Temozolomide in glioblastoma treatment: 15-year clinical experience and analysis of its efficacy.

AIM: To analyze retrospectively the efficacy of temozolomide (TMZ) in various treatment regimens in glioblastoma patients accounting for varying parameters of their treatment. MATERIALS AND METHODS: 302 glioblastoma patients were treated at the State Institution "Romodanov Institute of Neurosurgery of the National Academy of Medical Sciences of Ukraine" from 2003 through 2017. All the patients were surgically treated. In 205 patients, the surgery was followed by adjuvant radiotherapy (RT) with concomitant TMZ (RT + TMZ group). In 97 patients, the surgery was followed by adjuvant RT only (RT group). Kaplan - Meier survival analysis with log-rank test and Cox proportional hazards regression analysis were used for comparing overall survival (OS) and recurrence-free survival (RFS) depending on the age and gender of the patients, the extent of tumor resection, the chemotherapy intensity and the type of RT. RESULTS: In RT + TMZ group as a whole, OS median was 20.7 months vs 10.8 months in RT group (р < 0.0001). The RFS was 14.8 months vs 7.9 months, correspondingly (р < 0.0001).The survival did not depend on the age, gender or localization of the tumor. On the contrary, the intensity of CTX (the number of TMZ cycles in adjuvant mode), the extent of tumor resection, and the type of RT were among the factors affecting significantly OS and RFS. The improvement in OS and RFS with increasing number of the maintenance TMZ courses was more significant in the patients aged below 60. The use of stereotactic conformal mode for RT provides an advantage in the survival over the conventional RT in RT + TMZ group. CONCLUSIONS: The combination of concomitant and adjuvant maintenance CTX with TMZ was the most effective CTX regimen affecting positively OS and RFS.

The performance of spinal anesthesia is marginally more difficult in the elderly.

BACKGROUND AND OBJECTIVES: We sought to determine if spinal anesthesia is more difficult to perform in the elderly. METHODS: All spinal anesthetics administered over 18 months by 18 anesthesiologists were eligible. We excluded anesthetics for hip fractures and cesarean deliveries. We recorded time to completion, number of spinal needles used, and number of approaches. The patients were prospectively divided into three age categories: patients <50 years of age (group 1); 50-70 years of age (group 2); and >70 years of age (group 3). Descriptive statistics and chi-square test were performed. RESULTS: Nine hundred and ninety-nine anesthetics were analyzed. There were 368, 336, and 295 entries in groups 1, 2, and 3, respectively. Although the mean +/- SD (in min) times to accomplish the spinal technique were not significantly different (4.3 +/- 4.1, 4.4 +/- 3.2, and 4.6 +/- 3.4 for groups 1, 2, and 3), there was a statistically greater frequency of more than one spinal needle used and more than one approach needed in the elderly. CONCLUSIONS: We conclude that patient age is a minor independent predictor of increased technical difficulty with spinal anesthesia.

Videotape feedback in teaching laryngoscopy.

PURPOSE: To evaluate if videotape feedback provides educational insights for students learning laryngoscopy that they would not otherwise perceive. METHODS: Twenty-six medical students were videotaped while performing laryngoscopy for oral intubation. Before and after reviewing their performance on the videotape, they answered a standardized questionnaire assessing the adequacy of positioning, head movement during laryngoscopy, degrees of neck flexion and head extension, time elapsed, and whether the laryngoscope contacted the upper lip or teeth. After the review, they were asked if being videotaped was distracting, whether it provided new instructional insights and, if so, which was most important. RESULTS: Only 4% of students felt that initial head and neck positioning was suboptimal and this increased to 38% after videotape review (P = 0.029). The perceived inadequacy of positioning seemed related to initial overestimation of head extension (34.0 +/- 15 degrees) compared with that seen on videotape (21.5 +/- 13.5 degrees, P = 0.003). The estimated duration of laryngoscopy was underestimated (55 +/- 32 sec vs. 75 +/- 29 sec, P = .024) before videotape review. Although 26.9% (7/26) of students admitted feeling distracted by the video camera, all felt the experience had educational value. CONCLUSION: Videotape feedback changed students' perception of how they performed laryngoscopy. In particular, head extension was overestimated and duration of laryngoscopy underestimated.

Effects of brachial plexus fentanyl on supraclavicular block. A randomized, double-blind study.

BACKGROUND AND OBJECTIVES: The study examined the effects of adding fentanyl to mepivacaine supraclavicular blocks on block characteristics and postoperative analgesia. METHODS: Twenty patients undergoing upper extremity surgery with supraclavicular blocks were prospectively randomized to receive 75 micrograms fentanyl either added to the local anesthetic (30 mL mepivacaine 1.5% with epinephrine 5 micrograms/mL) or given intramuscularly. An equivalent volume of normal saline was given in one of the two sites as a control in a double-blind fashion. Sensory and motor block onset, time to completion, and duration were measured. After the operation, patient-controlled analgesia with morphine was administered and the total dose used over 24 hours recorded. Visual analog pain scale (VAS: 0 = no pain, 10 cm = worst pain) was measured at 0, 1, 2, 3, 4, and 12 hours after the operation. RESULTS: There was no statistically significant difference between the two groups in sensory or motor block characteristics. There was a significantly lower VAS score among the patients with fentanyl added to their blocks within the first hour after the operation (1.3 +/- 1.5 cm versus 3.8 +/- 3.1 cm; P < .05), but subsequent VAS scores and total 24-hour patient-controlled analgesia requirements were no different. CONCLUSIONS: Adding fentanyl 75 micrograms to mepivacaine supraclavicular blocks has no significant effects on block characteristics. It may enhance postoperative analgesia, but the duration of this effect is too brief to be clinically useful.

A retrospective comparison of spinal and general anesthesia for vaginal hysterectomy: a time analysis.

The authors sought to compare time efficiency of spinal versus general anesthesia. The charts of 106 consecutive patients who had undergone a vaginal hysterectomy were analyzed. This analysis divided the patients into three groups: Group 1, spinal anesthesia; Group 2, general anesthesia; Group 3, spinal anesthesia with subsequent general anesthesia. The perioperative time course was divided into six intervals from entry into the operating room to discharge from the postanesthesia care unit (PACU). Total time was calculated by adding the six intervals. There were 85 patients in Group 1, 17 patients in Group 2, and 4 patients in Group 3. The mean times for surgical readiness once the anesthesiologist was present for Group 1, Group 2, and Group 3 were 21.4 +/- 7.3, 21.4 +/- 6.0, and 25.0 +/- 5.8 min, respectively. The total time for the three groups was 278.3 +/- 72.0, 245.9 +/- 23.1, and 295.0 +/- 101.2 min, respectively (P < 0.01 Group 1 vs Group 2). The difference in total time between Groups 1 and 2 was accounted for mainly by the stay in the PACU. This study concludes that there is no difference in the efficiency of operating room time use between spinal and general anesthesia.

Spinal anaesthesia for caesarean section after Harrington instrumentation.

A case is presented of a 33-yr-old parturient with Harrington fusion of her spine who received spinal anaesthesia with 15 mg hyperbaric bupivacaine for Caesarean delivery. Multiple attempts of needle insertion in both midline and paramedian at the L3-4 interspace were unsuccessful, whereas the procedure was performed uneventfully at the midline of the L5S1 interspace. The anatomical considerations and difficulties in achieving reliable epidural anaesthesia after Harrington fusion are reviewed. Spinal anaesthesia performed at the L5S1 interspace may provide less technical difficulty and a more reliable result in such patients.