Inflammatory proteins in nasal lavage of workers exposed to occupational agents.

BACKGROUND: Low-molecular-weight (LMW) and high-molecular-weight (HMW) agents have been recognized as causes of occupational rhinitis (OR). Immunological mechanisms underlying OR differ according to the type of exposure. While HMW agents act mainly through IgE-mediated mechanisms, LMW agents appear to act through both immunological and non-immunological mechanisms. OBJECTIVE: The objective of this study was to identify potential differences in the upper airways inflammatory response after exposure to LMW and HMW agents by specific inhalation challenge test (SIC). METHODS: Nasal lavage (NL) samples from 20 subjects who were exposed to HMW (n = 10, Group I) and LMW (n = 10, Group II) at their workplaces were collected after SIC with control and specific occupational agents. These samples were analysed for 47 inflammatory markers using multiplex bead technology. RESULTS: After exposure to specific agent, Group I exhibited higher concentrations of the following proteins compared to Group II: fibrinogen (median (interquartile range) Group I: 0.09 (0.00) µg/mL, Group II: 0.04 (0.05) µg/mL, P = .05); haptoglobin (Group I: 0.86 (0.01) µg/mL, Group II: 0.14 (0.20) µg/mL, P = .02); vascular cell adhesion molecule-1 (VCAM-1) (Group I: 0.34 (0.67) ng/mL, Group II: 0.11 (0.11) ng/mL, P = .01); vascular endothelial growth factor (VEGF) (Group I: 157.0 (154.0) pg/mL, Group II: 98.0 (20.25) pg/mL, P = .01); and vitamin D (VDBP) (Group I: 0.06 (0.13) µg/mL, Group II: 0.03 (0.03) µg/mL, P = .04). No statistically significant differences in proteins profiles were observed between the groups after exposure to control agent. Also, subjects exposed to HMW agents showed a significant increase in NL levels of C-reactive protein compared to control-day exposure. CONCLUSIONS AND CLINICAL RELEVANCE: Exposure to HMW and LMW agents by SIC induced a differential nasal airway response including acute-phase reactants proteins (fibrinogen, haptoglobin and CRP), cell adhesion molecules (VCAM-1), endothelial growth factors (VEGF) and VDBP.

First Report of Canker Disease Caused by Neofusicoccum parvum and N. australe on Blueberry Bushes in Spain.

