Treatment of Palmar Hyperhidrosis With Radiofrequency Microneedling-Based on Ultrasound Measurements.

This study addresses the treatment of palmar hyperhidrosis, which has been difficult to manage. A new treatment has been developed using radiofrequency microneedling to reduce sweating non-surgically by ablating sweat glands. Based on ultrasound measurements of the dermis and precise microneedling damage, effective energy was applied to locate the sweat glands and disabled their function. Radiofrequency microneedling with ultrasound can safely and effectively treat hyperhidrosis in a minimally invasive way.

Prevalence and impact of incompetence of internal jugular valve on postoperative cognitive dysfunction in elderly patients undergoing robot-assisted laparoscopic radical prostatectomy.

Internal jugular vein (IJV) is the main pathway of cerebral venous drainage and its valves prevent regurgitation of blood to the brain. IJV valve incompetence (IJVVI) is known to be associated with cerebral dysfunctions. It occurs more often in male over 50 years old, conditions elevating intra-abdominal or intra-thoracic pressure. In robot-assisted laparoscopic radical prostatectomy (RALRP), elderly male undergoes surgery in Trendelenburg position with pneumoperitoneum applied. Therefore, we assessed the IJVVI during RALRP and its influence on postoperative cognitive function. 57 patients undergoing RALRP were enrolled. Neurocognitive tests including Mini-Mental State Examination (MMSE), Auditory Verbal Learning Test, Digit Symbol Substitution Test, Color Word Stroop Test, digit span test, and grooved pegboard test were performed the day before and 2 days after surgery. During surgery, IJVVI was assessed with ultrasonography in supine position with and without pneumoperitoneum, and Trendelenburg position with pneumoperitoneum. 50 patients underwent sonographic assessment and 41 patients completed neurocognitive examination. A total of 27 patients presented IJVVI, 19 patients in supine position without pneumoperitoneum, 7 patients in supine position with pneumoperitoneum and 1 patient in Trendelenburg position with pneumoperitoneum. In neurocognitive tests, patients with IJVVI showed statistically significant decline of score in MMSE postoperatively (p<0.05). IJVVI occurred in 38% in supine position but the incidence was increased to 54% after Trendelenburg position and pneumoperitoneum. Patients with IJVVI did not show significant differences in cognitive function tests except MMSE. Clinical and neurological significance of physiologic changes associated RALRP should be studied further.

Adequate sedation with single-dose dexmedetomidine in patients undergoing transurethral resection of the prostate with spinal anaesthesia: a dose-response study by age group.

BACKGROUND: Dexmedetomidine (DMT), a highly selective α2-adrenoceptor agonist, has been used safely as a sedative in patients under regional anesthesia. The purpose of this study was to determine the 50% effective dose (ED50) of single-dose DMT to induce adequate light sedation in elderly patients in comparison with younger patients undergoing transurethral resection of the prostate (TURP) with spinal anesthesia. METHODS: Forty-two male patients were recruited. The young age group (Group Y) included patients 45 to 64 years old and the old age group (Group O) included patients 65 to 78 years old. After the spinal anesthesia was performed, a pre-calculated dose of DMT was administered for 10 min. The Observer's Assessment of Alertness/Sedation (OAA/S) scale, bispectral index score (BIS) were assessed then at 2-min intervals for 20 min. A modified Dixon's up-and-down method was used to determine the ED50 of the drug for light sedation (OAA/S score 3/4). In the recovery room, regression times of the motor and sensory blocks were recorded. RESULTS: The ED50 of DMT was 0.25 (95% C.I. 0.15-0.35) µg/kg in Group O and 0.35 (95% C.I. 0.35-0.45) µg/kg in Group Y (p = 0.002). The ED95 was 33% lower in Group O compare with Group Y (0.38 (95% C.I. 0.29-0.39) µg/kg vs. 0.57 (95% C.I. 0.49-0.59) µg/kg). The regression time of sensory block was longer in Group O than in Group Y (109.0 ± 40.2 min vs. 80.0 ± 31.6 min) (p = 0.014). CONCLUSION: The single-dose of DMT for light sedation was lower by 21% in Group O compare with Group Y underwent TURP with spinal anesthesia. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01665586. Registered July 31, 2012.

