MRI angiography is superior to helical CT for detection of HCC prior to liver transplantation: an explant correlation

Helical computerized tomography (CT) and magnetic resonance imaging (MRI) are used for staging of hepatocellular carcinoma (HCC) prior to curative treatments but underestimate tumor extension in 30% to 50% of cases when compared with pathologic explants. This study compares a new technology, MRI angiography (MRA), with triphasic helical CT in detection of HCC. Fifty cirrhotic patients, 29 with HCC, undergoing liver transplantation were analyzed. MRA was performed with a 3-D breath-hold fast spoiled gradient-echo sequence by using an effective section thickness of 2 to 2.5 mm. The gold standard was the pathologic examination (liver cut into 5-mm slices). One hundred twenty-seven lesions were identified at the explant: 76 HCC, 13 high-grade dysplastic nodules, 31 macroregenerative nodules, 7 hemangiomas. Diameter of the main HCC nodules was 29 +/- 14 mm and 11 +/- 7 mm for the 47 additional nodules. On a per nodule basis, sensitivity of MRA was superior to CT (58/76 [76%] vs. 43/70 [61%], respectively, P =.001). Sensitivity of MRA for detection of additional nodules decreased with size (>20 mm: 6/6 [100%]; 10-20 mm: 16/19 [84%]; <10 mm: 7/22 [32%]) and was superior to CT for nodules 10 to 20 mm (84% vs. 47%, P =.016). Nonspecific hypervascular nodules >5 mm at MRA were HCC in two thirds of the cases. In conclusion, MRA has a high diagnostic accuracy for HCC > or =10 mm and is more sensitive than triphasic helical CT in nodules sized 10 to 20 mm. MRA is the optimal technique for HCC staging prior to curative therapies.     

Postoperative pain relief in children undergoing tympanomastoid surgery: is a regional block better than opioids?

Peripheral nerve blocks of the surgical site can reduce the need for perioperative opioids thereby decreasing their unwanted adverse effects, such as postoperative nausea and vomiting. In this prospective, randomized, double-blinded study, we examined the efficacy of a great auricular nerve (GAN) block compared with IV morphine sulfate in children undergoing tympanomastoid surgery. After the induction of general anesthesia, children were randomized to receive either a GAN block with 2 mL of 0.25% bupivacaine with epinephrine (1:200,000) and a sham IV injection of 2 mL of saline solution or a sham GAN block with 2 mL of saline solution with an IV injection of 0.1 mg/kg morphine sulfate diluted to 2 mL. Patients' objective pain scores were assessed by a blinded observer and the incidence of vomiting was recorded. The GAN-Block patients as a group required more pain rescue in the postanesthesia care unit; this difference was not statistically different from the IV-morphine group (P = 0.084). Nine GAN-Block patients never received opioid or other analgesics at any time in the first 24 h after surgery. The group that received the GAN block also had a less frequent incidence of vomiting requiring intervention (7 versus 19) during their entire hospitalization or at home (P = 0.027). The GAN-Block group also had more patients who never experienced vomiting (13 of 20 versus 5 of 20, P = 0.026). In this cohort, a peripheral nerve block decreased the overall incidence of postoperative vomiting thereby reducing associated costs. IMPLICATIONS: We prospectively compared the use of a great auricular nerve block versus IV morphine sulfate in a randomized double-blinded study in children undergoing tympanomastoid surgery. Analgesia was comparable between groups but nearly half the Block group never required additional analgesics and the number of vomiting events was nearly 66% less.     

Does a preemptive block of the great auricular nerve improve postoperative analgesia in children undergoing tympanomastoid surgery?