A field survey conducted in September 2009 at five plantations of six different cultivars of southern highbush blueberries (Vaccinium spp.) in Huelva, Spain, yielded 35 diseased plants. Diseased plants exhibited red-brown cankers and stem dieback. Blueberry cultivation in Huelva rose from 290 ha in 2007 to 777 ha in 2012, and the increase of these symptoms is of concern to producers. Stem pieces cut from the edge of lesions on infected plants were surface-disinfected with 5% sodium hypochlorite and cultured on potato dextrose agar (PDA). Based on colony characteristics on PDA, 18 colonies (one each from 18 different plants) were identified as Botryosphaeria spp. Species identities were confirmed by analysis of nucleotide sequences of the internal transcribed spacer (ITS), rDNA, and elongation factor 1-alpha (EF1-α) sequences, using ITS1-ITS4 (3) and EF728f-EF986r (2) as primer pairs, respectively. BLAST searches of GenBank showed a high similarity of the isolate sequences to the reference sequences. Molecular results confirmed these species as Neofusicoccum parvum, N. australe, and B. dothidea. N. parvum was the most prevalent (on 34% of the plants analyzed), followed by N. australe and B. dothidea (9% each). In phylogenetic analyses, isolates that clustered in the same group belonged to the same species with a high homogeneity index (>99%). One representative isolate of each species was selected for a pathogenicity assay. Amplified sequences from each selected isolate were deposited in GenBank with the following accession numbers: N. parvum, KC556958 (ITS) and KC556961 (EF); N. australe, KC556959 (ITS) and KC556962 (EF); and B. dothidea, KC556960 (ITS) and KC556963 (EF). The pathogenicity assay of these three isolates was conducted using two cultivars of southern highbush blueberry, 'Misty' and 'Star.' The isolates were cultured on acidified PDA at 25°C for 5 days. Stems of the plants were wounded at a height of 10 cm with a drill (5 mm diameter and ~4 mm deep). Six replicates per cultivar were inoculated per isolate by placing a colonized agar plug (4 to 5 mm diameter) in the hole and wrapping the stem with Parafilm. Plants treated identically with sterile agar plugs were used as controls. The plants were then maintained at 100% relative humidity for 2 h. This trial was conducted in a growth chamber at 28°C (night) and 30°C (day) with a 14-h photoperiod for 3 months. Disease was measured on a six-point scale: 0 = healthy plant; 1 = plant with a canker smaller than 3.5 cm; 2 = plant with a canker bigger than 3.5 cm; 3 = plant with one dry shoot; 4 = plant with some dry shoots; 5 = dead plant. At the end of the trial, disease was expressed as area under the disease progress curve. The results showed the N. parvum isolate to be the most aggressive, followed by the N. australe isolate. Espinoza et al. (1) also found that N. parvum showed more aggressiveness than N. australe on blueberries in Chile. B. dothidea was not pathogenic and behaved similarly to the controls (P < 0.05). Each pathogen was reisolated from all the inoculated plants, fulfilling Koch's postulates. To our knowledge, this is the first report of isolates of these pathogens, N. parvum and N. australe, causing stem canker and dieback on blueberry bushes in Spain. References: (1) J. G. Espinoza et al. Plant Dis. 93:1187, 2009. (2) A. J. L. Phillips et al. Mycol. 97:513, 2005. (3) T. J. White et al. Pages 315-322 in: PCR Protocols: a Guide to Methods and Amplifications. M. A. Innis et al., eds. Academic Press, San Diego, CA. 1990.

Occupational rhinitis caused by concurrent sensitization to two different allergens.

BACKGROUND: Exposure to wheat flour and guar gum is a well-known cause of occupational respiratory allergies among workers in the food processing industry. To date, there have been no reports of occupational rhinitis (OR) caused concurrently by two different allergens present in the workplace. AIMS: To report a case of OR likely to be induced concurrently by exposure to wheat flour and guar gum in a mid-40s male employed in the food processing industry. METHODS: Allergy tests and nasal challenge tests were performed to investigate and confirm the diagnosis of OR. We discuss potential mechanisms involved in the observed dual sensitization. RESULTS: The patient showed positive responses to wheat and guar gum extracts on skin prick testing. The total IgE was 1680 kU/l (0-100 kU/l). The diagnosis of OR was confirmed by nasal challenge tests with wheat flour and guar gum on different days. In contrast to the control day, the challenge with flour and guar gum induced an immediate clinical reaction associated with a decrease in nasal volume measured by acoustic rhinometry. The patient was advised to avoid exposure to wheat and guar gum, which resulted in a gradual resolution of nasal symptoms. CONCLUSIONS: Co-sensitization and cross-reactivity are possible mechanisms involved in cases of concurrent sensitization to related and unrelated allergens in patients complaining of work-related rhinitis symptoms.

Upper airway symptoms among workers with work-related respiratory complaints.