An ultrasound evaluation of laryngeal mask airway position in pediatric patients: an observational study.

BACKGROUND: In children, the laryngeal mask airway (LMA) is frequently displaced within the hypopharynx, resulting in repositioning of the device. When the tip of the LMA is placed in the esophageal inlet, the arytenoids are moved ventrally. When the LMA is rotated or deviated, the ventral movement of the arytenoids may result in asymmetric elevation of an arytenoid cartilage, which can be detected with ultrasound (US). In this study, we sought to estimate the incidence of LMA malposition detected with US in pediatric patients. The primary end point was to compare the incidence of LMA malposition between US and fiber optic bronchoscopy (FOB). The secondary end points were to find the interrelationship between US-detected and FOB-detected malposition of the LMA and to locate the diagnostic performance of US in detecting LMA malposition. METHODS: In this observational study, 100 consecutive children were included. After anesthetic induction, US evaluation was performed before and after LMA insertion to obtain the glottic image on the anterior neck. FOB was performed to assess LMA position (FOB LMA grade and LMA rotation grade). With a post-LMA US image, the symmetry of the arytenoid cartilages was evaluated. Asymmetrical elevation of an arytenoid cartilage in reference to the glottic midline and the opposite arytenoid cartilage was graded as 0 to 3 (US arytenoid grade). The interrelationships between US arytenoid grade and FOB LMA grade or LMA rotation grade were assessed. RESULTS: The incidence of asymmetrical elevation of an arytenoid was 50% (95% confidence interval [CI], 40%-60%). On FOB, the incidence of LMA malposition was 78% (95% CI, 69%-86%), and that of LMA rotation was 43% (95% CI, 33%-53%). The incidence of LMA malposition was higher with FOB (P < 0.0001), but the incidence of rotation was similar (P = 0.395). US arytenoid grade did not correlate with FOB LMA grade (P = 0.611) but showed a significant correlation with LMA rotation grade (P < 0.0001; 95% CI, 60%-83%). To detect a rotated LMA, US had a sensitivity of 93% (95% CI, 81%-98%) and a specificity of 82% (95% CI, 70%-91%). The positive and negative predictive values were 80% (95% CI, 66%-90%) and 94% (95% CI, 83%-99%), respectively. The accuracy was 87% (95% CI, 79%-93%). CONCLUSIONS: Although US could not detect the suboptimal depth of an LMA, US has promise of being an accurate tool in detecting a rotated LMA.

Ultrasound visibility of spinal structures and local anesthetic spread in children undergoing caudal block.

This study assessed ultrasound visibility of spinal structures in children and observed the extent of local anesthetic spread within the epidural space during caudal block. Spinal structures were evaluated with ultrasound from the sacral area to the thoracic area in 80 children, and drug spread levels were observed after caudal injection of 0.5, 1.0, 1.25 and 1.5 mL/kg local anesthetic. The conus medullaris, dural sac and dura mater were easily identified with ultrasound in most children. However, ligamentum flavum visibility declined with increasing vertebral level and markedly decreased at the thoracic level in children older than 7 mo or heavier than 8.5 kg. Drug spread was higher with increasing volume (p < 0.001) and in children ≤12 mo more than children >12 mo (p < 0.001); drug spread was significantly correlated with age (R(2) = 0.534). Spread levels assessed with ultrasound were roughly two to three segments lower than those in previous radiologic studies.

Palonosetron has superior prophylactic antiemetic efficacy compared with ondansetron or ramosetron in high-risk patients undergoing laparoscopic surgery: a prospective, randomized, double-blinded study.

