Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background The ideal location for single-injection adductor canal block that maximizes analgesia while minimizing quadriceps weakness after painful knee surgery is unclear. This triple-blind trial compares ultrasound-guided adductor canal block injection locations with the femoral artery positioned medial (proximal adductor canal), inferior (mid-adductor canal), and lateral (distal adductor canal) to the sartorius muscle to determine the location that optimizes postoperative analgesia and motor function. The hypothesis was that distal adductor block has (1) a superior opioid-sparing effect and (2) preserved quadriceps strength, compared with proximal and mid-locations for anterior cruciate ligament reconstruction. Methods For the study, 108 patients were randomized to proximal, mid-, or distal adductor canal injection locations for adductor canal block. Cumulative 24-h oral morphine equivalent consumption and percentage quadriceps strength decrease (maximum voluntary isometric contraction) at 30 min postinjection were coprimary outcomes. The time to first analgesic request, pain scores, postoperative nausea/vomiting at least once within the first 24 h, and block-related complications at 2 weeks were also evaluated. Results All patients completed the study. Contrary to the hypothesis, proximal adductor canal block decreased 24-h morphine consumption to a mean ± SD of 34.3 ± 19.1 mg, (P < 0.0001) compared to 64.0 ± 33.6 and 65.7 ± 22.9 mg for the mid- and distal locations, respectively, with differences [95% CI] of 29.7 mg [17.2, 42.2] and 31.4 mg [21.5, 41.3], respectively, mostly in the postanesthesia care unit. Quadriceps strength was similar, with 16.7%:13.4%:15.3% decreases for proximal:mid:distal adductor canal blocks. The nausea/vomiting risk was also lower with proximal adductor canal block (10 of 34, 29.4%) compared to distal location (23 of 36, 63.9%; P = 0.005). The time to first analgesic request was longer, and postoperative pain was improved up to 6 h for proximal adductor canal block, compared to mid- and distal locations. Conclusions A proximal adductor canal injection location decreases opioid consumption and opioid-related side effects without compromising quadriceps strength compared to mid- and distal locations for adductor canal block in patients undergoing anterior cruciate ligament reconstruction.
Extended abdominoplasty is a safe procedure with highly satisfactory results that should become common practice in plastic surgery. There is a group of patients who are best served by this procedure and a new classification system of the abdominal contour deformities that includes these patients is needed and is proposed by the authors.
ObjectivesFrom the first description by Leo Kanner [1], autism has been an enigmatic neurobehavioral phenomenon. The new genetic/genomic technologies of the past decade have not been as productive as originally anticipated in unveiling the mysteries of autism. The specific etiology of the majority of cases of autism spectrum disorder (ASD) is unknown, although numerous genetic/genomic variants and alterations of diverse cellular functions have been reported. Prompted by this failure, we have investigated whether the metabolomics approach might yield results which could simultaneously lead to a blood-based screening/diagnostic test and to treatment options. Methods Plasma samples from a clinically well-defined cohort of 100 male individuals, ages 2-16+ years, with ASD and 32 age-matched typically developing (TD) controls were subjected to global metabolomic analysis. ResultsWe have identified more than 25 plasma metabolites among the approximately 650 metabolites analyzed, representing over 70 biochemical pathways, that can discriminate children with ASD as young as 2 years from children that are developing typically. The discriminating power was greatest in the 2-10 year age group and weaker in older age groups. The initial findings were validated in a second cohort of 83 children, males and females, ages 2-10 years, with ASD and 76 age and gender-matched TD children. The discriminant metabolites were associated with several key biochemical pathways suggestive of potential contributions of increased oxidative stress, mitochondrial dysfunction, inflammation and immune dysregulation in ASD. Further, targeted quantitative analysis of a subset of discriminating metabolites using tandem mass spectrometry provided a reliable laboratory method to detect children with ASD. Conclusion Metabolic profiling appears to be a robust technique to identify children with ASD ages 2-10 years and provides insights into the altered metabolic pathways in ASD, which could lead to treatment strategies. ObjectivesTo uncover novel traits associated with nicotine and alcohol use genetics, we performed a phenome-wide association study in a large multi-ethnic cohort. Methods We investigated 7,688 African-Americans (AFR), 1,133 Asian-Americans (ASN), 14,081 European-Americans (EUR), and 3,492 Hispanic-Americans (HISP) from the Women's Health Initiative, analyzing risk alleles located in the CHRNA5-CHRNA3 locus (rs8034191, rs1051730, rs12914385, rs2036527, and rs16969968) for nicotine-related traits and ADH1B (rs1229984 and rs2066702) and ALDH2 (rs671) for alcohol-related traits with respect to anthropometric characteristics, dietary habits, social status, psychological circumstances, reproductive history, health conditions, and nicotine-and alcohol-related traits. ResultsThe investigated loci resulted associated with novel traits: rs1229984 were associated with family income (p=4.1*10 −12 ), having a pet (p=6.5*10 −11 ), partner education (p=1.8*10 −10 ), "usually expect the best" (p=2.4*10 −7), "felt calm and peaceful" (p=2.6*10 ), and num...
