The addition of clonidine 15 micro g to 6 mg of hyperbaric bupivacaine increases the spread of analgesia, prolongs the time to first analgesic request, and decreases postoperative pain, compared with bupivacaine alone, during inguinal herniorrhaphy under spinal anesthesia.

Introduction: Catheter ablation of atrial fibrillation (AF) has become an established therapy in the management of symptomatic AF. This systematic review aims to consolidate data of published literature to determine the frequency of acute complications of this procedure, and identify procedural predictors of adverse events.Methods: Databases were searched for English studies published up to 18th June 2012. 2065 references were evaluated for relevance by two independent reviewers. Reference lists of retrieved studies and pertinent review articles were also examined to ensure all relevant studies were included. Data was extracted from 192 studies, including a total of 83,236 patients.Results: The overall incidence of peri-procedural complications was 2.90% (95% CI, 2.60-3.22). There was a significant decrease in the acute complication rate over the last six years, 2007-2012, compared to the preceding six years, 2000-2006 (2.62% versus 4.01%, P = 0.003). The complication rate reported was higher in studies that prospectively defined complications they would identify, compared with studies that only retrospectively listed complications found (3.49% vs 2.70%, P = 0.028). No significant association was found between total procedure duration, radiofrequency energy application time, or the type of ablation strategy employed, and the acute complication rate.Conclusions: The acute complication rate of catheter ablation of AF has decreased significantly in recent years. This may reflect improved catheter technology and increased experience. The current use of different strate-gies across cardiovascular centers worldwide appears to be safe with no established relationship between the procedural variables studied and the complication rate. http://dx.

C atheter ablation of atrial fibrillation (AF) is an established rhythm control strategy in symptomatic AF. [1][2][3][4] The procedure aims to eliminate triggers and substrate that initiate, perpetuate, and sustain AF. Because catheter technology improves and experience increases, wider inclusion criteria are being used to select patients. Indeed, selected patients may benefit from ablation as first-line therapy. 5 A recent study reporting the outcomes of 2 meta-analyses found a 77% success rate for catheter ablation versus 52% for antiarrhythmic drugs. 6 Several randomized controlled trials have reported similar results.6-10 A meta-analysis of 4 of these studies found a >3.7-fold probability of freedom from AF with ablation compared with medical therapy. 11 Clinical Perspective on p 1088Catheter ablation can be associated with significant complications. Safety data reported from high-volume single-center series and the results of a recent international survey are inconsistent with regards to the incidence of acute complications ranging from <1% to 6%. [12][13][14][15][16][17] Furthermore, few studies have investigated the relationship between procedural variables and the complication rate. These have been limited to single-center series where low event rates have limited the identification of statistically significant predictors, and the applicability of results to other treatment settings is unclear.12, [14][15][16]18 The purpose of this review was to determine the incidence, temporal trends, and procedural predictors of complications associated with catheter ablation of AF. MethodsA literature search of the electronic databases, MEDLINE and EMBASE, was conducted on 18th June 2012 to identify all relevant studies describing complications of catheter ablation of AF. A detailed search methodology is presented in the online-only Data Supplement. This was supplemented by hand-searching bibliographies of retrieved articles as well as relevant review articles. Study SelectionStudies were eligible for the review if the participants were adults with symptomatic AF undergoing catheter ablation, and if complications were reported. Studies with both prospective and © 2013 American Heart Association, Inc. Gupta et al Complications of AF Ablation 1083retrospective designs were included. Abstracts, case reports, editorials, comments, conference proceedings, meta-analyses, and review articles were excluded. Studies involving surgical ablation, atrioventricular nodal ablation, exclusive right atrial ablation, or ablate-and-pace strategies were excluded. Animal and in vitro studies, as well as studies in languages other than English, were also excluded. Studies were included if there were ≥100 patients in the treatment arm. This minimum number was chosen to increase the likelihood of retrieving the best quality studies, as well as to exclude case reports and small series. These may have otherwise misrepresented the true incidence of rare adverse events by selectively reporting these cases in often niche patient subgroup...