BACKGROUND: Work-related rhinitis and asthma symptoms frequently co-exist. AIMS: To determine the prevalence and nature of nasal, pharyngeal, laryngeal and sinus symptoms among individuals with work-related respiratory symptoms. METHODS: Individuals referred to a tertiary occupational asthma clinic for investigations with specific inhalation challenges were evaluated using the RHINASTHMA quality of life questionnaire and a questionnaire that assessed the nature and frequency of upper airway symptoms, their relationship to the workplace and their temporal relationship with the onset of asthma symptoms. RESULTS: There were 83 study participants. At least one upper airway symptom was reported by all of these individuals: nasal in 92%; pharyngeal in 82%; laryngeal in 65% and sinus in 53% of participants. Overall, there were no significant differences in the frequencies of nasal, pharyngeal, laryngeal and sinus symptoms when comparing these with occupational asthma (OA), work-exacerbated asthma (WEA) and work-related respiratory symptoms (WRS), except that nasal bleeding was most frequent among those with WRS. The presence of laryngeal symptoms was significantly associated with rhinitis-specific quality of life impairment. Individuals with workplace exposures to high molecular weight agents had greater impaired quality of life than those who were exposed to low molecular weight agents (RHINASTMA Upper Airway sub-scores: 24.0±10.4 versus 19.8±6.8; P < 0.05). CONCLUSIONS: Individuals who were referred for work-related respiratory symptoms experienced high rates of work-related nasal, pharyngeal, laryngeal and sinus symptoms, regardless of having OA, WEA or WRS.

Impact of intraoperative colonoscopy on anastomotic leakage detection and prevention in colorectal anastomosis for rectal cancer.

INTRODUCTION AND AIM: The value of leakage testing during colorectal resections to identify anastomotic leaks or bleeding has not been established. Our aim was to compare the impact of intraoperative colonoscopy (IOC) versus insufflation with a syringe, as leakage testing in lower anterior resection (LAR) for rectal cancer, with respect to the incidence of postoperative leakage (PL). MATERIALS AND METHODS: A retrospective study utilizing a prospective database of 426 patients with rectal cancer that underwent elective LAR, within the time frame of January 2015 and December 2019, was conducted. The anastomotic leak test was chosen by the surgeon. The incidence of postoperative leakage was compared between patients that underwent IOC and those that had the syringe leak test, utilizing the logistic regression analysis. Propensity score matching was included. RESULTS: There were no significant differences in the clinical characteristics or morbidity and mortality rates between the two groups. Four patients were excluded, leaving a patient total of 422. Seventy patients with IOC were compared with 352 that had the syringe leak test. The incidence of postoperative leakage was 5.7% in the IOC group and 12.2% in the control group (p = 0.001). After propensity score matching (n = 221), balancing the characteristics between the groups, the incidence of postoperative leakage was 5.7% in the IOC group and 13.9% in the syringe leak test group (p = 0.001). CONCLUSION: IOC was shown to be a safe method for evaluating the integrity of colorectal anastomosis and was associated with a higher percentage of protective stoma use, appearing to reduce the risk for PL.

Tubulin cofactor B regulates microtubule densities during microglia transition to the reactive states.

Microglia are highly dynamic cells of the CNS that continuously survey the welfare of the neural parenchyma and play key roles modulating neurogenesis and neuronal cell death. In response to injury or pathogen invasion parenchymal microglia transforms into a more active cell that proliferates, migrates and behaves as a macrophage. The acquisition of these extra skills implicates enormous modifications of the microtubule and actin cytoskeletons. Here we show that tubulin cofactor B (TBCB), which has been found to contribute to various aspects of microtubule dynamics in vivo, is also implicated in microglial cytoskeletal changes. We find that TBCB is upregulated in post-lesion reactive parenchymal microglia/macrophages, in interferon treated BV-2 microglial cells, and in neonate amoeboid microglia where the microtubule densities are remarkably low. Our data demonstrate that upon TBCB downregulation both, after microglia differentiation to the ramified phenotype in vivo and in vitro, or after TBCB gene silencing, microtubule densities are restored in these cells. Taken together these observations support the view that TBCB functions as a microtubule density regulator in microglia during activation, and provide an insight into the understanding of the complex mechanisms controlling microtubule reorganization during microglial transition between the amoeboid, ramified, and reactive phenotypes.

Correlation between acoustic rhinometry and subjective nasal patency during nasal challenge test in subjects with suspected occupational rhinitis; a prospective controlled study.

