Medial orbital wall reconstruction with flexible Ethisorb patches.

OBJECTIVES: The aim of this study was to analyse the long-term result after reconstruction of the medial orbital wall with a flexible, biodegradable material (Ethisorb). MATERIALS AND METHODS: During a period of almost 8 years, 31 patients with a medial orbital wall fracture were analysed retrospectively. Inclusion criteria were patients with a maximum size fracture of the orbital medial wall measuring 1.5-2 cm(2). Exophthalmos, enophthalmos, bulbus motility, diplopia and skin sensation were investigated over a period of 6 months. In all patients, the medial orbital wall was reconstructed with Ethisorb patches. RESULTS: No significant intraoperative complications were detected. No postoperative infection, abscess or seroma was found in any of the patients receiving an Ethisorb patch. CONCLUSIONS: The advantage of the semiflexibility of the Ethisorb patch is that it supplies an anatomically correct fit to the orbital medial wall but does not require fixation by screws or the use of sutures. CLINICAL RELEVANCE: The low rate of reported bulbus motility disturbance, diplopia, exophthalmos and enophthalmos demonstrates acceptable results after medial orbital wall reconstruction using the Ethisorb patch.

Single umbilical artery in twin pregnancies.

OBJECTIVE: Our purpose was to evaluate the antenatal incidence of single umbilical artery (SUA) in twin pregnancies according to chorionicity and to assess its relationship with outcome. METHODS: Consecutive twin pregnancies undergoing ultrasound evaluation at our institutions were included. A targeted sonographic evaluation of the umbilical cord and vessels was performed in all cases. Chorionicity was determined according to standard ultrasound criteria. RESULTS: A total of 174 twin pregnancies, 100 dichorionic (DC) and 74 monochorionic (MC), were included in the study. An SUA was identified in 17 (9.8%) pregnancies, and in 18 (5.2%) fetuses. No difference was found in the incidence of SUA in DC and MC twins. Among affected pregnancies, all but one DC twin pregnancy were discordant for SUA. Structural and/or chromosomal abnormalities were present in 27.8% of fetuses with SUA. The prevalence of small-for-gestational-age fetuses and of discordant birth weight (> 20% discordance) was higher in the SUA group than in the rest of the population, although these differences were not statistically significant. Twin pairs discordant for SUA had significantly higher weight discordance than those with normal umbilical cords. The sonographic cross-sectional area of the SUA did not appear to show the typical adaptive dilatation usually seen in singleton pregnancies with SUA. CONCLUSIONS: The incidence of SUA in twins is higher than in singletons, with no difference between MC and DC twins. Intrapair discordance for SUA in identical twins provides evidence against an exclusively genetic origin of this anomaly. The apparent failure of compensatory dilatation of the umbilical artery in twins with SUA may explain in part the higher risk for fetal growth restriction in these cases.

Automation of peptide desalting for proteomic liquid chromatography - tandem mass spectrometry by centrifugal microfluidics.

For large-scale analysis of complex protein mixtures, liquid chromatography - tandem mass spectrometry (LC-MS/MS) has been proven to be one of the most versatile tools due to its high sensitivity and ability to both identify and quantify thousands of proteins in a single measurement. Sample preparation typically comprises site-specific cleavage of proteins into peptides, followed by desalting and concomitant peptide enrichment, which is commonly performed by solid phase extraction. Desalting workflows may include multiple liquid handling steps and are thus error prone and labour intensive. To improve the reproducibility of sample preparation for low amounts of protein, we present a centrifugal microfluidic disk that automates all liquid handling steps required for peptide desalting by solid phase extraction (DesaltingDisk). Microfluidic implementation was enabled by a novel centrifugal microfluidic dosing on demand structure that enabled mapping multiple washing steps onto a microfluidic disk. Evaluation of the microfluidic disk was performed by LC-MS/MS analysis of tryptic HEK-293 eukaryotic cell peptide mixtures desalted either using the microfluidic disk or a manual workflow. A comparable number of peptides were identified in the disk and manual set with 19 775 and 20 212 identifications, respectively. For a core set of 10 444 peptides that could be quantified in all injections, intensity coefficients of variation were calculated based on label-free quantitation intensities. The disk set featured smaller variability with a median CV of 9.3% compared to the median CV of 12.6% for the manual approach. Intensity CVs on protein level were lowered from 5.8% to 4.2% when using the LabDisk. Interday reproducibility for both workflows was assessed by LC-SRM/MS analysis of samples that were spiked with 11 synthetic peptides of varying hydrophobicity. Except for the most hydrophilic and hydrophobic peptides, the average CV was lowered to 3.6% for the samples processed with the disk compared to 7.2% for the manual workflow. The presented centrifugal microfluidic DesaltingDisk demonstrates the potential to improve reproducibility in the sample preparation workflow for proteomic mass spectrometry, especially for application with limited amount of sample material.

