Comparison of three different volumes of mepivacaine in axillary plexus block using multiple nerve stimulation

Background. The multiple injection technique for axillary block,in which the four distal nerves of the plexus are located bya nerve stimulator and separately injected, has been shown toprovide a high success rate and a short onset time. This randomizeddouble-blind study was conducted to compare the effectivenessof three different volumes of mepivacaine 10 mg ml^–1 inpatients undergoing elective distal upper limb surgery underaxillary brachial plexus block with the four-nerve approach.The number of complete sensory blocks was the primary efficacyvariable. Methods. A total of 114 adult patients were randomly allocatedto receive 36 (n=38), 28 (n=38), and 20 ml (n=38) of mepivacaine10 mg ml^–1. In each group, volumes were equally distributedin the four nerve territories. In all patients, performancetime, latency time, block characteristics, need of supplementaryblocks, tourniquet tolerance, duration of analgesia, and complicationswere recorded. Results. Complete sensory block was obtained in 97% of patientsreceiving a volume of 36 ml, 97% of those receiving 28 ml, and94% of those receiving 20 ml. One patient in the group of 28ml and five patients in the group of 20 ml experienced painon inflation of the tourniquet. Two months after surgery, nocase of postoperative neurological dysfunction was observed. Conclusions. The three volumes (38, 28, and 20 ml) of mepivacaine10 mg ml^–1 ensured a similar and high percentage of completesensory blocks in axillary brachial plexus anaesthesia withnerve stimulation involving the location of four motor responses. Br J Anaesth 2003; 91: 519–24     

Conservative treatment for infiltrating breast cancer: Ten years follow-up experience

Introduction We retrospectively analyze our experience in conservative treatment for infiltrating advanced breast cancer before implementation of selective sentinel node biopsy, specially focusing on characteristics, incidence, treatment and evolution of local-regional recurrences, disease-free survival time, overall survival and patient’s satisfaction. Material and methods From January 1984 to 31^st December 1998, 739 female patients were operated in our institution, diagnosed as having infiltrating breast cancer. One hundred and eighty-eight patients (25.43%) received conservative treatment and they were followed up until December 2003. Results Average age when diagnosed was 50.42 years old (24–87 years). 53.19% of the patients were premenopausal. After a median follow-up of 129 months (60–198 months), 13 women (6.91%) presented local-regional recurrence and the disease-free time was 48.4 months (8–108 months). Global survival rate was 83.5% and disease free survival rate was 80.85%. Conclusions The management of choice for early stage (I and II) infiltrating breast cancer is nowadays conservative, with a low local-regional recurrence rate and survival rate that are comparable to radical mastectomy, according to the literature. It’s a safe and efficient method that let us preserve the breast with a good esthetical result. In selected cases, when a regional recurrence occurs, a second conservative management is possible with a good control of the disease, although the most widely accepted treatment in these cases is total mastectomy.     

Chyle fistula in right cervical area after thyroid surgery

Thoracic duct injury is an infrequent (1-2.5%) but severe complication after neck surgery, leading to nutritional, metabolic and immunologic deficiencies. We report a case of a 34-year-old woman with a right thoracic duct injury after surgery of a thyroid medullar cancer effectively treated with conservative management (parenteral nutrition and intravenous somatostatin). Optimal treatment of these patients is unclear, without a clear limit between conservative and surgical treatment.     

Apparent lack of pharmacological effect of steviol glycosides used as sweeteners in humans. A pilot study of repeated exposures in some normotensive and hypotensive individuals and in Type 1 and Type 2 diabetics

Steviol glycosides, isolated from the plant Stevia rebaudiana (Bertoni) Bertoni, have been used as safe sweetening agents for more than 30 years. Beneficial effects of high doses of steviol glycosides on hyperglycemia and hypertension have been previously described when these abnormalities are present. This study was designed to evaluate the effects of steviol glycosides on blood glucose and on blood pressure (BP) in 3 groups of individuals. This was a randomized, double-blind, placebo-controlled, long-term study in three groups of patients: Group 1: subjects with Type 1 diabetes; Group 2: subjects with Type 2 diabetes; and Group 3: subjects without diabetes and with normal/low-normal BP levels. The subjects in each group were randomly allocated to active treatment (the steviol glycoside stevioside: 250mg t.d.s.) or to placebo treatment and followed-up for 3 months. Post-treatment systolic BP, diastolic BP, glucose and glycated hemoglobin (HbA1c) were not significantly different from baseline measurements, except for the placebo Type 1 diabetics group where a significant difference was observed for systolic BP and glucose. No side effects were observed in the two treatment groups. This study shows that oral steviol glycosides, taken as sweetener are well tolerated and have no pharmacological effect.     