OBJECTIVES: To assess the correlation between acoustic rhinometry and visual analogue scale endpoints in the context of nasal challenge with occupational agents. DESIGN: Prospective controlled study. SETTING: University teaching hospital. PARTICIPANTS: Sixty-seven subjects with a history of work-related rhinitis and asthma symptoms. MAIN OUTCOMES MEASURES: Subjects underwent nasal challenge with control and specific agent on consecutive days. Nasal congestive response to challenge was monitored by acoustic rhinometry and visual analogue scale. RESULTS: Results showed no correlation between visual analogue scale and acoustic rhinometry measurements at baseline on the control (r=-0.13, P=0.3) and active (r=0.14, P=0.2) challenge days. No correlation was found between acoustic rhinometry and visual analogue scale when analysing all measurements obtained at all times after challenge with the control and active agent (control: r=0.09, P=0.04; active: r=0.001, P=0.9). The correlation between acoustic rhinometry and visual analogue scale was good and significant (r=-0.62, P=<0.01) when the analysis was restricted to cases showing a decrease in nasal volume>40% from baseline values. CONCLUSIONS: We showed that the correlation between acoustic rhinometry and subjective nasal patency was poor on steady conditions. However, a significant correlation was observed in those cases showing a greater nasal congestive response after challenge measured by acoustic rhinometry.

Occupational rhinitis in workers investigated for occupational asthma.

BACKGROUND: The links between asthma and rhinitis are now referred to as united airways disease (UAD). Current evidence shows that the UAD model seems to be applicable to occupational rhinitis (OR) and occupational asthma (OA). A study was undertaken to objectively assess, in the context of specific inhalation challenge (SIC) testing, the concomitance of bronchial and nasal reaction in the investigation of OR and OA. METHODS: 43 subjects with a history of work-related asthma symptoms underwent SIC for confirmation of OA and investigation of OR. Changes in bronchial calibre were measured by spirometry and nasal patency and airway inflammation were assessed by acoustic rhinometry and nasal lavage. RESULTS: A positive nasal challenge was observed in 25 SIC tests and a positive bronchial challenge was observed in 17 SIC tests. A concomitant positive nasal and bronchial challenge was observed in 13 instances. This association was significant (risk ratio = 1.7; 95% CI 1.0 to 2.4; p = 0.04) and more frequent in subjects challenged with high molecular weight agents (n = 11/22) than with low molecular weight agents (n = 2/21). In subjects with a positive nasal challenge, nasal lavage showed a significant increase in eosinophils 30 min after exposure which correlated with changes in nasal patency. CONCLUSION: The results of this study provide objective evidence to support the concept of UAD using OR and OA as a model to demonstrate a significant concomitant physiological reaction of the nose and lungs after challenge. This study shows that OR can be assessed by objective means; it often coexists with OA but can be present without OA.

Occupational rhinitis.

The present document is the result of a consensus reached by a panel of experts from European and nonEuropean countries on Occupational Rhinitis (OR), a disease of emerging relevance, which has received little attention in comparison to occupational asthma. The document covers the main items of OR including epidemiology, diagnosis, management, socio-economic impact, preventive strategies and medicolegal issues. An operational definition and classification of OR tailored to that of occupational asthma, as well as a diagnostic algorithm based on steps allowing different levels of diagnostic evidence, are proposed. The needs for future research are pointed out. Key messages are issued for each item.

AIDS mortality among Puerto Ricans and other Hispanics in New York City, 1981-1987.

Analysis of AIDS mortality data for New York City for 1981-1987 reveals that Puerto Ricans represent the racial/ethnic group most severely affected by this city's AIDS epidemic. Cumulative age-adjusted AIDS mortality rates among Puerto Rico-born males are significantly higher (362 per 100,000) than among blacks (267), whites (182), or other Hispanic (217) males, and cumulative age-specific mortality rates for males are highest for the Puerto Rico-born in every adult age group. AIDS proportional mortality analysis indicates that in 1987 the proportion of all deaths due to AIDS was 10% among those Puerto Rican-born, 12% among other Hispanics (which includes at least 50% United States-born Puerto Ricans), 6% among blacks, and 2% among whites.

Acute posteroinferior wall myocardial infarction secondary to football chest trauma.