Tryptic digestion of human serum for proteomic mass spectrometry automated by centrifugal microfluidics.

Mass spectrometry has become an important analytical tool for protein research studies to identify, characterise and quantify proteins with unmatched sensitivity in a highly parallel manner. When transferred into clinical routine, the cumbersome and error-prone sample preparation workflows present a major bottleneck. In this work, we demonstrate tryptic digestion of human serum that is fully automated by centrifugal microfluidics. The automated workflow comprises denaturation, digestion and acidification. The input sample volume is 1.3 µl only. A triplicate of human serum was digested with the developed microfluidic chip as well as with a manual reference workflow on three consecutive days to assess the performance of our system. After desalting and liquid chromatography tandem mass spectrometry, a total of 604 proteins were identified in the samples digested with the microfluidic chip and 602 proteins with the reference workflow. Protein quantitation was performed using the Hi3 method, yielding a 7.6% lower median intensity CV for automatically digested samples compared to samples digested with the reference workflow. Additionally, 17% more proteins were quantitated with less than 30% CV in the samples from the microfluidic chip, compared to the manual control samples. This improvement can be attributed to the accurate liquid metering with all volume CVs below 1.5% on the microfluidic chip. The presented automation solution is attractive for laboratories in need of robust automation of sample preparation from small volumes as well as for labs with a low or medium throughput that does not allow for large investments in robotic systems.

PEAT-CLSM: A Specific Treatment of Peatland Hydrology in the NASA Catchment Land Surface Model.

Peatlands are poorly represented in global Earth system modeling frameworks. Here we add a peatland-specific land surface hydrology module (PEAT-CLSM) to the Catchment Land Surface Model (CLSM) of the NASA Goddard Earth Observing System (GEOS) framework. The amended TOPMODEL approach of the original CLSM that uses topography characteristics to model catchment processes is discarded, and a peatland-specific model concept is realized in its place. To facilitate its utilization in operational GEOS efforts, PEAT-CLSM uses the basic structure of CLSM and the same global input data. Parameters used in PEAT-CLSM are based on literature data. A suite of CLSM and PEAT-CLSM simulations for peatland areas between 40°N and 75°N is presented and evaluated against a newly compiled data set of groundwater table depth and eddy covariance observations of latent and sensible heat fluxes in natural and seminatural peatlands. CLSM's simulated groundwater tables are too deep and variable, whereas PEAT-CLSM simulates a mean groundwater table depth of -0.20 m (snow-free unfrozen period) with moderate temporal fluctuations (standard deviation of 0.10 m), in significantly better agreement with in situ observations. Relative to an operational CLSM version that simply includes peat as a soil class, the temporal correlation coefficient is increased on average by 0.16 and reaches 0.64 for bogs and 0.66 for fens when driven with global atmospheric forcing data. In PEAT-CLSM, runoff is increased on average by 38% and evapotranspiration is reduced by 19%. The evapotranspiration reduction constitutes a significant improvement relative to eddy covariance measurements.

A pharmacokinetic study of two modified-release methylphenidate formulations under different food conditions in healthy volunteers.