BACKGROUND: Postoperative nausea and vomiting (PONV) continues to be a major problem, because PONV is associated with delayed recovery and prolonged hospital stay. Although the PONV guidelines recommended the use of 5-hydroxy-tryptamine (5-HT3) receptor antagonists as the first-line prophylactic agents in patients categorized as high-risk, there are few studies comparing the efficacies of ondansetron, ramosetron, and palonosetron. The aim of present study was to compare the prophylactic antiemetic efficacies of three 5HT3 receptor antagonists in high-risk patients after laparoscopic surgery. METHODS: In this prospective, randomized, double-blinded trial, 109 female nonsmokers scheduled for elective laparoscopic surgery were randomized to receive intravenous 4 mg ondansetron (n = 35), 0.3 mg ramosetron (n = 38), or 75 µg palonosetron (n = 36) before anesthesia. Fentanyl-based intravenous patient-controlled analgesia was administered for 48 h after surgery. Primary antiemetic efficacy variables were the incidence and severity of nausea, the frequency of emetic episodes during the first 48 h after surgery, and the need to use a rescue antiemetic medication. RESULTS: The overall incidence of nausea/retching/vomiting was lower in the palonosetron (22.2%/11.1%/5.6%) than in the ondansetron (77.1%/48.6%/28.6%) and ramosetron (60.5%/28.9%/18.4%) groups. The rescue antiemetic therapy was required less frequently in the palonosetron group than the other groups (P < 0.001). Kaplan-Meier analysis showed that the order of prophylactic efficacy in delaying the interval to use of a rescue emetic was palonosetron, ramosetron, and ondansetron. CONCLUSIONS: Single-dose palonosetron is the prophylactic antiemetics of choice in high-risk patients undergoing laparoscopic surgery.

Is close monitoring in the intensive care unit necessary after elective liver resection?

PURPOSE: Many surgical patients are admitted to the intensive care unit (ICU), resulting in an increased demand, and possible waste, of resources. Patients who undergo liver resection are also transferred postoperatively to the ICU. However, this may not be necessary in all cases. This study was designed to assess the necessity of ICU admission. METHODS: The medical records of 313 patients who underwent liver resections, as performed by a single surgeon from March 2000 to December 2010 were retrospectively reviewed. RESULTS: Among 313 patients, 168 patients (53.7%) were treated in the ICU. 148 patients (88.1%) received only observation during the ICU care. The ICU re-admission and intensive medical treatment significantly correlated with major liver resection (odds ratio [OR], 6.481; P = 0.011), and intraoperative transfusions (OR, 7.108; P = 0.016). Patients who underwent major liver resection and intraoperative transfusion were significantly associated with need for mechanical ventilator care, longer postoperative stays in the ICU and the hospital, and hospital mortality. CONCLUSION: Most patients admitted to the ICU after major liver resection just received close monitoring. Even though patients underwent major liver resection, patients without receipt of intraoperative transfusion could be sent to the general ward. Duration of ICU/hospital stay, ventilator care and mortality significantly correlated with major liver resection and intraoperative transfusion. Major liver resection and receipt of intraoperative transfusions should be considered indicators for ICU admission.

Efficacy and safety of a lidocaine/tetracaine medicated patch or peel for dermatologic procedures: a meta-analysis.

BACKGROUND: To justify the use of the lidocaine/tetracaine medicated patch or peel as a preventive treatment for reducing pain and discomfort in adults and children. We reviewed randomized controlled trials (RCTs) to evaluate the efficacy and safety of the lidocaine/tetracaine medicated patch or peel compared with placebo. METHODS: Ten RCTs (574 patients) were included in this systemic review. Relevant studies were identified through searches of MEDLINE, SCOPUS and the Cochrane database library. The outcome was the adequacy of cutaneous anesthesia reflected in the patient's assessment of pain intensity during minor dermatologic procedures and adverse effects after application of the lidocaine/tetracaine medicated patch or peel versus placebo. RESULTS: The efficacy of the lidocaine/tetracaine patch or peel was consistently very significantly beneficial 30 or 60 minutes after the application compared to placebo (Relative risk, RR: 2.5; Number needed to treat, NNT: 2.2). We did not identify any difference in the effectiveness of adequate analgesia between the lidocaine/tetracaine patch and peel (the number needed to treat or to harm, NNT 2.4 vs. 2.0). No serious side effects or adverse events were observed with the lidocaine/tetracaine medicated patch or peel and placebo. Minor skin reactions were transient and resolved without treatment (Odd ratio, OR: 1.4 and 95% confidence interval, CI: 0.9-2.1; NNT: 14.9). CONCLUSIONS: The lidocaine/tetracaine medicated patch or peel is a well accepted, effective and safe method for minor dermatologic procedures based on pooled data of trials in terms of adequacy of cutaneous anesthesia and adverse effects.

