative analysis may show maturation of the white matter during childhood and adolescence. In the present study we performed multi-echo T2 relaxometry in 33 healthy subjects (girls, 15; boys, 18) aged 3-15 years. T2 relaxation times of the genu and splenium were measured. In healthy subjects, the T2 relaxation times were significantly correlated with age in both girls (r=0.611, p=.016) and boys (r=0.721, p=.001) in the splenium, but not in the genu (p>.05). To further confirm genu-to-splenium signal intensity ratio changes, a total of 389 brain MRIs were retrospectively selected from the patients who had normal results (189 girls/women, 200 boys/men; age range, 3-20 years). The genu-to-splenium signal intensity ratio was obtained from the T2-weighted images. In patients with normal MRI, the genu-to-splenium signal intensity ratio was significantly decreased with age (p<.001) by 16 years. The T2 relaxation times gradually increase in the splenium during childhood and adolescence, suggestive of maturation.