OBJECTIVES: Primary objective was to investigate bioequivalence of Ritalin LA(R); 40 mg compared to Medikinet retard 40 mg in healthy male volunteers under fasted and fed conditions. Secondary objectives included assessment of tolerability and determination of further pharmacokinetic parameters. The difference between the kinetic profiles of Ritalin LA(R) and Medikinet retard with respect to breakfast intake was additionally explored. METHODS: 28 subjects were randomized in this open-label, four-treatment, cross-over-design study. Pharmacokinetic evaluations included AUC(0-inf), Cmax, tmax, elimination half life (t1/2) and mean residence time MRT(0-inf)). The relative bioavailability of Ritalin LA(R) and Medikinet retard and the food effect were assessed using a 90% confidence interval (CI) based on the lower and upper endpoints of the CI for the ratios of the geometric means being within the 80 - 125% equivalence criterion. RESULTS: 25 volunteers completed all treatment arms. Frequency of adverse events were comparable for all treatments. Under fasted condition Ritalin LA(R) showed a consistent bimodal concentration time profile with two tmax peaks. Medikinet retard showed a steady absorption with a single tmax peak. The point estimators for AUC(0-inf) and Cmax were found to be 99.7% and 85.9%, respectively. Under fed condition both Ritalin LA(R) and Medikinet retard showed a bimodal concentration time profile with two tmax peaks. The point estimators for AUC(0-inf) and Cmax were estimated as 89.8% and 68.6%, respectively. CONCLUSIONS: Both methylphenidate formulations were safe and well tolerated. Ritalin LA and Medikinet retard were bioequivalent in fasted state but not in fed state. Only Ritalin LA had a biphasic kinetic profile under both fasted and fed conditions. This difference in the kinetic profiles might be of clinical relevance and might offer a potential advantage of Ritalin LA.

Soil and surface runoff phosphorus relationships for five typical USA midwest soils.

Excessively high soil P can increase P loss with surface runoff. This study used indoor rainfall simulations to characterize soil and runoff P relationships for five Midwest soils (Argiudoll, Calciaquaoll, Hapludalf, and two Hapludolls). Topsoil (15-cm depth, 241-289 g clay kg(-1) and pH 6.0-8.0) was incubated with five NH4H2PO4 rates (0-600 mg P kg(-1)) for 30 d. Total soil P (TPS) and soil-test P (STP) measured with Bray-P1 (BP), Mehlich-3 (M3P), Olsen (OP), Fe-oxide-impregnated paper (FeP), and water (WP) tests were 370 to 1360, 3 to 530, 10 to 675, 4 to 640, 7 to 507, and 2 to 568 mg P kg(-1), respectively. Degree of soil P saturation (DPS) was estimated by indices based on P sorption index (PSI) and STP (DPSSTP) and P, Fe, and Al extracted by ammonium oxalate (DPSox) or Mehlich-3 (DPSM3). Soil was packed to 1.1 g cm(-3) bulk density in triplicate boxes set at 4% slope. Surface runoff was collected during 75 min of 6.5 cm h(-1) rain. Runoff bioavailable P (BAP) and dissolved reactive P (DRP) increased linearly with increased P rate, STP, DPSox, and DPSM3 but curvilinearly with DPSSTP. Correlations between DRP or BAP and soil tests or saturation indices across soils were greatest (r > or = 0.95) for FeP, OP, and WP and poorest for BP and TPS (r = 0.83-0.88). Excluding the calcareous soil (Calciaquoll) significantly improved correlations only for BP. Differences in relationships between runoff P and the soil tests were small or nonexistent among the noncalcareous soils. Routine soil P tests can estimate relationships between runoff P concentration and P application or soil P, although estimates would be improved by separate calibrations for calcareous and noncalcareous soils.

Technical and surgical aspects of the sphenopalatine ganglion (SPG) microstimulator insertion procedure.

Cluster headache (CH) is a debilitating, severe form of headache. A novel non-systemic therapy has been developed that produces therapeutic electrical stimulation to the sphenopalatine ganglion (SPG). A transoral surgical technique for inserting the Pulsante SPG Microstimulator into the pterygopalatine fossa (PPF) is presented herein. Technical aspects include detailed descriptions of the preoperative planning using computed tomography or cone beam computed tomography scans for presurgical digital microstimulator insertion into the patient-specific anatomy and intraoperative verification of microstimulator placement. Surgical aspects include techniques to insert the microstimulator into the proper midface location atraumatically. During the Pathway CH-1 and Pathway R-1 studies, 99 CH patients received an SPG microstimulator. Ninety-six had a microstimulator placed within the PPF during their initial procedure. Perioperative surgical sequelae included sensory disturbances, pain, and swelling. Follow-up procedures included placement of a second microstimulator on the opposite side (n=2), adjustment of the microstimulator lead location (n=13), re-placement after initial unsuccessful placement (n=1), and removal (n=5). This SPG microstimulator insertion procedure has sequelae comparable to other oral cavity procedures including tooth extractions, sinus surgery, and dental implant placement. Twenty-five of 29 subjects (86%) completing a self-assessment questionnaire indicated that the surgical effects were tolerable and 90% would make the same decision again.

