Safety and technical success of diphenhydramine as an alternative local anaesthetic agent for radiology procedures.

AIM: To evaluate retrospectively the safety and technical success of subcutaneous diphenhydramine as an alternative local anaesthetic for radiology procedures. MATERIALS AND METHODS: Between January 2000 and April 2021, 84 image-guided procedures were performed in 81 adult patients (mean age 61 years, 86% female) using 1% injectable diphenhydramine as a local anaesthetic. Indications were history of severe allergy to "-caine" local anaesthetics in 76 (90%) patients and recent administration of bupivacaine liposomal injectable suspension in eight (10%) patients. Twelve of the 84 (14%) procedures were performed with concomitant moderate sedation. Patient characteristics, procedural techniques, and clinical outcomes were reviewed. Early and delayed (30-day) complications were classified as either related to local diphenhydramine injection or to the procedure itself. Procedure-related complications were gradated using the Clavien-Dindo system. RESULTS: Percutaneous biopsy was the most frequently performed procedure (57/84, 67%). Fifty-nine (70%) of the 84 procedures were ultrasound guided. The most common procedural site was the breast (34/84, 40%). All procedures were technically successful. There were two minor injection-related complications related to post-procedural pain. A single minor procedure-related complication involved a patient requiring hospital admission for post-renal biopsy related haematuria. CONCLUSION: Injectable diphenhydramine appears to be a safe and effective local anaesthetic alternative in patients with "-caine" class contraindications undergoing radiology procedures. A future prospective trial would be useful to assess the safety profile in an large cohort of patients.

Patients triaged to neoadjuvant chemotherapy have higher rates of sarcopenia: An opportunity for prehabilitation.

OBJECTIVE: To compare baseline body composition measures (BCM), including sarcopenia, between patients with advanced epithelial ovarian cancer (EOC) undergoing primary cytoreductive surgery (PCS) versus neoadjuvant chemotherapy/interval cytoreductive surgery (NACT/ICS) and evaluate changes in BCM pre-NACT versus pre-ICS. METHODS: Patients with stage IIIC/IV EOC who underwent PCS or NACT with curative intent between 1/1/2012 and 7/31/2016 were included. Computed tomography scans were evaluated via a semi-automated program to determine BCM. Measures evaluated include skeletal muscle area (SMA), skeletal muscle density (SMD), skeletal muscle index (SMI), and skeletal muscle gauge (SMG). Sarcopenia was defined as SMI <39.0 cm2/m2. RESULTS: The study included 200 PCS patients and 85 NACT/ICS patients, of which 76 had both pre-NACT and pre-ICS scans. NACT patients were significantly more likely to be sarcopenic compared to PCS patients (40.0% vs 27.5%, p = 0.04). Mean SMA (107.3 vs 113.4 cm2, p = 0.004) and mean SMG (1344.6 vs. 1456.9 (cm2 x HU)/m2, p = 0.06) were lower in NACT patients. Among NACT/ICS patients, mean SMI significantly decreased -1.4 cm2/m2 (p = 0.005) at the time of surgery, resulting in a non-statistically significant increase in the percentage of sarcopenic patients from baseline (40.8% vs. 50.0%, p = 0.09). CONCLUSIONS: Sarcopenia is more common in patients with advanced EOC undergoing NACT compared to PCS when using an evidence-based triage system for triage decisions. Body composition changes significantly over the course of NACT. Sarcopenia may be an indicator of debility and another factor for consideration in treatment planning. Further research into body composition's effects on prognosis and altering sarcopenia is necessary.

Ozone-augmented percutaneous discectomy: a novel treatment option for refractory discogenic sciatica.

AIM: To assess the short and medium-term efficacy and safety of a novel, minimally invasive therapeutic option combining automated percutaneous lumbar discectomy, intradiscal ozone injection, and caudal epidural: ozone-augmented percutaneous discectomy (OPLD). MATERIALS AND METHODS: One hundred and forty-seven patients with a clinical and radiological diagnosis of discogenic sciatica who were refractory to initial therapy were included. Fifty patients underwent OPLD whilst 97 underwent a further caudal epidural. Outcomes were evaluated using McNab's score, improvement in visual analogue score (VAS) pain score, and requirement for further intervention. Follow-up occurred at 1 and 6 months, and comparison was made between groups. RESULTS: OPLD achieved successful outcomes in almost three-quarters of patients in the short and medium term. OPLD achieved superior outcomes at 1 and 6 months compared to caudal epidural. There was a reduced requirement for further intervention in the OPLD group. No significant complications occurred in either group. DISCUSSION: OPLD is a safe and effective treatment for patients with refractory discogenic sciatica in the short and medium term. OPLD has the potential to offer an alternative second-line minimally invasive treatment option that could reduce the requirement for surgery in this patient cohort.

Establishment of normative biometric data for body composition based on computed tomography in a North American cohort.

BACKGROUND & AIMS: Accurate and reproducible biomarkers are required to allow a more personalized approach to patient care. Body composition is one such biomarker affecting outcomes in a range of surgical and oncological conditions. The aim of this study is to determine the age and sex specific distribution of body composition data, based on information gathered from computed tomography (CT). METHODS: This prospective study used healthy subjects from the medical records linkage of the Rochester Epidemiology Project, based in Minnesota, USA. Each patient had a CT scan without intravenous contrast performed between 1999 and 2001. Quantification was performed using previously validated semi-automated in-house developed software for body composition analysis. Subcutaneous adipose tissue area, visceral adipose tissue area, intermuscular adipose tissue area and skeletal muscle area were measured and indexed to subject height. Generalized Additive Models for Location, Scale and Shape were used to assess the location, scale, and shape of each variable across age, stratified by sex. Z-scores specific to sex were assessed for each of the parameters analyzed. Age-specific z-scores were calculated using the formula: Z = (Index Variable - µ)/σ or Z = (√ (Index Variable) - µ)/σ. RESULTS: There were 692 subjects enrolled in the study. The fitted model equation was offered for each variable with values presented for µ and σ. Modelling with penalized splines was performed for VAT index, IMAT index and total adipose tissue index. Scatterplots of each variable were produced with lines of Z-scores as a visual representation. CONCLUSION: This study offers comparative data to allow comparison amongst multiple populations. This will form an important reference for future research and clinical practice.