Molecular mechanisms of the diabetogenic effects of arsenic: inhibition of insulin signaling by arsenite and methylarsonous acid

BACKGROUND: Increased prevalences of diabetes mellitus have been reported among individuals chronically exposed to inorganic arsenic (iAs). However, the mechanisms underlying the diabetogenic effects of iAs have not been characterized. We have previously shown that trivalent metabolites of iAs, arsenite (iAs(III)) and methylarsonous acid (MAs(III)) inhibit insulin-stimulated glucose uptake (ISGU) in 3T3-L1 adipocytes by suppressing the insulin-dependent phosphorylation of protein kinase B (PKB/Akt). OBJECTIVES: Our goal was to identify the molecular mechanisms responsible for the suppression of PKB/Akt phosphorylation by iAs(III) and MAs(III). METHODS: The effects of iAs(III) and MAs(III) on components of the insulin-activated signal transduction pathway that regulate PKB/Akt phosphorylation were examined in 3T3-L1 adipocytes. RESULTS: Subtoxic concentrations of iAs(III) or MAs(III) had little or no effect on the activity of phosphatidylinositol 3-kinase (PI-3K), which synthesizes phosphatidylinositol-3,4,5-triphosphate (PIP(3)), or on phosphorylation of PTEN (phosphatase and tensin homolog deleted on chromosome ten), a PIP(3) phosphatase. Neither iAs(III) nor MAs(III) interfered with the phosphorylation of 3-phosphoinositide-dependent kinase-1 (PDK-1) located downstream from PI-3K. However, PDK-1 activity was inhibited by both iAs(III) and MAs(III). Consistent with these findings, PDK-1-catalyzed phosphorylation of PKB/Akt(Thr308) and PKB/Akt activity were suppressed in exposed cells. In addition, PKB/Akt(Ser473) phosphorylation, which is catalyzed by a putative PDK-2, was also suppressed. Notably, expression of constitutively active PKB/Akt restored the normal ISGU pattern in adipocytes treated with either iAs(III) or MAs(III). CONCLUSIONS: These results suggest that inhibition of the PDK-1/PKB/Akt-mediated transduction step is the key mechanism for the inhibition of ISGU in adipocytes exposed to iAs(III) or MAs(III), and possibly for impaired glucose tolerance associated with human exposures to iAs.     

Gender perspective in the analysis of the relationship between long workhours, health and health-related behavior

OBJECTIVES: The objective of this study was to analyze gender differences in the impact of long workhours (>40 hours per week) on a variety of health outcomes and health-related behavior. METHODS: The sample included all salaried contract workers aged 16-64 years (1658 men and 1134 women) and interviewed in the 2002 Catalonian Health Survey. RESULTS: Whereas the men with a high job status were more likely to work >40 hours a week, long workhours were associated with situations of vulnerability (low job status and being separated or divorced) among the women. For both genders, working >40 hours was related to a shortage of sleep [adjusted odds ratio (aOR) 1.54, 95% confidence interval (95% CI) 1.21-1.98, for the men and aOR 1.63, 95% CI 1.11-2.38, for the women]. Among the women, long workhours were also associated with poor mental health status (aOR 1.58, 95% CI 1.04-2.40), hypertension (aOR 2.25, 95% CI 1.17-4.32), job dissatisfaction (aOR 1.77, 95% CI 1.08-2.90), and smoking (aOR 1.71, 95% CI 1.22-2.39). In addition, among the women working more hours at home, long workhours were related to sedentary leisure time activity (aOR 1.98, 95% CI 1.06-3.71). CONCLUSIONS: The relationship between long workhours and health and health-related behavior was found to be directly related to long worktime and indirectly related to long exposure to poor work conditions among the women and, to a less extent, to domestic work. The pathways that explain the relationship between long workhours and health and health-related behavior seems to depend on the outcome being analyzed.     

Nonmetastatic pelvic Ewing sarcoma: report of the French society of pediatric oncology.

