A Randomised Clinical Trial of Buffered Tumescent Local Anaesthesia During Endothermal Ablation for Superficial Venous Incompetence.

OBJECTIVE/BACKGROUND: Endovenous thermal ablation (EVTA) is the recommended first line intervention for superficial venous incompetence (SVI). While the infiltration of perivenous tumescent local anaesthesia (TLA) is key to procedural success, it is paradoxically the predominant source of patient reported discomfort. This randomised controlled trial investigates the potential to reduce peri-procedural pain and improve patient reported outcome measures (PROMs), including quality of life (QoL) using TLA buffered to physiological pH. METHODS: Patients undergoing great saphenous vein EVTA with concomitant phlebectomies were randomised to either standard (ST) or buffered (BT) TLA. Follow up assessments were performed at weeks 1, 6, and 12. The primary outcome was patient reported peri-procedural pain on a 100 mm visual analogue scale (VAS). Secondary outcomes were one week post-procedural pain VAS and analgesia use, QoL (disease specific: Aberdeen Varicose Vein Questionnaire [AVVQ]; generic: Short Form-36 [SF-36] and EuroQol 5 Dimensions Questionnaire [EQ-5D]), patient satisfaction VAS, technical success on duplex ultrasound (DUS) examination, and complications. RESULTS: Ninety-seven patients were randomised: 50 to ST and 47 to BT. The groups had comparable baseline demographics, Clinical Etiologic Anatomic Pathological, Venous Clinical Severity Score, QoL, and DUS parameters. Equally, intra-procedural parameters (volume of TLA, length of ablation, and linear energy delivered) were also comparable. Peri-procedural pain scores were significantly lower in the BT group with a mean ± SD score of 2.86 ± 3.57 versus 4.44 ± 2.94 (p = .001). Pain scores and analgesia use over the subsequent week were equivalent. SF-36 Bodily Pain domain scores were significantly better in the BT group at week 1 (77 vs. 62; p = .008). AVVQ, SF-36, and EQ-5D scores were otherwise similar between the groups throughout follow up, significantly improving over baseline. Technical success was high in both groups, with no major complications and few minor complications. CONCLUSION: Buffered TLA offers a significantly lower peri-procedural pain experience for patients undergoing EVTA and should replace current tumescent formulae.

Globalization and anaphylaxis.

PURPOSE OF REVIEW: To understand the impact of globalization in the management of anaphylaxis and identify potential strategies to improve patients' care and prevention. RECENT FINDINGS: Developments in the field of anaphylaxis have been consistently following these globalization trends offering possibilities of collaborations of the allergy community and integrated international initiatives to reach quality care of allergic patients worldwide. SUMMARY: Globalization is the process of interaction and integration between people, companies, and governments worldwide. Developments in the field of anaphylaxis have been following these globalization trends offering possibilities of collaborations and integrated international initiatives to reach quality care of allergic patients worldwide. Complex disorders, such as anaphylaxis, have called for complex integrative strategies, leading to a new acceptance of outside traditions. Allergy is encouraging us to accept holistic and integrative medical practices as viable options. With the dissolution of multinational boundaries and the universal free access to information, the notion of holistic and global-based care is emerging as the new reality of the medicine. We strongly believe that the integrated action plan to the management and prevention of anaphylaxis, just possible through the globalization, is a key health, political and economical move that advocates for the best practice of allergology.

History full circle: 'Novel' sympathomimetics in supplements.

Since the banning of ephedrine in over-the-counter nutritional supplements a decade ago, a plethora of untested and/or unsafe sympathomimetic stimulants have taken its place. This paper argues that these 'novel' stimulants in supplements recapitulate the work of synthetic chemists at commercial pharmaceutical firms during the 1930s and 1940s, all seeking substitutes for recently successful products based on ephedrine and amphetamine. Copyright © 2015 John Wiley & Sons, Ltd.

Effects of local anesthesia with bupivacaine plus epinephrine on blepharoptosis and levator palpebrae muscle function.

PURPOSE: To evaluate the effect of local anesthesia with bupivacaine plus epinephrine on the extent of blepharoptosis and levator palpebrae muscle function. METHODS: : In this prospective interventional case series, patients with blepharoptosis who were candidates for aponeurotic surgery were included. After initial preparations in the operating room, a total of 1 ml of a mixture of bupivacaine 0.5% plus epinephrine 1:100,000 were injected into the upper eyelid. The margin reflex distance 1 (MRD1) and the extent of levator muscle function were measured before and 2, 5, 10, and 15 minutes after injection. RESULTS: A total of 36 eyes including 21 men (58.3%) and 15 women (41.7%) with an average age of 41.81 ± 23.09 (17-83 years) were studied. There were 21 eyes with myogenic and 15 eyes with aponeurotic blepharoptosis. The mean MRD1 was 1.18 ± 1.06 mm before injection and -0.02 ± 0.85, 0.52 ± 0.98, 0.98 ± 1.05, and 1.02 ± 1.06 mm at 2, 5, 10, and 15 minutes after injections, respectively. The changes in the MRD1 measurements were statistically significant at all time points. The MRD1 values decreased during the first 2 minutes after injection in 88.8% of eyes, but returned to initial value after 15 minutes in 84.3%. The change in the levator muscle function measurements was statistically significant at 2 and 5 minutes after injections; however, the differences were clinically negligible. CONCLUSIONS: : The local anesthesia of the eyelid with 1 ml bupivacaine plus epinephrine causes a temporary increase of blepharoptosis within the first few minutes with minimal effect on levator muscle function measurements.