Glatiramer acetate (GA) induces IL-13/IL-5 secretion in naive T cells.

In order to define possible mechanisms of immunomodulation by glatiramer acetate (GA), we investigated the primary in vitro cytokine response of peripheral blood mononuclear cells (PBMCs) and T-cell subpopulations. In PBMCs from healthy subjects and untreated patients with multiple sclerosis (MS) GA-induced T-cell proliferation and mRNA expression/cytokine, secretion of IL-13 and IL-5 but not of IL-10, TGF-beta or IL-12, IL-4 was detected at the mRNA level only. IFN-gamma was induced in a few subjects at very low concentrations. The response to GA was driven by the CD4(+)/CD45RA(+) T-cell subpopulation and was mediated by T-cell receptor (TCR) engagement as determined by anti-TCR blocking antibodies. The findings are compatible with the hypothesis that GA functions as partial or weak TCR-agonist activating naive T cells to produce the Th2 cytokines IL-13 and IL-5.

Soil phosphorus, management practices, and their relationship to phosphorus delivery in the Iowa Clear Lake agricultural watershed.

Clear Lake is on Iowa's list of impaired water bodies because of high P concentration. This study assessed soil-test phosphorus (STP), management practices, and P loads from its agricultural watershed. Management practice histories and STP for eight basins were surveyed in 1999. Soil samples (15-cm depth) were analyzed for STP with agronomic [Bray P1 (BP), Olsen (OP), Mehlich 3 (M3P) and environmental [iron oxide-impregnated paper (FeP) and water extraction (WP)] tests. Total phosphorus (TP) concentrations in water discharge from five basins were measured during two years, and TP loads were measured for two basins. The agronomic P tests showed that 46 to 83% (depending on the test) of the area tested above optimum for crops. Correlations among tests were high for OP, M3P, and FeP (r > 0.96) and lower for BP and WP (r = 0.88-0.93). Moldboard- and chisel-plow tillage predominated (82% of the area). Applied P (mainly fertilizer) averaged 15 kg P ha(-1) yr(-1), and 40% of the high-testing area (M3P test) was being fertilized. The mean annual water TP concentration across five basins was 275 to 474 microg L(-1). The two-year mean TP loads for the two gauged basins were 1504 and 1510 g P ha(-1) yr(-1). Water TP concentration increased linearly with increasing STP. Relationships were stronger for M3P and FeP (R2 = 0.96-0.97 for annual means and 0.77-0.79 for storm-flow events) than for BP or WP (R2 = 0.88-0.91 and 0.59-0.69, respectively). Improving P and soil conservation practices in high-testing areas could reduce P loads to the lake.

The importance of in-hospital mortality for patients requiring free tissue transfer for head and neck oncology.

Mortality is a rare but disastrous complication of microvascular head and neck reconstruction. The investigators attempt to identify the procedure-related mortality cases and analyse the causes of death. A retrospective analysis of 804 consecutive free flap procedures during a 19-year period was performed and fatal cases were identified (n=42 deaths). Multivariate logistic regression was employed to determine the association of in-hospital mortality with patient-related characteristics. The 30-day post-operative mortality rate was 1% (8 out of 804 patients), and the in-hospital mortality rate (post-operative deaths in-hospital before or after the 30th post-operative day without discharge) was 5.2% (42 out of 804 patients). Cancer recurrence and metastases related pneumonia were the most common causes of death (n=26, 62%), followed by cardiac, pulmonary, infectious and hepatic/renal aetiologies. Logistic regression analysis revealed that patients with stage IV disease and an operation time of >9h were significantly associated with post-operative mortality. Malignancy-related conditions were the most common causes of death following free flap transfer for head and neck reconstruction. For patients with stage IV head and neck cancer, this aggressive surgical approach should be cautiously justified due to its association with post-operative mortality. To shorten the operation time, experienced microsurgical operation teams are necessary.

Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps.

