Assessing knowledge and confidence of surgical residents in inguinal hernia repair using a low-cost synthetic model.

PURPOSE: Open repair of groin hernia is an essential skill for the general surgeon. This study aimed to develop a low-cost hernia model based on a validated high-fidelity model and assess its effectiveness in teaching inguinal hernia repair to surgical trainees from many institutions throughout Africa. METHODS: Using inexpensive, locally available materials, a low-cost hernia model was created. Six models were constructed, and a workshop was conducted for surgical residents. Pre- and post-workshop surveys were administered to assess knowledge, confidence, and understanding. Statistical analyses were performed using paired t tests and the Wilcoxon signed-rank test. RESULTS: The low-cost hernia model consisted of various readily available materials and cost an average of $5.07. Sixty-eight trainees participated in the workshop, and 59 completed the post-workshop survey. Participants reported a significant increase in confidence for both mesh and non-mesh repairs and an improved understanding of hernia anatomy after the workshop. Trainees scored an average of 5.6 (SD 1.9) out of 10 questions on the pre-workshop quiz and 7.9 (SD 1.4) out of 10 on the post-workshop quiz (p < 0.001), indicating improved knowledge. All trainees supported the use of the model for education. CONCLUSION: The low-cost hernia model demonstrated its effectiveness in enhancing trainees' understanding of hernia anatomy and increasing their confidence in hernia repair. Integrating low-cost hernia models into training programs can help improve trainees' knowledge and confidence in a safe and affordable environment.

Frequent occurrence of esophageal cancer in young people in western Kenya.

Esophageal cancer has a strikingly uneven geographical distribution, resulting in focal endemic areas in several countries. One such endemic area is in western Kenya. We conducted a retrospective review of all pathology-confirmed malignancies diagnosed at Tenwek Hospital, Bomet District, between January 1999 and September 2007. Tumor site, histology, sex, age, ethnicity, and location of residence were recorded. Cases were analyzed within and outside a traditional catchment area defined as < or = 50 km from the hospital. Since 1999, the five most common cancer sites were the esophagus, stomach, prostate, colorectum, and cervix. Esophageal cancer accounted for 914 (34.6%) of the 2643 newly diagnosed cancers and showed increasing trends within and outside the catchment area. Fifty-eight (6.3%) patients were < or = 30 years old and 9 (1%) were < or = 20 years old; the youngest patient was 14 years at diagnosis. Young cases (< or = 30) were more common among patients of Kalenjin ethnicity (9.2%) than among other ethnicities (1.7%) (odds ratio [95% confidence interval] 5.7 [2.1-15.1]). This area of western Kenya is a high-risk region for esophageal cancer and appears unique in its large proportion of young patients. Our findings support the need for further study of both environmental and genetic risk factors for esophageal cancer in this area.

The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor.

UNLABELLED: Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block. IMPLICATIONS: A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.

Anesthetic management of the exit (ex utero intrapartum treatment) procedure.

The EXIT (ex utero intrapartum treatment) procedure is used to maintain fetal-placental circulation during partial delivery of a fetus with a potentially life-threatening upper airway obstruction. We performed the EXIT procedure on a fetus with a large intra-oral cyst. Sevoflurane was used as the anesthetic because of its rapid titratability. Sevoflurane provided excellent maternal and fetal anesthesia. Modifications to previously described monitoring techniques for the EXIT procedure were also used.

Comparison of epidural fentanyl versus epidural sufentanil for analgesia in ambulatory patients in early labor.

UNLABELLED: Epidural sufentanil, after a lidocaine and epinephrine test dose, provides adequate analgesia and allows for ambulation during early labor. Epidural fentanyl has not been evaluated in this setting. The current study was designed to determine whether there is an analgesic difference between epidural fentanyl and epidural sufentanil in laboring patients. Forty-six laboring nulliparous women, at <5-cm cervical dilation, who requested epidural analgesia were enrolled. After a 3-mL test dose of lidocaine with epinephrine, patients were randomized to receive either sufentanil 20 microg or fentanyl 100 microg. After administration of the analgesic, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean durations of analgesia were similar between the sufentanil group (138 +/- 50 min) and the fentanyl group (124 +/- 42 min). Side effects were similar between the two groups. In early laboring patients, epidural fentanyl 100 microg, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 microg. IMPLICATIONS: In early laboring patients, epidural fentanyl 100 microg, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 microg.

Sumatriptan in patients with postdural puncture headache.