The effects of adding epinephrine or xylazine to lidocaine solution for lumbosacral epidural analgesia in fat-tailed sheep.

This blinded, randomised experimental study was designed to compare the analgesic effects of lumbosacral epidural administration of lidocaine-epinephrine or lidocaine-xylazine combinations in fat-tailed sheep. Nine healthy fat-tailed male lambs (mean ± s.d. age, 4.6 ± 0.4 months; weight, 24.6 kg ± 2.5 kg) were randomly allocated into four groups of six sheep: lidocaine 2% (LID), lidocaine-epinephrine 5 µg/mL (LIDEP), lidocaine-xylazine 0.05 mg/kg (LIDXY) or bupivacaine 0.5% (BUP). The onset and duration of flank, perineum and hindlimb anaesthesia and the onset and duration of hindlimb paralysis were recorded. Epidural administration of LID, LIDEP, LIDXY or BUP produced anaesthesia within 6.6 min, 7.6 min, 3.4 min and 8.4 min, respectively. The mean onset of anaesthesia in the LIDXY group was significantly shorter compared with the BUP group (p = 0.02). The mean duration of anaesthesia was 107.9 min, 190.4 min, 147.6 min and 169.7 min for LID, LIDEP, LIDXY and BUP, respectively. The onset of hindlimb paralysis was faster in the LIDXY group than in the BUP group; however, the duration of hindlimb paralysis was shorter in LIDXY compared with LIDEP. Epidural administration of LIDEP or LIDXY provides a comparable duration of local anaesthesia without any adverse effects in fat-tailed sheep. Epidural LIDXY did not appear to be advantageous over epidural LIDEP.

Age-associated changes of appetite-regulating peptides.

Aging is associated with a progressive decrease in appetite and food intake. The reasons for the decline in food intake are multifactorial, and relate to both peripheral and central mechanisms. Current studies about the regulation of food intake suggest that there are many central mediators that control the appetite. To determine the mechanism of age-associated decrease in appetite and food intake, we focused on the age-associated changes of the suppressing and stimulatory effect of some appetite-regulating peptides. At first, we examined cholecystokinin (CCK), one of the typical appetite-suppressing factors. Although sensitivity to CCK is enhanced in old animals, the mechanism underlying this effect has not been elucidated. Next, we focused on the appetite-stimulating peptides, orexin-A, neuropeptide Y (NPY) and ghrelin, which are known to play a critical role in food intake. To determine the age-associated decrease in appetite and food intake, we compared the stimulatory effect of intracerebroventricular administration of orexin-A, NPY and ghrelin. We report the studies of the age-associated changes of appetite-regulating peptides in this review.

Ischemic stroke associated with cough and cold preparation containing methylephedrine and supplement containing Chinese herbal drugs.

Methylephedrine is generally harmless and is contained in many cough and cold preparations. Likewise, Chinese herbal drugs are considered to be effective and to have few side effects. A 32-year-old woman experienced ischemic stroke attributed to concomitant administration of a cough and cold preparation containing methylephedrine and a supplement containing Chinese herbal drugs. Computed tomography and magnetic resonance imaging of the brain showed acute infarctions bilaterally in the cerebellum. Conventional angiography and magnetic resonance angiography showed transient stenosis of the left vertebral artery. These findings suggested vasospasm or dissection, presumably related to hypertension and/or angiitis or vasoconstriction of large cerebral arteries leading to local thrombosis as a result of stasis and sympathomimetic-induced platelet activation. Combining methylephedrine and Chinese herbal drugs might carry a risk of stroke.

Multiple arrhythmogenic foci associated with the development of perpetuation of atrial fibrillation.

BACKGROUND: The presence of multiple arrhythmogenic sources may be associated with the perpetuation of atrial fibrillation (AF). In this study, we investigated the hypothesis that multiple foci might be involved in the development of AF persistency. METHODS AND RESULTS: Two hundred fourteen consecutive patients with AF undergoing catheter ablation were enrolled in this study. The location of the arrhythmogenic foci was determined using simultaneous recordings from multipolar catheters before and after pulmonary vein isolation during an isoproterenol administration. We detected 500 arrhythmogenic foci (263 foci as AF initiators, and 237 foci as non-AF initiators). High-dose isoproterenol infusions (ranging from 2 to 20 microg/min) revealed potential arrhythmogenic foci, especially non-pulmonary vein foci (55%). Persistent AF was more highly associated with an incidence of multiple (>2) foci than paroxysmal AF (88% versus 65%, P=0.002), and a multivariate analysis demonstrated that multiple foci (>2) were an independent contributing factor for persistent AF (odds ratio; 95% confidence interval, 4.69; 1.82 to 12.09, P<0.001). In paroxysmal AF, the number of foci was higher in patients with long-term AF (>24 hours) than in those with short-lasting AF (2.64+/-0.14 versus 1.77+/-0.16, P=0.001). In the persistent AF group, the patients with short-lasting AF (<12 months) had a greater number of foci than did those with long-term AF (>12 months) (3.62+/-0.15 versus 1.92+/-0.16, P=0.04). CONCLUSIONS: Multiple foci were likely to be involved in the development of persistent AF. However, if AF persisted for >12 months, they may not have had a significant effect on the AF perpetuation.