Streamwater nitrate concentrations in six agricultural catchments in Scotland.

The concentrations of nitrate-N (NO3-N) in catchment inputs and outputs have been compared and contrasted between 6 farm catchments in Scotland, 3 in the West and 3 in the North-East. Forms of intensive animal farming ranging between beef and dairy cattle, sheep and poultry give different sources for potential NO3-N leakage from the systems. While stream reaches bordered by intensive cereal production give rise to the largest inputs to surface waters, climatic influences result in the more-efficient use of fertilizer- and farm waste-N in the West, and an enhanced potential for N-loss to waters in the cooler North-East, regardless of the N-inputs being considerably lower in the latter region. Although the EC Nitrate Directive limit of 11.3 mg NO3-N 1(-1) was not exceeded, peak values occurring during summer baseflows and autumn soil rewetting were commonly larger than the 'target' maximum concentration of 5.65 mg NO3-N 1-1.

Prospective, blinded trial of whole-body magnetic resonance imaging versus computed tomography positron emission tomography in staging primary and recurrent cancer of the head and neck.

OBJECTIVES: To compare the use of computed tomography - positron emission tomography and whole-body magnetic resonance imaging for the staging of head and neck cancer. PATIENTS AND METHODS: From January to July 2009, 15 consecutive head and neck cancer patients (11 men and four women; mean age 59 years; age range 19 to 81 years) underwent computed tomography - positron emission tomography and whole-body magnetic resonance imaging for pre-therapeutic evaluation. All scans were staged, as per the American Joint Committee on Cancer tumour-node-metastasis classification, by two blinded consultant radiologists, in two sittings. Diagnoses were confirmed by histopathological examination of endoscopic biopsies, and in some cases whole surgical specimens. RESULTS: Tumour staging showed a 74 per cent concordance, node staging an 80 per cent concordance and metastasis staging a 100 per cent concordance, comparing the two imaging modalities. CONCLUSION: This study found radiological staging discordance between the two imaging modalities. Whole-body magnetic resonance imaging is an emerging staging modality with superior visualisation of metastatic disease, which does not require exposure to ionising radiation.

Cement burns: the dublin national burns unit experience.

OBJECTIVE: Cement burns account for relatively few admissions to a burn unit; however, these burns deserve separate consideration because of special features of diagnosis and management. Cement burns, even though potentially disabling, have rarely been reported in literature. METHODS: A retrospective review was performed of all patients admitted with cement burns injuries to the national burns unit at the St James's Hospital in Dublin, Ireland, over a 10-year period for the years 1996-2005. RESULTS: A total of 46 patients with cement burns were admitted. The majority of patients were aged 16-74 years (mean age = 32 years). Eighty-seven percent of injuries occurred in an industrial and 13% in a domestic setting. The upper and lower extremities were involved in all the patients, and the mean total body surface area affected was 6.5%. The mean length of hospital stay was 21 days with a range of 1-40 days. Thirty-eight (82%) were surgically managed involving debridement and split-thickness skin graft (SSG) and four (9%) were conservatively managed. A further four did not have data available. CONCLUSION: Widespread inexperience in dealing with this group of cement burns patients and delays in referral to burns unit highlights the potential for greater levels of general awareness and knowledge in both prevention and treatment of these burns. As well, early debridement and split-thickness skin grafting at diagnosis constitutes the best means of reducing the high socioeconomic costs and allows for early return to work.

Routine mobilization of the splenic flexure is not necessary during anterior resection for rectal cancer.

PURPOSE: Splenic flexure mobilization is widely considered to be an essential component of anterior resection for rectal cancer. It was our hypothesis that selective splenic flexure mobilization would reduce operative times without increasing morbidity or affecting cure. METHODS: A total of 100 consecutive patients with rectal cancer (mean 8 (range, 4-15) cm from anal verge) who underwent anterior resection for cure between 1996 and 2002 had splenic flexure mobilization only as required to achieve a tension-free anastomosis. Operative time, postoperative morbidity, pathologic findings, and recurrence rates were recorded. RESULTS: There were no clinicopathologic differences between those who had splenic flexure mobilization (n = 26) and those who did not (n = 74). Mean operative time in the splenic flexure mobilization group was longer, 167 (range, 130-200) minutes vs. 120 (range, 95-180) minutes in the nonmobilized group (P = 0.023). Mean length of specimen resected was longer in the splenic flexure mobilization group: 36 vs. 18 cm (P = 0.008). Anastomotic complications (4 percent), local recurrence (7 percent, median follow-up, 38 months), perioperative morbidity (32 percent) and mortality (2 percent), and survival did not differ between the two groups. CONCLUSIONS: Routine splenic flexure mobilization is not required for safe anterior resection in patients with rectal cancer. Avoiding splenic flexure mobilization results in shorter operative times and does not increase postoperative morbidity, anastomotic leakage, or local recurrence.