Myocardial infarction secondary to nonpenetrating chest trauma is rare. We present the case of a sportsman who developed an acute transmural posteroinferior wall myocardial infarction due to chest trauma by a football. The angiographic study revealed total obstruction of the proximal right coronary artery.

Noninvasive nasal mask ventilation beyond the ICU for an exacerbation of chronic respiratory insufficiency.

STUDY OBJECTIVE: To assess the usefulness of noninvasive nasal mask ventilation (NMV) in the treatment of an exacerbation of chronic respiratory insufficiency in patients stable enough to be admitted to a non-ICU ward. DESIGN: A prospective study in which the beneficial effect of NMV was compared with conservative treatment. SETTING: A ward of respiratory medicine of a tertiary-referral teaching hospital. PATIENTS: The study group included 15 patients with acute respiratory acidosis. These patients had pH less than 7.35 and PaCO2 more than 60 mm Hg, respiratory rate of 30 breaths or less per minute, hemodynamic stability, and alertness and willingness of cooperation with the NMV treatment. The control group consisted of 16 patients who fulfilled the same arterial blood gas requirements, retrospectively selected from the discharge forms of the ward of respiratory medicine for the year 1993. INTERVENTIONS: Patients underwent NMV for two sessions per day (one in the morning and one in the afternoon), each session lasting 4 h. A volumetric respirator (Monnal D; Taema; Paris, France) was used in four patients with restrictive disease. A positive-pressure ventilator (DP90; Taema; Paris, France) was used in 11 patients with obstructive disease. Control patients received standard medical, oxygen, and chest physical therapy. RESULTS: As compared with pre-NMV values, mean pH was significantly higher at 4 h of NMV after the patient's ventilatory adaptation (t = 8.814, p < 0.001) and at the end of NMV (t = 12.06, p < 0.001). Ventilatory support also produced a significant improvement in hypercapnia (pre-NMV vs NMV after the patient's ventilatory adaptation, t = 6.675, p < 0.001; pre-NMV vs post-NMV, t = 6.976, p < 0.001). Posttreatment pH and PaCO2 values were significantly higher and lower, respectively, in NMV-treated patients than in controls. At the end of treatment, a significantly higher PaO2/FIO2 ratio was documented in the study group than in controls (post-NMV vs posttreatment, t = 2.846, p < 0.01). CONCLUSIONS: NMV associated with standard treatment may be more beneficial than conservative treatment alone for improving blood gas exchange in patients with chronic respiratory insufficiency admitted to the hospital (but not the ICU) for an episode of acute decompensation and respiratory acidosis.

Changes in sex behaviour after menopause: effects of tibolone.

In order to analyse both sexual desire after menopause and its response to treatment with tibolone, a randomized placebo/tibolone trial has been designed with 28 postmenopausal patients. They were asked to answer a questionnaire designed by us to obtain quantitative measurements to describe changes in sexual desire. After selection, the patients were randomly assigned to two groups as follows: 14 in the group treated with 2.5 mg/day of tibolone and 14 in the placebo group treated with 500 mg/day of calcium. The patients were monitored after 3, 6 and 12 months. Before joining this study, they had signed a written consent. It was observed that the sexual desire after menopause underwent a significant fall, with decline in arousability and intercourse. The comparative results show that the patients treated with tibolone experience an improvement after the third month of treatment and this improvement was maintained until the end of treatment. We conclude that the questionnaire proposed here is a useful non-parametric method to diagnose a patient's sexuality status at the baseline assessment and a valuable tool for monitoring various therapies. Furthermore, tibolone proved to be effective in managing reduced sexual desire which appears in postmenopausal patients.

Nutritional and immunologic evaluation of patients with gastric cancer before and after surgery.