This study analyzed the surgical outcome and complications of 1000 microvascular free flaps performed at the authors' institution in Germany, between 1987 and 2010. 972 patients underwent reconstruction with 1000 flaps: 28% latissimus dorsi flaps, 27% radial forearm flaps, 20% iliac crest flaps, 12% fibula flaps, 6% jejunal flaps, 2% anterolateral thigh flaps, and 5% other flaps. 130 failures (7.6%) were encountered, including 58 complete flap failures (44.6%) and 72 partial free-flap failures (55.4%). This study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck, but it is essential that complications be recognized and addressed early in their course to prevent or minimize devastating consequences. Owing to the large number of possible errors in flap transplantation, microsurgeons should always check everything for themselves. The on-duty doctors and nursing staff should not be trusted blindly. Venous thrombosis and cervical haematoma are the most common complications at the recipient site and are mainly responsible for flap failure, while complications occurring at the donor site may result from dehiscence and graft necrosis. When a compromised flap is identified, surgical re-exploration should not be deferred.

A hematogenous spread brain abscess invading the right damaged temporomandibular joint.

We report a rare case of a brain abscess which drained spontaneously in a temporomandibular joint damaged by osteoarthritis. The female patient presented to our hospital with a severe headache and pain in the temporomandibular joint. She showed elevated inflammatory parameters with unknown cause. Magnetic resonance imaging of her whole body revealed a large temporal brain abscess extending into the glenoid fossa of the temporomandibular joint. The brain abscess was incised and drained by neurosurgeons in our hospital and in the same operation we resected the articular disc and the affected part of the right temporomandibular joint. Histological examination confirmed a chronic arthrosis in the resected bone of the temporomandibular joint and an inflammatory abscess in the resected brain tissue. The patient recovered well and the inflammation resolved as seen in postoperative investigations. Magnetic resonance imaging a month later confirmed local consolidation in the brain with no sign of residual inflammation.

Diagnostic and therapeutic aspects in the treatment of gunshot wounds of the viscerocranium.

Gunshot wounds of the viscerocranium are a rare occurrence during times of peace in Europe. The removal of projectiles is recommended; in some cases, however, this is controversial. The material properties of projectiles and destruction of anatomical landmarks make it difficult to determine their precise location. Therefore, navigation systems and cone-beam computed tomography (CT) provide the surgeon with continuous intraoperative orientation in real-time. The aim of this study was to report our experiences for image-guided removal of projectiles, the use of cone-beam computed tomography and the resulting intra- and postoperative complications. We investigated 50 patients with gunshot wounds of the facial skeleton retrospectively, 32 had image-guided surgical removal of projectiles in the oral and maxillofacial region, 18 had surgical removal of projectiles without navigation assistance and in 28 cases we used cone-beam CT in the case of dislocated projectiles and fractured bones. There was a significant correlation (p = 0.0136) between the navigated versus not navigated surgery and complication rate (8 vs. 32%, p = 0.0132) including major bleeding, soft tissue infections and nerve damage. Furthermore, we could reduce operating time while using a navigation system and cone-beam CT (p = 0.038). A high tendency between operating time and navigated surgery (p = 0.1103) was found. In conclusion, there is a significant correlation between reduced intra- and postoperative complications including wound infections, nerve damage and major bleeding and the appropriate use of a navigation system. In all these cases we were able to present reduced operating time. Cone-beam CT plays a key role as a useful diagnostic tool in detecting projectiles or metallic foreign bodies intraoperatively.

Clinical indication for intraoperative 3D imaging during open reduction of fractures of the neck and head of the mandibular condyle.

PURPOSE: This study aimed to evaluate the use of intraoperative cone-beam computed tomography (CBCT) in monitoring the results of repositioning and osteosynthesis of condylar process and head (capitulum) fractures of the mandible to see if CBCT is beneficial for these patients. PATIENTS AND METHODS: Sixty patients (22 females and 38 males, age range 16-79 years, average 36.5 years) with condylar process and head fractures according to the classification of Spiessl and Schroll were treated during the study period. Thirty-four of the 60 patients received a CBCT scan immediately after surgical treatment under aseptic conditions. RESULTS: In all 34 cases, intraoperative CBCT provided high-quality imaging of the condylar process in all three planes. In four patients (11.8%), unsatisfactory reposition or unexpected complications were detected which could immediately be corrected with a surgical revision. CONCLUSION: Intraoperative use of CBCT enables optimization of the surgical outcome for fractures of the condylar process and head of the mandible, reduces postoperative complications, and spares patients from repeated intervention. In addition, intraoperative CBCT enables safer treatment with minimally invasive approaches.