Institutional review board (IRB) and ethical issues in clinical research.

Clinical research has expanded tremendously in the past few decades and consequently there has been growing interest in the ethical guidelines that are being followed for the protection of human subjects. This review summarizes historical scandals and social responses chronologically from World War II to the Death of Ellen Roche (2001) to emphasize the lessons we must learn from history. International ethical guidelines for studies with human subjects are also briefly described in order to understand the circumstances of clinical research. The tasks and responsibilities of the institutions and investigators in human subject research to preserve the safety and welfare of research subjects are summarized. Next, several debated ethical issues and insights are arranged as controversial topics. This brief review and summary seeks to highlight important arguments and make suggestions to institutional review boards (IRBs) to contribute to the future evolution of ethics in clinical research as we advance forward.

Ramosetron for the prevention of postoperative nausea and vomiting (PONV): a meta-analysis.

BACKGROUND: Postoperative nausea and vomiting (PONV) remains a challenge for patients and health professionals despite various newly developed prophylactic interventions. We reviewed the efficacy and safety of ramosetron in randomized controlled trials (RCTs) for the prevention of PONV. METHODS: We reviewed 18 randomized controlled trials investigating the efficacy and safety of ramosetron in comparison with placebo or any other drugs. Relevant studies were searched in the MEDLINE, SCOPUS, and the Cochrane database libraries. Our end points of concern were prevention of PONV and adverse effects as dichotomous data. RESULTS: The prophylactic effect of 0.3 mg ramosetron was observed in early PON (relative risk, RR: 0.4; 95% CI 0.3-0.6), early POV (RR: 0.3; 95% CI 0.1-0.6), late POV (RR: 0.3; 95% CI 0.1-0.6), but not late PON (RR: 0.7; 95% CI 0.5-1.0). Compared with placebo, the efficacy of 0.3 mg ramosetron in adults and 6 µg/kg in children were consistently beneficial in preventing PONV overall (RR: 0.4; 95% CI: 03-0.6). The effects of 0.3 mg ramosetron and 3 mg granisetron were similar. No serious side effects or adverse events resulted from ramosetron and other active drugs, and incidence was similar to those of the placebo group. CONCLUSIONS: Ramosetron is effective and safe in children and adults without serious adverse effects compared with placebo or other active drugs, as shown in pooled data of RCTs, in terms of the prevention of PONV.

Fentanyl-sparing effect of acetaminophen as a mixture of fentanyl in intravenous parent-/nurse-controlled analgesia after pediatric ureteroneocystostomy.

BACKGROUND: Although acetaminophen has been used widely and is well tolerated in children, its efficacy and safety have not been clarified when combined with an opioid in intravenous parent-/nurse-controlled postoperative analgesia. METHODS: Sixty-three children (aged 6-24 months) who had undergone elective ureteroneocystostomies were enrolled in this prospective, randomized, double-blinded study. After the surgery, an analgesic pump was programmed to deliver fentanyl at a basal infusion rate of 0.25 microg.kg(-1).h(-1) and 0.25 microg/kg bolus after a loading dose of 0.5 microg/kg(-1). In the fentanyl-acetaminophen group, acetaminophen was coadministered as a solution mixture at a basal infusion rate of 1.5 mg.kg(-1).h(-1) and 1.5 mg/kg bolus after a loading dose of 15 mg/kg, whereas saline was administered to the fentanyl group. RESULTS: Postoperative pain scores were similar between the two groups. The total dose (micrograms per kilogram per day, mean+/-SD) of fentanyl at postoperative days 1 (8.3+/-3.7 vs. 18.1+/-4.6, P=0.021) and 2 (7.0+/-2.4 vs. 16.6, P=0.042) was significantly less in the fentanyl-acetaminophen group compared with that in the fentanyl group. The incidences of vomiting (16.1 vs. 56.3%, P=0.011) and sedation (9.7 vs. 46.9%, P=0.019) were significantly lower in the fentanyl-acetaminophen group than those in the fentanyl group. CONCLUSIONS: Acetaminophen has significant fentanyl-sparing effects and reduces side effects when combined with fentanyl in intravenous parent-/nurse-controlled analgesia for postoperative pediatric pain management.