BackgroundInjection pressure monitoring using in-line devices is affordable and easy to implement into a regional anesthesia practice. However, solid evidence regarding their performance is lacking. We aimed to evaluate if opening injection pressure (OIP), measured with a disposable in-line pressure monitor, can prevent intraneural (subepineural) injection using 15 pound per square inch (PSI) as the reference safety threshold.MethodsAn isolated nerve model with six tibial and six common peroneal nerves from three unembalmed fresh cadavers was used for this observational study. A mixture of 0.5% ropivacaine with methylene blue was injected intraneurally at a rate of 10 mL/min, to a maximum of 3 mL. OIP was recorded for each injection as well as evidence of intraneural contrast. Injected volume at 15 and 20 PSI was recorded, and when it leaked out the epineurium, if it occurred.ResultsIn all cases, OIP was<15 PSI and intraneural contrast was evident before the safety threshold. The 15–20 PSI mark was attained in 5 of 12 injections (41%), with a median injected volume of 0.9 mL (range 0.4–2.3 mL). Peak pressure of >20 PSI was reached in two injections (at 0.6 mL and 2.7 mL). Contrast leaked out the epineurium in 11 of 12 injections (91%) with a median injected volume of 0.6 mL (range 0.1–1.3 mL).ConclusionsOur results suggest that in-line pressure monitoring may not prevent intraneural injection using an injection pressure of 15 PSI as reference threshold. Due to the preliminary nature of our study, further evidence is needed to demonstrate clinical relevance.
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Genicular nerves block is a promising technique to treat acute postoperative pain in total knee arthroplasty. Similar to surgeon-administered local infiltration analgesia, it targets sensory branches from the knee capsule, but through a selective ultrasound-guided injection that reduces local anaesthetic dose (150 ml ropivacaine 0.2% with local infiltration analgesia vs. 20 ml with genicular nerves block). This randomised non-inferiority trial compared the analgesic efficacy of genicular nerves block vs. local infiltration analgesia in the first 24 h following total knee arthroplasty. Sixty patients were randomly allocated to receive either ultrasound-guided block of five genicular nerves or local infiltration analgesia. The primary outcome was rest pain numeric rating scale (0-10) at 24 h. Secondary outcomes included pain numeric rating scale (rest and movement) and cumulative opioid consumption during the first 24 h. We analysed 29 patients in the genicular nerves block group and 30 in the local infiltration analgesia group. We found that the median difference (95%CI) in postoperative rest pain at 24 h (non-inferiority criteria, D = 1) was À1.0 (À2.0 to 1.0, p < 0.001). Median difference in cumulative opioid consumption was 0.0 mg (À3.0-5.0, p < 0.001) meeting the non-inferiority criteria, D = 23 mg. We conclude that genicular nerves block of five nerves provides non-inferior analgesia in the first 24 h following surgery compared with local infiltration analgesia, but with a considerable reduction in the local anaesthetic dose.
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