OBJECTIVE: To determine the efficacy of sumatriptan in the management of patients presenting for an epidural blood patch for the management of postdural puncture headache. BACKGROUND: Postdural puncture headache can be quite severe, requiring invasive therapy (ie, epidural blood patch). Sumatriptan has been used successfully in patients with postdural puncture headache, however, its use has not been investigated in a controlled fashion. METHODS: Ten patients with postdural puncture headache presenting for an epidural blood patch were given either saline or sumatriptan subcutaneously. The severity of the headache was evaluated at baseline and 1 hour following injection. If the headache remained severe, an epidural blood patch was performed. RESULTS: Only one patient in each group received relief from the injection. CONCLUSIONS: We do not recommend sumatriptan in patients who have exhausted conservative management of postdural puncture headache.

Nitroglycerin for rapid tocolysis: development of a protocol and a literature review.

OBJECTIVE: A protocol for nitroglycerin (NTG) use based on experiences with regard to new and previously described obstetric cases is presented. The efficacy of NTG tocolysis for obstetric emergencies is clinically evaluated. STUDY DESIGN: Hemodynamically stable parturients requiring acute tocolysis were treated with intravenous NTG and closely monitored. Clinical information was subsequently abstracted from medical records and compared with data from previous reviews. RESULTS: Tocolytic treatment was successful in all cases (22 of 22, 100%). Complications were clinically insignificant. The most common problem was transient hypotension, which occurred in 9 of 22 (41%) cases. CONCLUSION: NTG is an effective tocolytic with minimal complications, rapid onset, and a brief half-life. These characteristics favor its use during select obstetric procedures. However, strict adherence to protocols for administration is advised.

Effect of epidural clonidine added to epidural sufentanil for labor pain management.

Labor analgesia with intrathecal sufentanil has been shown to be prolonged by the addition of intrathecal clonidine. The current study was designed to determine if epidural clonidine would prolong labor analgesia provided by epidural sufentanil. Forty laboring primiparous women at less than 5 cm cervical dilation requesting epidural analgesia were enrolled. Following a 3 mL test dose of lidocaine with epinephrine, patients were randomized to receive 10 mL of either sufentanil 20 microg (S) or sufentanil 20 microg with clonidine 75 microg (SC). After administration of the analgesic, pain scores and side-effects were recorded for each patient at 5, 10, 15, 20 and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean duration of analgesia was similar between the S group (153 +/- 78 min) and the SC group (178 +/- 55 min). Side-effects were similar between the two groups. There was no difference between the two groups in time from sufentanil administration to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 20 microg after a lidocaine test dose provides analgesia comparable to that of sufentanil 20 microg with clonidine 75 microg; there was no significant difference in analgesic duration between the two groups.

Intrathecal sufentanil versus epidural lidocaine with epinephrine and sufentanil for early labor analgesia.

UNLABELLED: Intrathecal sufentanil provides approximately 2 h of excellent labor analgesia with minimal motor blockade. Epidural sufentanil has received less scrutiny but may provide the same benefits as intrathecal sufentanil. In this study, we compared epidural sufentanil 40 microg after a lidocaine with an epinephrine test dose with intrathecal (i.t.) sufentanil 10 microg with respect to onset and duration of analgesia, degree of motor block, side effect profile, and mode of delivery. Seventy ASA physical status I or II parturients in early labor (< or = 4 cm cervical dilation) were randomized to receive either i.t. sufentanil 10 microg with a combined spinal-epidural technique (CSE) or epidural sufentanil 40 microg (e.p.) after epidural catheter placement and testing with 3 mL of 1.5% lidocaine with epinephrine (15 microg). After the administration of analgesia, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. The study period was completed when the patients requested additional analgesia. All patients, except one, achieved adequate analgesia with the initial study dose and satisfactorily completed the study. There were no demographic differences between the two groups. Pain relief was rapid for all patients; pain scores were significantly lower at 5 and 10 min in the i.t. group versus the e.p. group. The mean duration of analgesia was similar between the e.p. group (127 +/- 40 min) and the i.t. group (110 +/- 48 min). No patient experienced any motor block. Side effects were similar between the two groups, except for pruritus-both the incidence and severity were significantly more profound at 5, 10, 15, 20, and 30 min in the i.t. group. There was no difference in time from analgesic to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 40 microg after a lidocaine test dose provides analgesia comparable to that of i.t. sufentanil 10 microg with less pruritus. IMPLICATIONS: We compared the efficacy and side effects of intrathecal sufentanil with epidural sufentanil with a local anesthetic test dose for analgesia during labor. Analgesia was equally good, although the intrathecal group experienced more itching.

Colloid cyst of the third ventricle: radiologic-pathologic correlation.