[FTY720 (Fingolimod) as a new therapeutic option for multiple sclerosis]. / FTY720 (Fingolimod) als neue Therapiemöglichkeit der Multiplen Sklerose.

All currently available therapeutic options for multiple sclerosis have to be administered parenterally. Several oral substances are currently in the late clinical development stage. One of them, FTY720 (also known as fingolimod) is highlighted in this review. The biological effects of FTY720 are presented as well as animal data and first clinical data from a phase II trial in multiple sclerosis patients. The effects of FTY720 are based on an innovative approach and apparently target several key elements in the pathogenesis of multiple sclerosis. The first clinical data with FTY720 show very promising results, with a relapse reduction of over 50% compared to placebo and an acceptable safety profile. These results currently await confirmation in two international phase III studies which are recruiting patients worldwide.

Correlation of serum IL-13 and IL-5 levels with clinical response to Glatiramer acetate in patients with multiple sclerosis.

Glatiramer acetate (GA) is effective in the treatment of Multiple Sclerosis (MS) presumably by the induction of an immunoregulatory T-cell response. We have previously shown that GA directly induces the Th2 cytokines IL-13 and IL-5 in T-cells in vitro. In the present study we compared the in vitro response to GA in healthy controls, untreated and GA-treated MS patients and tested whether the induction of IL-13 and IL-5 secretion is also detectable in the serum of 25 MS patients treated with GA. Patients were grouped into clinical responders and nonresponders in order to determine a possible correlation with the immunological response. As a result we found a significant increase of IL-13 in the serum of clinical GA-responders whereas IL-13 was not detectable in controls, untreated MS (P < 0.001) and nonresponders (P = 0.015). Similarly, GA-treatment increased serum levels of IL-5 (P = 0.001). The correlation of serum IL-5 and clinical response was also significant (P = 0.039), however, there was an overlap between the different groups. The selective induction of IL-13 and IL-5 but not IL-4 by GA treatment suggests that the specific biological functions of these cytokines might be important for the therapeutic mechanism of GA. Measurement of serum IL-13 and IL-5 levels is a simple and inexpensive tool for monitoring the response to GA in MS patients.

Intravenous regional anesthesia using lidocaine and clonidine.

BACKGROUND: Clonidine has been added to local anesthetic regimens for various peripheral nerve blocks, resulting in prolonged anesthesia and analgesia. The authors postulated that using clonidine as a component of intravenous regional anesthesia (IVRA) would enhance postoperative analgesia. METHODS: Forty-five patients undergoing ambulatory hand surgery received IVRA with lidocaine, 0.5%, and were assigned randomly and blindly to three groups. The control group received intravenous saline, the intravenous clonidine group received 1 microg/kg clonidine intravenously, and the IVRA clonidine group received 1 microg/kg clonidine as part of the IVRA solution. After their operations, the patients' pain and sedation scores and analgesic use were recorded. RESULTS: Patients in the IVRA clonidine group had a significantly longer period of subjective comfort when they required no analgesics (median [range]) for 460 min (215-1,440 min), compared with 115 min (14-390 min) for the control group and 125 min (17-295 min) for the intravenous clonidine group (P<0.0001). The patients who received IVRA with clonidine reported significantly lower pain scores 1 and 2 h after tourniquet deflation compared with the other groups, and they required no fentanyl in the postanesthesia care unit. They also required fewer analgesic tablets (325 mg acetaminophen with 30 mg codeine) in the first 24 h (2+/-1, mean +/- SD) compared with the other two groups, 5+/-1 tablets (control) and 4+/-2 tablets (intravenous clonidine) (P<0.0001). No significant postoperative sedation, hypotension, or bradycardia developed in any of the patients. CONCLUSION: The addition of 1 microg/kg clonidine to lidocaine, 0.5%, for IVRA in patients undergoing ambulatory hand surgery improves postoperative analgesia without causing significant side effects during the first postoperative day.

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.