We performed a double-blinded randomized controlled trial to evaluate the efficacy of preemptive analgesia in children undergoing tympanomastoid surgery. Children were divided into two groups: group block-block (BB) received a preemptive great auricular nerve block (GAN-block) with 0.25% bupivacaine with 1:200,000 epinephrine before incision followed by a second GAN-block with 0.25% bupivacaine with 1:200,000 epinephrine 1 h before the end of the procedure. Group sham block-block (SB-B) received a preemptive GAN-block with normal saline before surgical incision followed by a GAN-block with 0.25% bupivacaine with 1:200000 epinephrine 1 h before the completion of the procedure. All patients were evaluated for pain with the objective pain score (OPS) by a blinded observer. There was no difference in pain rescue requirements in the postanesthesia care unit (BB versus SB-B, 1 of 20 versus 3 of 20, P= 0.60) or in the short-stay unit (BB versus SB-B, 5 of 20 versus 11 of 20, P = 0.107) or for the entire hospital stay (P = 0.20). There was no significant difference between groups in the time to first rescue pain medication (BB versus SB-B, 226 +/- 71 min versus 201 +/- 94 min). There was no significant difference between groups regarding vomiting in the postoperative period (P = 0.52). We conclude that a preoperative GAN-block does not offer significant advantages for postoperative pain relief in children undergoing tympanomastoid surgery. IMPLICATIONS: This double-blinded randomized controlled trial compared the efficacy of preemptive analgesia with a peripheral nerve block of the great auricular nerve for decreasing postoperative pain in children undergoing tympanomastoid surgery. Preemptive analgesia did not improve the quality or duration of postoperative analgesia in our cohort.     

Dobutamine-induced eosinophilia

A man with dilated cardiomyopathy presented with decompensated heart failure and marked eosinophilia. After extensive clinical and laboratory evaluation for hypereosinophilic syndrome, including a myocardial biopsy, it was determined by means of rechallenge (second dobutamine infusion) that the patient was afflicted with dobutamine-induced eosinophilia. This report is important because of the high utilization rate of this drug in a sick population. Simply discontinuing it or switching to another agent can avert the high cost and risk of the evaluation for hypereosinophilic syndrome in this compromised group of patients.     

A comparison of flow rates and warming capabilities of the Level 1 and Rapid Infusion System with various-size intravenous catheters

Cases involving massive blood transfusion may require the use of specialized blood warmers, such as the Level 1 (L-1) (Level 1 Technologies, Inc., Rockland, MA) or the Rapid Infusion System (RIS) (Haemonetics Corp., Braintree, MA). In this in vitro study, we compared the infusion and warming capabilities of the L-1 (model 1000) versus the RIS using pediatric- and adult-sized IV catheters. The time to infuse 2 L of lactated Ringer's solution and the end temperature after infusion through 20-, 18-, 16-, and 14-gauge catheters, and 4-, 5-, 6-, 7-, and 8.5-French catheters using both the L-1 and RIS were measured. The flow rates of both systems were similar for 18- and 20-gauge catheters; however, the flow rates with the RIS were progressively faster than the L-1 as catheter size increased to >18 gauge. The heating capabilities of the RIS were superior to the L-1 for all catheters >or=16 gauge. We conclude that the RIS was superior to the L-1 for both flow rates and warming capacity for all IV catheters >18 gauge, i.e., those used for cases with massive blood loss. The RIS provided no advantage (with regard to heating and flow) when used with typical pediatric-sized catheters. IMPLICATIONS: The rapid infusion system is superior to the Level 1 for warming and flow of crystalloid for IV catheters >18 gauge in vitro. The rapid infusion system provides no advantage with catheters typically used in small children (相似文献   

The Role of Nonvitamin K Antagonist Oral Anticoagulants (NOACs) in Stroke Prevention in Patients with Atrial Fibrillation

Anticoagulation is important in stroke prevention in patients with atrial fibrillation. Until recently, heparins and vitamin K antagonists were the only available therapy for stroke reduction in atrial fibrillation (AF) patients. Non-vitamin K antagonist oral anticoagulants (NOACs) including direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) are now available and offer new options for stroke prevention. This article reviews the available data on the use of NOACs for primary and secondary stroke prevention in AF patients and describes specific patient populations to guide clinician in making the informed decision regarding appropriate use of those agents. It also addresses the use of NOACs early after acute stroke and use of thrombolysis while on NOAC.