Perineural invasion (PNI) occurring in non-melanoma skin cancers (NMSC) is associated with an increased risk of locoregional recurrence and reduced disease-free survival. This necessitates early and accurate diagnosis, appropriate risk-stratification and a clear management strategy. The diagnosis of PNI is based on careful clinical assessment, imaging and histopathology. Surgery, preferably with margin control, and definitive or adjuvant radiotherapy (ART) are established treatment strategies for PNI. Clinical uncertainty remains over the role of ART in incidental PNI. This review synthesises current literature to ascertain which clinicopathological features impart a higher risk to individuals with PNI in NMSC, in order to provide treatment algorithms, including the identification of patient subsets that are most likely to benefit from ART. This includes those with extratumoural PNI, involvement of larger-calibre nerves, tumour invasion beyond dermis, recurrent tumour or diffuse intratumoural spread. Patients with clinical PNI may be optimally managed by a multidisciplinary head and neck cancer service that is best placed to offer skull base surgery and intensity-modulated radiation therapy (IMRT). The management options presented are stratified by histological subtype and a new classification of PNI into low-risk, medium-risk and high-risk groups.

Originally published by BMJ -

Intraoperative bleeding causing poor visibility of surgical field is of major concern during functional endoscopic sinus surgery (FESS) and impaired visibility may result in many complications. The study aimed to compare surgical conditions for FESS during controlled hypotension provided by esmolol or nitroglycerine (NTG) under general anaesthesia. 52 adult patients of both sexes requiring FESS under general anaesthesia were randomly divided to receive either esmolol (group ESM, n = 26) or NTG (group NTG, n = 26) to provide controlled hypotension. Surgical condition was assessed by surgeon using average category scale (ACS) of 0-5, a value of 2-3 being ideal. In both groups mean arterial blood pressure (MABP) was gradually reduced till ACS for assessment of surgical condition (ACS) of 2-3 or lowest targeted MABP (60 mm of Hg) was achieved. Both the drugs produced desired hypotension and improved surgical condition by reducing operative field bleeding but ideal operative conditions were achieved at mild hypotension (MABP 75-70) in ESM group while same conditions were achieved at MABP of 69-65 mm of Hg in NTG group. Mean heart rate was significantly higher in NTG group as compared to ESM group. Blood loss was significantly less in ESM group. Both NTG and esmolol can be used safely to provide controlled hypotension during FESS. Both the drugs improved visibility of surgical field by reducing capillary bleeding. But esmolol offered better operative conditions with only minimal reduction in MABP. No reflex tachycardia and less intraoperative haemorrhage were additional advantages of esmolol.

Aims to compare the efficacy of Proseal laryngeal mask airway(PLMA) and endotracheal tube (ETT) in patients undergoing laparoscopic surgeries under general anaesthesia. This prospective randomised study was conducted on 60 adult patients, 30 each in two groups, of ASA I-II who were posted for laparoscopic procedures under general anaesthesia. After preoxygenation, anaesthesia was induced with propofol, fentanyl and vecuronium. PLMA or ETT was inserted and cuff inflated. Nasogastric tube (NGT) was passed in all patients. Anaesthesia was maintained with N2 O, O2, halothane and vecuronium. Ventilation was set at 8 ml/kg and respiratory rate of 12/min. The attempts and time taken for insertion of devices, haemodynamic changes, oxygenation, ventilation and intraoperative and postoperative laryngopharyngeal morbidity (LPM) were noted. There was no failed insertion of devices. Time taken for successful passage of NGT was 9.77 s (6-16 s) and 11.5 s (8-17 s) for groups P and E, respectively. There were no statistically significant differences in oxygen saturation (SpO2) or end-tidal carbon dioxide (EtCO2) between the two groups before or during peritoneal insufflation. Median (range) airway pressure at which oropharyngeal leak occurred during the leak test with PLMA was 35 (24-40) cm of H2O. There was no case of inadequate ventilation, regurgitation, or aspiration recorded. No significant difference in laryngopharyngeal morbidity was noted. A properly positionedPLMA proved to be a suitable and safe alternative to ETT for airway management in elective fasted, adult patients undergoing laparoscopic surgeries. It provided equally effective pulmonary ventilation despite high airway pressures without gastric distention, regurgitation, and aspiration.

These results are a compelling impetus to improve current standards of dermatology teaching, learning and assessment. The introduction of a national core curriculum would provide guidelines for dermatology teaching in medical schools, enabling the more effective utilisation of available time for key learning outcomes.