We describe a patient with a large colloid cyst of the third ventricle and resultant hydrocephalus. An unenhanced brain CT demonstrated the central portion of the mass to be of increased density relative to the peripheral portion. On T1-weighted images, the central portion of the mass was of increased signal intensity relative to brain, whereas the periphery was isointense. On T2-weighted images, the central portion was markedly hypointense to brain, while the peripheral portion was isointense. These imaging findings corresponded to an actual pathological difference between the central and peripheral portions of the mass. The central portion was solid, whereas the periphery was liquid. Since no histological difference was identified between the central and peripheral portions of the mass, we hypothesize that the differences in densities on CT and signal characteristics on MR were related to the state of hydration in the mass where the central portion possibly had a higher protein concentration than the periphery.

Pregnancy and delivery in a patient with recent peripartum cardiomyopathy.

We present a case of successful pregnancy and delivery in a patient with peripartum cardiomyopathy who conceived only 3 months after a vaginal delivery complicated by peripartum cardiomyopathy. Following the onset of labor, an arterial pressure catheter and pulmonary artery catheter were placed. A combined epidural spinal technique was performed without difficulty for labor analgesia. After a few hours of labor, the fetal heart rate tracing revealed repetitive variable decelerations, and a decision was made to proceed with operative delivery. The mother's hemodynamic changes are presented, and the specifics of the anesthetic care are outlined.

A microscopic analysis of cut-bevel versus pencil-point spinal needles.

UNLABELLED: An in vitro examination of 25-gauge Quincke and 25-gauge and 27-gauge Whitacre spinal needles was performed after insertion in 210 consenting adult patients. In addition, 300 unused Quincke needles and 300 unused pencil-point needles were examined under a dissecting microscope. When the microscopic evaluation was performed on the needles after spinal blockade, burrs or blunting of the needle tip were noted in 24% of the Quincke needles compared with only 3% of the 25-gauge Whitacre needles and 10% of the 27-gauge Whitacre (P < 0.05). Bony contact with 25-gauge Quincke and 27-gauge Whitacre needles resulted in an increased incidence of microscopic tip damage (versus 25-gauge Whitacre). Needle-tip damage with the Whitacre needles was limited to blunting of the tip. The analysis of unused needles revealed significant differences among manufacturers of the cut-bevel needles with respect to stylet-to-needle length and burrs on the end of the stylet. The leading edge of the stylet protruded beyond the opening of the needle tip in 7% of the Quincke needles. However, only minor needle-tip abnormalities were noted with the pencil-point needles (i.e., variability in the side-port opening to needle tip distance, side-port opening integrity). In conclusion, bony contact produced more damage to the cut-bevel than to the pencil-point needle tips. In addition, fewer inherent manufacturing defects were noted with the pencil-point versus cut-bevel needles. IMPLICATIONS: It has been suggested that damaged needle tips may contribute to a higher incidence of headaches after spinal anesthesia. A microscopic examination revealed that the pencil-point (versus cut-bevel) needles had fewer manufacturing flaws and were less susceptible to tip damage when bony contact occurred during the placement of the spinal needle.

Transient osteoporosis of the knee.

The MR findings in transient osteoporosis of the knee have been described as showing a diffuse area of decreased signal intensity (relative to normal bone marrow) on T1-weighted images and increased signal intensity on T2-weighted images. We report a case of transient osteoporosis, in which MRI showed a crescentic area of abnormal signal intensity in the posterior portion of the lateral femoral condyle, which was bordered by a rim of low signal intensity, best seen on the T2-weighted images. This abnormality was shown to resolve on follow-up MR scans.

Patient-controlled epidural analgesia: interactions between nalbuphine and hydromorphone.

Epidural opioid analgesia can offer advantages over intravenous administration, however, opioid-related side effects are common after epidural administration. We studied the effect of adding nalbuphine (NB), an opioid agonist-antagonist, to hydromorphone (HM) for patient-controlled epidural analgesia (PCEA) in 78 healthy women after elective cesarean delivery. Patients were randomly assigned to one of four treatment groups. The control group received preservative-free HM (Dilaudid) alone, 0.075 mg/mL, while the three study groups received HM, 0.075 mg/mL, containing preservative-free NB (Nubain) 0.02, 0.04, or 0.08 mg/mL. Intraoperatively, all patients received epidural bupivacaine 0.5%. Postoperatively, a patient-controlled anesthesia (PCA) device was connected to the epidural catheter and programmed to deliver a 3-mL loading dose of the analgesic solution. Subsequently, patients could self-administer 2 mL bolus doses on demand with a 30-min lockout interval. Patients were encouraged to ambulate approximately 8 h after surgery, and PCEA therapy was discontinued when a clear liquid diet was tolerated. Visual analog scale scores were used to assess pain at 8-h intervals while using PCEA therapy. Although the overall incidences of nausea (19%-35%) and pruritus (32%-62%) were similar in all four groups, the addition of NB decreased the need for bladder catheterization. The highest NB concentration resulted in increased PCA demands during the 32-h study period. In conclusion, the combination of HM 0.075 mg/mL and NB 0.04 mg/mL resulted in lower nausea scores and a decreased incidence of urinary retention compared with HM alone, without increasing the opioid analgesic requirement.