Treatment of generalized hyperhidrosis with oxybutynin in post-menopausal patients.

Postmenopausal hyperhidrosis is a form of secondary hyperhidrosis, and hormone-replacement therapy is a commonly used therapeutic option. However, some women do not benefit from this treatment, and oral anticholinergics are a logical alternative for reducing generalized sweating in these patients. Twenty-one patients were medicated with 5 or 10 mg of oxybutynin per day. After a 3-month follow-up period, efficacy was assessed with the Hyperhidrosis Disease Severity Scale (HDSS) and the Dermatology Life Quality Index (DLQI) was used to assess the improvement in patients' quality of life. The HDSS score was 3.2 +/- 0.4 (mean +/- SD) before medication and 1.9 +/- 0.4 after 3 months. The baseline DLQI score of 8.4 +/- 1.0 was reduced to 4.4 +/- 0.9. No serious side-effects or adverse events resulted from treatment. Oxybutynin was a well-tolerated, effective, and safe method for treating postmenopausal sweating. However, long-term medication and the limited effects of the treatment were disadvantages.

Fentanyl sparing effects of combined ketorolac and acetaminophen for outpatient inguinal hernia repair in children.

PURPOSE: In this prospective, randomized, double-blinded study we sought to evaluate the efficacy and safety of combined use of intravenous ketorolac and acetaminophen in small children undergoing outpatient inguinal hernia repair. MATERIALS AND METHODS: We studied 55 children 1 to 5 years old who were undergoing elective repair of unilateral inguinal hernia. After induction of general anesthesia children in the experimental group (28 patients) received 1 mg/kg ketorolac and 20 mg/kg acetaminophen intravenously. In the control group (27 patients) the same volume of saline was administered. All patients received 1 microg/kg fentanyl intravenously before incision. We also evaluated the number of patients requiring postoperative rescue fentanyl, total fentanyl consumption, pain scores and side effects. RESULTS: Significantly fewer patients receiving ketorolac-acetaminophen received postoperative rescue fentanyl compared to controls (28.6% vs 81.5%). A significantly lower total dose of fentanyl was administered to patients receiving ketorolac-acetaminophen compared to controls (0.54 vs 1.37 microg/kg). Pain scores were significantly higher in the control group immediately postoperatively but eventually decreased. The incidences of sedation use (55.6% vs 25.0%) and vomiting (33.3% vs 10.7%) were significantly higher in controls. CONCLUSIONS: Preoperative intravenous coadministration of ketorolac and acetaminophen is a simple, safe and effective method for relieving postoperative pain, and demonstrates highly significant fentanyl sparing effects in small children after outpatient inguinal hernia repair.

Paracetamol reduces postoperative pain and rescue analgesic demand after robot-assisted endoscopic thyroidectomy by the transaxillary approach.

BACKGROUND: Postoperative pain following endoscopic thyroidectomy, although less severe than after open methods, is still a source of marked discomfort and surgical stress. This clinical trial was conducted to determine if repeated intravenous paracetamol could decrease postoperative pain and rescue analgesic requirements after robot-assisted endoscopic thyroidectomy via the transaxillary approach. MATERIALS AND METHODS: This prospective, randomized, double-blinded, and placebo-controlled study enrolled 124 women 21-60 years of age who were scheduled for elective gasless robot-assisted endoscopic thyroidectomy via the transaxillary approach. The patients were given placebo or 1 g of paracetamol as a 100 ml solution infused over 15 min 1 h before the induction of anesthesia, and then at 6-h intervals for the following 24 h. RESULTS: Postoperative pain scores were significantly lower at 1, 3, 6, and 24 h after surgery in the paracetamol group than in the placebo group. Significantly fewer patients in the paracetamol group received rescue analgesics compared to the placebo group (9.5% vs. 65.6%, respectively). First analgesic time was similar in the two groups. Postoperative nausea (44.3% vs. 22.2%) and vomiting (21.3% vs. 6.3%) were more frequent in the placebo group than in the paracetamol group. Other postoperative side effects, including sedation, confusion, and pruritus, were similar in the two groups. CONCLUSIONS: We concluded that repeated administration of 1 g of intravenous paracetamol over 24 h is easy, effective, safe, and well tolerated for pain management in patients with moderate to severe postoperative pain after gasless robot-assisted endoscopic thyroidectomy performed via the transaxillary approach.

Detection of subclinical CO2 embolism by transesophageal echocardiography during laparoscopic radical prostatectomy.

OBJECTIVES: To document incidences of subclinical embolism in laparoscopic radical prostatectomy with continuous monitoring using transesophageal echocardiography (TEE). METHODS: A total of 43 patients scheduled for elective robotic-assisted laparoscopic radical prostatectomy under general anesthesia were enrolled in this study. A 4-chamber view of 5.0-MHz multiplane TEE was continuously monitored to detect any intracardiac bubbles as an embolism. An independent TEE specialist reviewed the tapes for interpretation, and emboli were classified as 1 of 5 stages. Cardiorespiratory instability during gas emboli entry was defined as an appearance of cardiac arrhythmias, sudden decrease in mean arterial blood pressure >20 mm Hg, or an episode of pulse oximetric saturation <90%. RESULTS: Gas embolisms were observed in 7 of 41 (17.1%) patients during transection of the deep dorsal venous complex. Of them, 1, 3, 1, and 2 showed stage I, II, III, and IV, respectively. However, there were no signs of cardiorespiratory instability associated with emboli. The 95% confidence interval for gas embolism was 0.204%-0.138%. No correlation was observed between episodes of gas embolism and blood gas variables or end-tidal CO(2) partial pressure. CONCLUSIONS: Subclinical gas embolisms occur in 17.1% of laparoscopic radical prostatectomies. We should consider that this procedure has a potential for serious gas embolism, especially with the increasing popularity of laparoscopic prostatectomy using robot-assisted techniques.

Influence of T3 or T4 sympathicotomy for palmar hyperhidrosis.

BACKGROUND: This retrospective study aimed to compare the efficacy of video-assisted thoracoscopic sympathicotomy at the T3 or T4 level in the treatment of palmar hyperhidrosis. METHODS: Patients were operated on for palmar hyperhidrosis from April 2004 to December 2007, and classified as the T3 (n = 56) or T4 (n = 63) sympathicotomy group. RESULTS: The rate of dryness and compensatory hyperhidrosis (CH) was significantly lower in the T4 sympathicotomy group than the T3 group (P < .01). Satisfaction rate, recurrence, and improvement of plantar sweating were of no statistical significance in either group. CONCLUSIONS: Although both sympathicotomies were effective, safe, and minimally invasive methods for the treatment of palmar hyperhidrosis, T4 appeared to be a more optimal technique with less CH.

Ultrasound evaluation of the sacral area and comparison of sacral interspinous and hiatal approach for caudal block in children.

BACKGROUND: Although caudal block via the sacral hiatus is a common regional technique in children, it is sometimes difficult to identify the hiatus. A needle approach via the S2-3 interspace can be used as an alternative to the conventional approach. The authors compared the feasibility and clinical characteristics between the S2-3 approach and hiatal approach, in addition to ultrasound study. METHODS: Sacral space depth, dural sac end level, and caudal space depth were evaluated using ultrasound with high-frequency linear probe in the lateral decubitus position in 317 anesthetized children (study 1). In another 162 children who underwent ambulatory urological surgeries, success rate, drug spread, and clinical characteristics were compared between the hiatal and S2-3 approaches (study 2). RESULTS: The dural sac end level was S2U (S3M-L5M). The median depth of the sacral space at the S2-3 level was 7.3 mm, whereas the caudal space depth at the hiatus was 2.9 mm. The overall success rate was 96.3% in both groups. The success rates at the first puncture attempt were 96.2% in the S2-3 group and 77.5% in the hiatus group. Drug spread level and clinical characteristics were similar between the two groups. CONCLUSIONS: The S2-3 approach can be applied as a useful fallback method to the conventional landmark approach in children, especially in those older than 36 months who present with difficult identification of the sacral hiatus.