The main objective was to evaluate a patient's immunologic and nutritional status as a prognostic indicator of morbidity and mortality in patients with gastric cancer. A prospective clinical study carried out at the National Cancer Institute in Bogotá, Colombia. Our study group consisted of 40 patients with a diagnosis of gastric adenocarcinoma that was treated surgically. Blood samples were taken before and 5 d after surgery; mononuclear cell typing was done by flow cytometry allowing a bicolor analysis. Nutritional evaluation was obtained through measurement of albumin levels, average weight loss, and nutritional risk index (NRI). Half of the malignancies were localized to the middle and lower third of the stomach: stage I, 17.55%; stage II, 10%; stage III, 55%; and stage IV, 17.5%. Twenty subtotal gastrectomies, 11 total gastrectomies, 7 gastrojejunostomies, and 2 esophagogastrectomies with D1 and D2-D3 lymph node resection were performed. A postoperative morbidity of 22.5% and a mortality of 7.5% were observed. A preoperative cellular immunosuppression was identified, with a helper lymphocyte (CD4) to suppressor/cytotoxic lymphocyte (CD8) ratio of 1.38 normal value (NV > 1.5), which increased according to the stage of the disease. Patients who died presented with a significantly greater preoperative cellular immunosuppression than those who survived (P = 0.05). Postoperative mortality correlated significantly with hypoalbuminemia (P = 0.008). In those who died, weight loss was greater than in those who survived (P = 0.06). Patients with severe malnutrition had greater postoperative mortality according to the NRI. Severe preoperative cellular immunosuppression (CD4/CD8 < 1), hypoalbuminemia, weight loss, and severe NRI have a positive predictive value for mortality in patients with gastric cancer.

Potentiometric study of the protonation and distribution equilibria of d-gluconic-delta-lactone acid in sodium perchlorate solutions at 25 degrees C and construction of a thermodynamic model.

The protolytic behavior of d-gluconic-delta-lactone acid has been studied by means of automated potentiometric titrations at different ionic strengths in the range 0.1

Orthotopic heart transplantation for dilated cardiomyopathy in a patient with persistent left superior vena cava and atresia of the right superior vena cava.

OBJECTIVE: To describe the surgical procedure of an orthotopic heart transplantation in a recipient with persistent left superior vena cava and atresia of right superior vena cava. EXPERIMENTAL DESIGN: Case report. PATIENT: A 43 year old male with persistent left superior vena cava, atresia of the right superior vena cava and dilated cardiomyopathy. INTERVENTIONS: Orthotopic heart transplantation with selective cannulation of the left superior vena cava via recipient coronary sinus for cardiopulmonary bypass. RESULTS: No perioperative complications, satisfactory postoperative course. No rejection episodes at 7 months postoperative with non invasive procedure surveillance. CONCLUSION: Technique described to preserve left superior vena cava is a useful alternative for this patient with no surgical complications.

[Assisted ventilation via nasal mask in patients hospitalized in a pneumology ward for decompensation of their chronic air-flow obstruction]. / Ventilación asistida vía máscara nasal en pacientes hospitalizados en una sala de neumología por descompensación de su obstrucción crónica al flujo aéreo.

Our aim was to evaluate the efficacy of assisted ventilation through a nasal mask (AVN) in treating chronic obstructive pulmonary disease (COPD) patients who were admitted to a pneumology ward due to decompensation, with PaCO2 > 60 mmHg and pH < 7.35. We studied 13 COPD patients who were first observed for 1-2 days until adaptation and then given 2 daily sessions of AVN lasting 4 hours with double positive pressure (DP90) devices through Sullivan mask with a cannula for hyperoxia. Gasometric readings were recorded, along with subjective assessment of condition and problems with the mask. Gasometric readings were taken as follows: the first upon admission to the ward (AW), the second with AVN 2 days after adaptation and the third 3 hours after the second (POST). Statistical analysis was with a Student t-test for paired series. Mean age was 64 +/- 3 years and FEV1 was 0.69 +/- 0.14 l. Interruptions were due to the need for mouth opening even at minimum pressures, and the inability to adapt to the consequent tachypnea. No other problems were reported by the remaining patients and all perceived improvement subjectively. The pH of 7.29 +/- 0.03 at AW increased to 7.41 +/- 0.03 with AVN (p < 0.001) and held steady at 7.39 +/- 0.01 at POST (p < 0.001 POST-AW and p = NS POST-AVN). PaO2/FiO2 was 223 +/- 49 mmHg at AW and 267 +/- 41 mmHg at the POST reading (p = 0.06). PaO2 with AVN was 67 +/- 8 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