Nalmefene or naloxone for preventing intrathecal opioid mediated side effects in cesarean delivery patients.

This study was designed to evaluate the efficacy of nalmefene vs. naloxone in preventing side effects resulting from intrathecal opioids, in patients undergoing cesarean delivery. Eighty patients who were scheduled for elective cesarean delivery under spinal anesthesia were included in a double-blind, placebo-controlled study. Patients were randomized into four groups: saline; intravenous nalmefene 0.25 micro.kg(-1) every 12 h x 2; intravenous nalmefene 0.5 microg.kg(-1) every 12 h x 2; and naloxone infusion 48 microg.h(-1) (1.2 microg.ml(-1)). There were no significant differences among the groups with respect to pain, sedation, satisfaction, or the occurrence or treatment of pruritus or nausea. There was a significant difference among the groups with respect to the occurrence of vomiting (P < 0.03): both nalmefene groups had a higher rate of vomiting than did the control group; the 0.25 microg.kg(-1) nalmefene group had a higher rate than did the naloxone group. The use of narcotic antagonists does not result in improved comfort in obstetrical patients receiving intrathecal morphine and fentanyl.

Acquired port-wine stains.

BACKGROUND: An acquired port-wine stain is a rarely reported vascular lesion that mimics a congenital port-wine stain clinically, but is acquired after birth. METHODS: Clinical and histologic information concerning ten patients with acquired port-wine stains was recorded. Stains of seven of these patients were treated with either the copper vapor or pulsed dye laser. RESULTS: Collected information suggests that many acquired port-wine stains are idiopathic in nature. Light microscopic examination of tissue showed vascular dilation identical to that seen in congenital port-wine stains. Results of laser treatment were excellent in four patients, good in one patient, and poor in two patients. CONCLUSIONS: Although some differences exist, acquired port-wine stains are similar to congenital port-wine stains in their clinical morphology, histologic findings, and response to laser treatment.

Hints for hemostasis.

As dermatologists perform more complex and extensive surgical procedures, persistent bleeding and hematoma formation may be encountered more frequently. Several hints for hemostasis are presented that will help dermatologists prevent uncontrolled hemorrhage and manage bleeding complications. Employing these techniques will ease patient and surgeon anxiety and help avoid unwanted surgical complications.

Role of psychological factors in postoperative pain control and recovery with patient-controlled analgesia.

OBJECTIVE: We examined the extent to which preoperative state and trait anxiety, general need to control, need to control analgesia, expectations regarding postoperative pain, and demographic variables predict the severity of postoperative pain, discomfort, anxiety, duration of recovery, and patient-controlled analgesia (PCA) behaviors. DESIGN: Preoperative and outcome variables were analyzed using Pearson product-moment correlations and forward stepwise multiple linear regression. SETTING: This study was conducted at a university hospital in preoperative and postoperative settings. PATIENTS: Ninety-nine consecutively consenting ASA physical status I-II women (age 46 +/- 11 years, 70% caucasian, 28% Afro-American, 2% Hispanic) undergoing simple hysterectomy procedures with no known cancer were included in the study. INTERVENTIONS: Standardized general anesthesia, surgery, and PCA therapy was conducted. OUTCOME MEASURES: The McGill Pain Questionnaire (MPQ), patient requests and delivered analgesic medication, visual analog scales (VAS) for pain and anxiety, time to oral medications and hospital discharge, and Likert scale measurements of overall pain and discomfort were utilized. RESULTS: Older patients generally reported less pain, but used the same amount of analgesic medication as younger patients. Preoperative trait anxiety correlated with increased PCA requests, but not with postoperative pain. In contrast, preoperative state anxiety correlated positively with postoperative pain and with shorter time to hospital discharge. The patients' need for control was positively correlated with the Present Plan Index scale of the MPQ, with morphine requirement, and with PCA requests. CONCLUSIONS: Psychological factors do influence postoperative recovery and pain control in women receiving PCA therapy after abdominal hysterectomy, and attention to individual patient differences may lead to improved postoperative outcomes.