[Translated article] The haematoma block is not enough as method of anaesthesia in reduction of displaced distal radius fractures.

BACKGROUND: Two out of three wrist fractures seen in an emergency department are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess pain during closed reduction of distal radius fractures after using haematoma block as method of anaesthesia. PATIENTS AND METHODS: Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilisation during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analogue scale at different times of reduction and complications were registered. RESULTS: Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the haematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed. CONCLUSIONS: Haematoma block is only a mildly effective method to reduce wrist pain during closed reduction of distal radius fractures. This technique slightly decreases the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options. LEVEL OF EVIDENCE: Therapeutic study. Cross-sectional study - Level IV.

The hematoma block is not enough as method of anesthesia in reduction of displaced distal radius fractures. / El bloqueo del hematoma no es suficiente como método de anestesia en la reducción de fracturas desplazadas de radio distal.

BACKGROUND: Two out of three wrist fractures seen in the emergency are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess the pain during closed reduction of distal radius fractures after using the hematoma block as method of anaesthesia. PATIENTS AND METHODS: Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilization during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analog scale at different times of reduction and complications were registered. RESULTS: Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the hematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed. CONCLUSIONS: The hematoma block is only a mild effective method to reduce the wrist pain during closed reduction of distal radius fractures. This technique decreases slightly the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options. LEVEL OF EVIDENCE: Therapeutic study. Cross-sectional study - Level IV.

Dual growth hormone (GH) response to repeated GH releasing hormone stimulus in children and adults.

Several authors have demonstrated that plasma growth hormone (GH) levels as response to acute GH releasing hormone (GHRH) stimulation in adults are decreased by a previous GHRH injection whereas they are maintained in children. Probably the most accepted hypothesis for this finding is the increase in the somatostatinergic tone. The aim of the present study was to evaluate the dual GH response to repeated GHRH stimuli to clarify the possible influence of somatostatinergic activity in the type of response. Eighteen healthy prepubertal children, mean age 9.2 years (range: 6.0-12.9 years) and 19 healthy adult volunteers, mean age 25.5 years (range: 17-35 years) were studied with the GHRH test. An additional group of 10 normal adults with similar characteristics (mean age 31 years, range 25-35 years) were also recruited as a control group for somatostatinergic assessment. The GH response to the first GHRH bolus was similar in both children and adults. However, while children showed a preserved response to the second stimulus, it was diminished in adults. As expected, thyroid stimulating hormone (TSH) was within the normal range in all subjects. When the evolution of TSH was compared between the group of non-responders and the control group, no significant differences were found either at basal time or at 120 min, showing a similar decreasing trend for serum TSH level. The variation of TSH levels were also expressed as the proportion of TSH response after 2 hours compared to the basal level (TSH-120/TSH-0) but no significant differences were found (GHRH non-responders group mean: 73.6%, range: 51.3-93.7; control group mean: 70.7%, range: 62.9-92.5). In conclusion, the results confirm that in adults but not in children, the somatotrope responsiveness to GHRH is inhibited by a previous bolus of GHRH. The finding that the plasma TSH level diminishes in a similar manner in both non-responders and the control group is in agreement with the rejection of the hypothesis of the influence of somatostatin.

Gonadal dysgenesis (46,XY) and gonocytoma.

A case of 46,XY gonadal dysgenesis with a type III Teter's gonocytoma occurred in the left ovary of a 22-year-old woman. Hormonal, genetic and laparoscopic studies were performed before the diagnosis of gonadal dysgenesis was made. Gonadal neoplasm was found after bilateral gonadectomy.

Cardiac sympathetic denervation in symptomatic and asymptomatic carriers of the E46K mutation in the α synuclein gene.

OBJECTIVE: The aim of this study was to analyze autonomic function and cardiac sympathetic innervation in symptomatic and asymptomatic carriers of the E46K alpha-synuclein gene (SNCA) mutation. PATIENTS AND METHODS: Autonomic function tests were performed in six patients, four of whom were symptomatic carriers (ages: 46, 59, 52 and 28-years) and two who were asymptomatic carriers (ages: 52 and 29 years). Autopsy studies were performed on an additional two symptomatic carriers not eligible for autonomic testing. Patients completed the SCOPA autonomic questionnaire, and underwent the head-up tilt test accompanied by measurements of plasma norepinephrine. Valsalva maneuver and deep breathing tests, along with recording of sympathetic skin response (SSR) and cardiac MIBG scintigraphy were carried out. Myocardial tissue sections removed from the two autopsied cases were subjected to routine histological staining and immunohistochemical processing with monoclonal antibodies against tyrosine hydroxylase and alpha-synuclein. RESULTS: Both the four symptomatic and the older asymptomatic carriers reported abnormalities in the SCOPA questionnaire and had markedly diminished cardiac MIBG uptake. Plasma norepinephrine in the supine and tilted positions was normal in all subjects. Only one patient had significant orthostatic hypotension. There was a complete absence of tyrosine hydroxylase immunostaining in the myocardium of the two autopsied cases. INTERPRETATION: We have found imaging and histological evidence of cardiac sympathetic denervation in symptomatic and asymptomatic carriers of the E46K alpha-synuclein gene mutation. The sympathetic denervation appears to be organ-specific, with selective affectation of the heart given that plasma norepinephrine levels and blood pressure were normal.

[Utility of the study of the vegetative nervous system in the differential diagnosis between Parkinson's disease and multiple system atrophy]. / Utilidad del estudio del sistema nervioso vegetativo en el diagnóstico diferencial entre la enfermedad de Parkinson y la atrofia multisistémica.

INTRODUCTION: The aim of this study is to show if the exploration of the autonomic nervous system is useful to improve the specificity of clinical criteria of Parkinson's Disease (PD) and Multiple System Atrophy (MSA). PATIENTS AND METHODS: 20 patients with PD and 13 patients with MSA were studied. After 12 hours in off medication, NE and GH were measured in supine position and NE after 5 minutes standing. Later, GH levels were recorded at 15, 30, 45 and 60 minutes after a dose of 0.005 mg/kg of apomorphine. Finally, analysis of the symptoms of autonomic dysfunction and levodopa test were carried out. RESULTS: Sympathetic response to postural changes was significantly higher in patients with PD (NE increase in relation to basal: PD: 170.90 +/- 110.08 pg/ml; MSA: 91.33 +/- 73.79 pg/ml; p = 0.029). No differences were found in the response of GH to apomorphine (GH peak at 45 minutes: PD: 2.37 +/- 2.7 ng/ml; MSA: 1.69 +/- 1.90 ng/ml; ns). The symptoms of autonomic dysfunction were more frequently in patients with MSA. The stridor was specific to MSA. Improvement in motor scores in the levodopa test was higher in patients with PD (PD: 39.7 %; MSA: 17.89; p = 0.019). DISCUSSION: Sympathetic response to postural changes, description of symptoms of autonomic dysfunction, and motor response to levodopa test are useful tools in order to improve specificity of the diagnostic criteria of PD and MSA. The GH test with apomorphine was not useful for a differential diagnosis.