BACKGROUND: Since January, 1984, 59 children with histologically confirmed Ewing sarcoma of the pelvic bone have been treated with three successive chemotherapy protocols recommended by the French Society of Pediatric Oncology. The purpose of the current study was to evaluate the role of surgery and/or radiotherapy in local progression-free, disease-free, and overall survivals (LPFS, DFS, and OS, respectively). PROCEDURE: We retrospectively examined 59 children treated for nonmetastatic, pelvic Ewing sarcoma over the last 12 years. All were first treated with chemotherapy according to the current French protocol. Six patients developed progressive disease before local treatment and were excluded for local control and survival analysis. Local treatment was surgery alone in 17 cases, radiation therapy in 27 cases, and surgery plus radiation therapy in 9 cases. RESULTS: With a median of follow-up of 6.5 years, no significant differences in local control or survival were observed with the three chemotherapeutic protocols. Of the 53 patients evaluable for local control, 6 relapsed locally only, 8 had local and distant relapses, and 9 had distant metastases only. The 5-year OS rate was worst for patients with radiotherapy alone compared to those with surgery or combined modality treatment (44 % vs. 72 %, P = 0.043). The 5-year LPFS and DFS rates were worst in the radiotherapy-alone group but not significantly (63% vs. 79%, P = 0. 22 and 42% vs 71%, P =0.07, respectively). The importance of surgery to OS and DFS was confirmed by multivariate analysis (P = 0.026 and P = 0.048, respectively). One surviving patient was diagnosed with in-field fibrosarcoma, which was presumably radiation induced. CONCLUSIONS: Despite intensive, multiagent chemotherapy, survival from pelvic Ewing sarcoma has not improved over the past decade; however, the survival rate does not seem to be worse than that from Ewing sarcoma at other locations, insofar as at least 50% of the patients were cured. Surgery or a combination of surgery and radiation therapy are the best local treatment; exclusive radiation therapy should be reserved for patients with inoperable lesions or partially or nonchemosensitive tumors or when surgery would be an amputation.     

Portal vein thrombosis after laparoscopic splenectomy in benign hematologic diseases

INTRODUCTION: Portal vein thrombosis is an unfrequent, but potentially deadly, complication of the laparoscopic splenectomy procedure. The laparoscopic approach has shortened the duration of hospital stay; portal vein thrombosis may appear after the patient has left the hospital, determining a later diagnosis. Because of the mild, nonspecific symptoms, the diagnosis can even be missed and only achieved when chronic complications take place. OBJECTIVES: In this study, we aimed to determine the appearance of portal vein thrombosis in a consecutive series of patients who underwent laparoscopic splenectomy by performing a contrast-enhanced computed tomography (CT) scan postoperatively. MATERIALS AND METHODS: A transversal study was established, performing in 2005 a contrast-enhanced CT scan on 20 patients who underwent laparoscopic splenectomy between 1999 and 2005 at Ramón y Cajal University Hospital (Madrid, Spain). The presence of thrombosis in the splenoportomesenteric axis was investigated. Results: Two (2) cases (10%) of portal vein thrombosis were detected: 1 symptomatic case, 7 days after surgery, was treated with anticoagulation, resulting in the disappearance of the thrombus in a new CT scan 6 months later; the second case was asymptomatic and was discovered during the performance of this study. CONCLUSIONS: The contrast-enhanced CT scan shows the best accuracy for the diagnosis of portal vein thrombosis, and it must be performed when any clinical manifestation appear; also, it must still be determined if a contrast-enhanced CT scan should be systematically performed in high-risk thromboembolic patients. An ultrasound Doppler may present many diagnostic errors. It is probably advisable to prolong the antithromboembolic prophylaxis.     

Guía Europea de Prevención Cardiovascular en la Práctica Clínica. Adaptación española del CEIPC 2008

The present CEIPC Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care doctors in promoting a healthy life style, based on increasing physical activity, changing dietary habits, and not smoking. The therapeutic goal is to achieve a Blood Pressure<140/90 mmHg, but in patients with diabetes, chronic kidney disease, or definite CVD, the objective is<130/80 mmHg. Serum cholesterol should be<200 mg/dl and cLDL<130 mg/dl, although in patients with CVD or diabetes, the objective is<100 mg/dl (80 mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by body mass index and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin<7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice.