Reducing the Hypertensive Effects of the Prolonged Surgical Tourniquet Using a Dual-Cuff Strategy: A Prospective Randomized Controlled Trial.

We evaluated whether moving the "line of crush" from thigh to the calf before onset of tourniquet-mediated hypertension would prevent or diminish it. We also evaluated any change in pain or functional outcome. Twenty adult patients were recruited and randomly assigned to either control or intervention groups. Inclusion criteria: any willing participant >18 years old with foot and/or ankle pathology requiring an operation lasting >90 minutes. Exclusion criteria included contraindication to general anesthesia, peripheral neuropathy affecting lower limbs of any etiology, or chronic pain requiring regular opiate analgesia. The intervention group received a thigh tourniquet for 60 minutes, after which a calf tourniquet was inflated and the thigh tourniquet was deflated. The control group received only a thigh tourniquet throughout surgery. At 90 minutes, the control group had mean arterial pressure of 86.8 mmHg, compared with the intervention group at 76.3 mmHg (p ≤ .014). At end of surgery, the difference had increased further (control 98.1 mmHg, intervention 78.3 mmHg (p ≤ .001). Moving the line of crush during limb tourniquet application prevents development of the hypertensive response. For cases in which a prolonged tourniquet application is required, a dual-tourniquet technique will prevent intraoperative hypertension and may influence long-term pain and function.

A spiralling origin of the median nerve around an accessory coracobrachialis brevis muscle.

During an ultrasound-guided axillary brachial plexus block, sonoanatomy demonstrated a delayed formation of the lateral root to the median nerve from the lateral cord, an accessory coracobrachialis brevis muscle, and a course of the lateral root to the median nerve 'spiralling' around the accessory muscle prior to locating lateral to the brachial artery. This rare variant is further discussed in the context of median, musculocutaneous and coracobrachialis variations.

Unauthorized Immigrants Prolong the Life of Medicare's Trust Fund.

BACKGROUND AND OBJECTIVE: Unauthorized immigrants seldom have access to public health insurance programs such as Medicare Part A, which pays hospitals and other health facilities and is funded through the Medicare Trust Fund. DESIGN AND MAIN MEASURES: We tabulated annual and total Trust Fund contributions and withdrawals by unauthorized immigrants (i.e., outlays on their behalf) from 2000 to 2011 using the Current Population Survey and Medical Expenditure Panel Surveys. We estimated when the Trust Fund would be depleted if unauthorized immigrants had neither contributed to it nor withdrawn from it. We estimated Trust Fund surpluses by unauthorized immigrants if 10 % were to become authorized annually over the subsequent 7 years. KEY RESULTS: From 2000 to 2011, unauthorized immigrants contributed $2.2 to $3.8 billion more than they withdrew annually (a total surplus of $35.1 billion). Had unauthorized immigrants neither contributed to nor withdrawn from the Trust Fund during those 11 years, it would become insolvent in 2029-1 year earlier than currently predicted. If 10 % of unauthorized immigrants became authorized annually for the subsequent 7 years, Trust Fund surpluses contributed by unauthorized immigrants would total $45.7 billion. CONCLUSIONS: Unauthorized immigrants have prolonged the life of the Medicare Trust Fund. Policies that curtail the influx of unauthorized immigrants may accelerate the Trust Fund's depletion.

Persistent median artery (palmar type) and median nerve block in the forearm: observational study of prevalence.

BACKGROUND: We sought to define the crude prevalence rate of the persistent median artery (PMA) (palmar type). Although there is no reported case in the anesthetic literature, a few sporadic case reports and series reported in anatomical and orthopedic journals describe an incidence of between 1.5% and 27.1%. METHODS: We conducted a prospective observational study to define the crude prevalence of the PMA (palmar type) by scanning 100 forearms of 50 volunteers using a high-frequency ultrasound probe. RESULTS: We found 19 PMAs in 13 individuals, thus giving a prevalence of 19%. Other arterial variants were also identified within this population. CONCLUSIONS: Anatomical variations of the blood supply to the forearm and hand can be identified with available high-frequency ultrasound equipment. Arterial variants immediately adjacent to the median nerve may occur in approximately 1 in 5 limbs. Practitioners should actively seek their presence or absence.