[Growth and polysaccharide formation in Sinorhizobium meliloti strains in an air-lift-type fermentor. Effect on nodulation velocity in alfalfa plants]. / Crecimiento y formación de polisacáridos de cepas de Sinorhizobium meliloti en un fermentador tipo air-lift. Influencia en la velocidad de nodulación en plantas de alfalfa.

In this paper the influence of the exopolysaccharides produced by Sinorhizobium meliloti strains on the nodulation rates in alfalfa plants has been considered. The experiments were performed in a rotary shaker and in an air-lift type fermentor. Different Sinorhizobium meliloti strains were used. Bacterial growth rates were determined by viable cell counts. Exopolysaccharide concentration was determined by precipitation with ethanol. It was observed that maximum cell concentration was in the order of 1 x 10(10) cell/ml and exopolysaccharide content was approximately 11 g/l. The experiments performed with alfalfa plants in a controlled environment chamber showed that, when inoculation was carried out with diluted suspensions (1/10), nodulation time was reduced from 10 to 4 days, while the strains retained their symbiotic properties.

[Anaesthesia and recovery in a case of placenta percreta]. / Anestesia y reanimación en un caso de placenta pércreta.

Placenta percreta is a sub-type of placenta accreta in which this organ invades the whole uterine wall and affects the adjacent organs. It is a condition with a high surgical risk which generally requires an obstetric hysterectomy. We present the case of a 36 year-old pregnant woman diagnosed with placenta percreta with bladder and intestinal invasion. She suffered a hypovolaemic shock during surgery which required a massive transfusion of blood products and inotropic support. Three further successive surgeries were required due to the bleeding, with selective embolisation of the hypogastric arteries being performed in one of them. She required 13 days in intensive care. The total volume of blood products transfused was, 43 units of red cells, 28 units of plasma, and 8 platelet pools. The importance of early prenatal diagnosis is emphasised in order to adequately plan the operation, and should include a multidisciplinary team (general surgeons, urologists, vascular surgeons), as well as experienced anaesthesiologists and obstetricians.

[Control of postoperative pain in knee arthroplasty: single dose femoral nerve block versus continuous femoral block]. / Control del dolor postoperatorio en artroplastia de rodilla: bloqueo del nervio femoral con dosis única frente a bloqueo femoral continuo.

INTRODUCTION: To compare the efficacy of a multimodal analgesia with 2 different techniques (femoral nerve block with a single dose and continuous femoral nerve block) in the control of pain, use of opioids, and secondary effects in patients subjected to total knee replacement. MATERIAL AND METHODS: A prospective randomised study of patients subjected to knee replacement with subarachnoid anaesthesia. The postoperative analgesia consisted of tramadol, dexketoprofen and paracetamol, and one of the following techniques: Femoral nerve block with a single dose of 30mL of 0.5% ropivacaine, or that dose plus a continuous infusion via a femoral catheter of 0.375% ropivacaine 6ml/h for 48h. The demographic, anaesthetic and surgical variables were recorded, along with the pain intensity using a visual analogue scale, opioid use, and complications at 24 and 48h after surgery. RESULTS: A total of 104 patients were included. There no differences in the demographic data between the groups. The pain intensity was lower in the group that had continuous femoral block, particularly at 48h, compared to the single-dose block, and with a lower use of rescue analgesia in the continuous femoral block. The incidence in secondary effects was similar, with a lower long-term sensory block being observed in the femoral block with a single dose. CONCLUSIONS: The use of peripheral nerve block is accepted practice for analgesia after knee replacement surgery. Continuous femoral block is a valid alternative, decreasing the use of rescue opiates and pain intensity (particularly at 48h) compared to isolated femoral block.