There is no universally agreed set of anatomical structures that must be identified on ultrasound for the performance of ultrasound-guided regional anesthesia (UGRA) techniques. This study aimed to produce standardized recommendations for core (minimum) structures to identify during seven basic blocks. An international consensus was sought through a modified Delphi process. A long-list of anatomical structures was refined through serial review by key opinion leaders in UGRA. All rounds were conducted remotely and anonymously to facilitate equal contribution of each participant. Blocks were considered twice in each round: for “orientation scanning” (the dynamic process of acquiring the final view) and for the “block view” (which visualizes the block site and is maintained for needle insertion/injection). Strong recommendations for inclusion were made if ≥75% of participants rated a structure as “definitely include” in any round. Weak recommendations were made if >50% of participants rated a structure as “definitely include” or “probably include” for all rounds (but the criterion for “strong recommendation” was never met). Thirty-six participants (94.7%) completed all rounds. 128 structures were reviewed; a “strong recommendation” is made for 35 structures on orientation scanning and 28 for the block view. A “weak recommendation” is made for 36 and 20 structures, respectively. This study provides recommendations on the core (minimum) set of anatomical structures to identify during ultrasound scanning for seven basic blocks in UGRA. They are intended to support consistent practice, empower non-experts using basic UGRA techniques, and standardize teaching and research.
Amateur choral singing is a common pastime and worthy of study, possibly conferring benefits to health and social behaviour. Participants might be expected to possess musical ability and share some behavioural characteristics. Polymorphisms in genes concerned with serotonergic neurotransmission are associated with both behaviour and musical aptitude. Those investigated previously include the variable number tandem repeats RS1, RS3 and AVR in the AVPR1A (arginine vasopressin receptor 1a) gene and STin2 in the SLC6A4 (solute carrier family 6 [neurotransmitter transporter, serotonin], member 4) gene, as well as the SLC6A4 promoter region polymorphism, 5-HTTLPR. We conducted a genetic association study on 523 participants to establish whether alleles at these polymorphisms occur more commonly in choral singers than in those not regularly participating in organised musical activity (non-musicians). We also analysed tagging single nucleotide polymorphisms (SNPs) for AVPR1A and SLC6A4 to determine whether other variants in these genes were associated with singer/non-musician status. At the STin2 polymorphism, overall association with singer/non-musician status was evident at P = 0.006. The 9-repeat (P = 0.04) and 12-repeat (P = 0.04) alleles were more common in singers and the 10-repeat allele less so (P = 0.009). Odds ratios were 0.73 (95% CI 0.57–0.94) for the 10-repeat allele and 2.47 (95% CI 0.88–6.94) for the rarer 9-repeat allele. No overall association was detected at P<0.05 between any other polymorphism and singer/non-musician status. Our null findings with respect to RS3, RS1 and AVR, polymorphisms associated with musical ability by other authors, suggest that choir membership may depend partly on factors other than musical ability. In a related musical project involving one participating choir, a new 40-part unaccompanied choral work, “Allele”, was composed and broadcast on national radio. In the piece, each singer's part incorporated their personal RS3 genotype.
Background:The Serratus anterior muscle plane (SAP) block has recently been described for the purpose of perioperative pain management following cases of trauma and breast surgery. It might prove a safer alternative to the other regional thoracic paravertebral and central neuraxial blockade techniques. There are no descriptive cadaveric studies in the pre-existing literature to delineate the anatomical plane for this novel technique. The main objectives for our study were to examine the location of the Serratus anterior muscle belly, assess the efficacy of achieving adequate delineation of the muscle plane utilising ultrasound imaging with agitated water as the contrast agent, and finally, to observe the extent of the cepahlo-caudal spread of the injectate in the SAP.Materials and Methods:Seven cadavers were studied. 20 mls of saline was injected into posterior axillary line (PAL) at the level of the 4-5th rib under ultrasound guidance. This was followed by injection of 10 mls of water with air (8 mls water and 2 mls of air). The presence of hyperechoic air bubbles in the fluid distended SAP (hypoechoic) area demonstrated the spread of water and air.Results:In 36% of cadavers, fully formed Serratus Anterior muscle belly was identified at the midaxillary line (MAL), 14% in PAL, and remaining 50% between PAL and MAL. The lower most limit of air-water spread was identified at the subcostal margin. Cephalad spread of contrast was noted in 2nd intercostal space ICS (7%), 3rd ICS (71%), and 4th ICS (22%).Conclusion:This study describes that the serratus anterior muscle is well-formed near the PAL and the injectate spread can be determined with the help of agitated water contrast on ultrasound. Furthermore, there was variability in the cephalad spread of the injectate.
The patient was successfully treated with a continuous infusion of local anesthetic into the subpectoral interfascial plane. We also discuss the use and potential benefits of the subpectoral interfascial plane block in the treatment of pain from sternal fractures.
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