Transient Neurologic Symptoms after Spinal Anesthesia: A Lower Incidence with Prilocaine and Bupivacaine than with Lidocaine

Background: Recent evidence suggests that transient neurologic symptoms (TNSs) frequently follow lidocaine spinal anesthesia but are infrequent with bupivacaine. However, identification of a short-acting local anesthetic to substitute for lidocaine for brief surgical procedures remains an important goal. Prilocaine is an amide local anesthetic with a duration of action similar to that of lidocaine. Accordingly, the present, prospective double-blind study compares prilocaine with lidocaine and bupivacaine with respect to duration of action and relative risk of TNSs.

Methods: Ninety patients classified as American Society of Anesthesiologists physical status I or II who were scheduled for short gynecologic procedures under spinal anesthesia were randomly allocated to receive 2.5 ml 2% lidocaine in 7.5% glucose, 2% prilocaine in 7.5% glucose, or 0.5% bupivacaine in 7.5% glucose. All solutions were provided in blinded vials by the hospital pharmacy. Details of spinal puncture, extension and regression of spinal block, and the times to reach discharge criteria were noted. In the evening of postoperative day 1, patients were evaluated for TNSs by a physician unaware of the drug administered and the details of the anesthetic procedure.

Results: Nine of 30 patients receiving lidocaine experienced TNSs, 1 of 30 patients receiving prilocaine (P = 0.03) had them, and none of 30 patients receiving bupivacaine had TNSs. Times to ambulate and to void were similar after lidocaine and prilocaine (150 vs. 165 min and 238 vs. 253 min, respectively) but prolonged after bupivacaine (200 and 299 min, respectively; P < 0.05).     

Active catabolism of glucocorticoids by 11 beta-hydroxysteroid dehydrogenase in vivo is a necessary requirement for natural resistance to infection with Listeria monocytogenes

The results from the present study demonstrate that the innate defense mechanisms which control the progressive growth of Listeria monocytogenes in normal animals in vivo are dependent upon the active catabolism of endogenous glucocorticoids by the enzyme 11 beta- hydroxysteroid dehydrogenase (11 beta-HSD). When 11 beta-HSD activity was pharmacologically inhibited in vivo, host susceptibility to progressive bacterial disease was markedly increased. Depressed natural resistance following 11 beta-HSD inhibition correlated with changes in the patterns of inducible cytokines by macrophages and T cells. Similar changes were observed when normal adult animals were treated with low doses of dexamethasone prior to experimental infection with Listeria.      

Reactive perforating collagenosis associated with scabies in a diabetic

Reactive perforating collagenosis (RPC) in adults commonly manifests in patients with diabetes mellitus. Pruritus and consequent induced scratching have been identified as the bases for the evolution of this skin disease. We present the unusual case of a 55-year-old female diabetic with characteristic umbilicated skin lesions and a long history of scabies. Histology from a crusty nodule revealed transepidermal elimination of collagen. Following antiscabietic treatment, two courses of oral doxycycline demonstrated beneficial effects in controlling the perforating skin disorder.     

Comparison of intracellular bactericidal activities of human neutrophils and eosinophils

Eosinophils from a patient with hypereosinophilia were observed to phagocytize radiolabeled E. coli or S. aureus as effectively as neutrophils from a normal control. This was observed at a number of bacteria/cell ratios and a various time intervals following initial challenge and was confirmed by direct microscopic examination. In spite of comparables rates of phagocytosis, the eosinophils were consistently less capable of killing the bacteria. This correlates with an inability of eosinophil peroxidase to catalyze the peroxidase-H2O2-CI--mediated decarboxylation of amino acids; in contrast, both eosinophil and neutrophil peroxidases showed similar capabilities to iodinate protein in vitro. These data are compatible with the importance of the chloride- mediated mechanism in the bactericidal activity of intact phagocytes.     

Cutaneous non‐tuberculous Mycobacterial infections: a clinical and histopathological study of 17 cases from Lebanon

Background Only a few studies characterized cutaneous non‐tuberculous Mycobacterium (NTM) infections in this region of the world . Objective The aim of this study was to describe the epidemiological, clinical and histological findings of cutaneous NTM infections in Lebanon. Patients/Methods Retrospective study of 17 patients (19 histological specimens) diagnosed with cutaneous NTM infections and confirmed by culture‐based partial sequencing of the 16S rRNA gene at the American University of Beirut Medical Center between 2005 and 2008. Results Of 17 cases, 14 were caused by Mycobacterium marinum. All patients were immunocompetent except for one. Clinically, the most common presentation was multiple sporotrichoid lesions over an extremity (8/17). Many patients had peculiar presentations including bruise‐like patches, herpetiform lesions, annular ulcerated plaques, symmetrical nodules over the buttocks and locally disseminated lesions with surrounding pale halo. Almost all patients cleared their infection on either minocycline or clarithromycin monotherapies. Histologically, a dermal small vessel proliferation with mixed inflammation (granulation tissue‐like changes) was identified in 58% of specimens. The most common type of granulomatous inflammation was the suppurative (47%) followed by the tuberculoid (30%), sarcoidal (11%), and palisading (5%) types. Lichenoid granulomatous dermatitis was noted in 42% of cases. Special staining highlighted mycobacteria in only two specimens. Conclusions The incidence of cutaneous NTM infections is high in our area. Many patients had peculiar clinical presentations. Our study is the second to report the common presence of granulation tissue‐like changes as a good histological indicator of cutaneous NTM infections. Minocycline and clarithromycin remain the drugs of choice in our area.     

Peripheral nerve block at the elbow and wrist

Wrist and elbow blocks are used to provide anaesthesia and analgesiafor hand and forearm surgery. They may be used to supplementa brachial plexus block or to provide perioperative analgesiaafter a regional or a general anaesthetic. Wrist or elbow blocksalone may be used to provide anaesthesia for minor hand procedures;thus, sparing the patient the complications of general anaesthesiaand providing excellent postoperative analgesia with a reducedrequirement for opioid analgesics.¹ Proximal brachial plexusblock is associated with more motor block, but will providepartial or complete tourniquet anaesthesia. Therefore, solereliance on peripheral arm blocks can only be advocated in proceduresthat do not require a tourniquet or last approximately <20min.²