Topical anaesthesia in children: reducing the need for specialty referral.

OBJECTIVE: The management of wounds in children is stressful, not only for the child, but also for parents and staff. In our Emergency Department (ED), we currently do not have a paediatric sedation policy, and thus children requiring suturing, not amenable to distraction and infiltrative anaesthesia, are referred to specialty teams for general anaesthesia. We proposed that the introduction of a topical anaesthetic gel (lidocaine, adrenaline, tetracaine - LAT) might help to reduce the number of referrals, by allowing the ED staff to perform the procedures, in combination with nonpharmacological approaches. METHODS: We carried out a retrospective review of ED records of all children aged 14 years or less attending with wounds, over an 8-month period, from 01 May 2007 to 31 January 2008. RESULTS: Two hundred and one (50.6%) patients presented before the introduction of LAT gel, whereas 196 (49.3%) patients presented afterwards. A total of 39 (19.4%) patients were referred for specialty review pre-LAT, whereas only 19 (9.7%) patients were referred in the LAT group. Of these, 31 (15.4%) pre-LAT and 15 (7.7%) LAT group required general anaesthesia. There is a significant difference between these two groups, using Fischer's exact test, P=0.018. CONCLUSION: We have found that the introduction of topical anaesthetic gel in ED has significantly reduced the number of children with wounds referred to specialty teams for general anaesthesia. This has important implications for patient safety and hospital resources.

Expanding the use of topical anesthesia in wound management: sequential layered application of topical lidocaine with epinephrine.

UNLABELLED: Topical anesthesia eliminates the need for injection of anesthetic. Most studies on the use of topical anesthesia were done on children, using 3 active ingredients (lidocaine, epinephrine, tetracaine, or tetracaine, adrenaline, cocaine) for relatively small wounds of the face and scalp. OBJECTIVES: To demonstrate that topical anesthesia is effective and safe in adults of all ages and for larger wounds, using a preparation with 2 active ingredients, topical lidocaine and epinephrine (TLE). METHODS: One hundred patients were enrolled in a randomized controlled trial, with 50 in each group. The study group received TLE using a unique method of "sequential layered application." The control group received 2% lidocaine infiltration anesthesia. Patients rated the pain from the application of anesthesia and from suturing, using a 0 to 10 visual analog pain scale. Follow-up interviews were conducted to assess for complications and to rate patients' wound repair experience. RESULTS: Patients in the study group reported significantly less pain from TLE application, with 66% reporting no pain vs 0% reporting no pain from the infiltration in the control group (P < .001). There was no difference in pain during wound repair between the 2 groups (P approximately .59). On follow-up, 95% of patients contacted in the TLE group rated their experience in regard to pain as "excellent," compared to 5% of patients in the control group (P < .001). CONCLUSION: Topical lidocaine and epinephrine "sequential layered application" is an effective, safe, and less painful method of anesthesia for a wide variety of lacerations. Patients recall their experience with this technique very favorably.

What do patients with chronic rhinitis do with their disease?

There are numerous patients suffering from chronic rhinitis. What kind of doctors do they consult? What are their symptoms? What kind of examinations do they do? What kind of medication do they use? Are they ever treated surgically? The objective of this study was to give answers to such questions. This is a study of 269 patients suffering from chronic rhinitis aged from 3 to 72 years. Of the 269 patients, 198 had already visited another physician before consulting us. The most common symptom was nasal obstruction. The most commonly used oral medication was antihistamines, whereas the most commonly used topical medication was sympathomimetic agents. Additionally, 2.2% of them had used natural herbs intranasally, herbs they had collected by themselves and not sold in drugstores. The operation most commonly performed was polypectomy. Sufferers from rhinitis most commonly consult general practitioners. The percentage of patients using alternative medication is limited in comparison with other studies.

[The circadian effects of antiglaucomatous drugs]. / Effets nycthéméraux des molécules anti-glaucomateuses.

PURPOSE: To collect data reflecting the current knowledge on the interactions of medical antiglaucomatous therapy and circadian variations. METHOD: Review of the available literature published on this topic in common electronic databases. RESULTS: The IOP-reducing effect of a molecule throughout the day depends on many parameters and still remains poorly investigated. It is well known that beta-blockers have a poor efficacy at night, while prostaglandins prevent nocturnal IOP variations because of their original mechanism. DISCUSSION: The lack of a 24-hour IOP recording device limits our ability to track the effect of antiglaucomatous drugs over 24 hours, an important point because these antiglaucomatous drugs vary in terms of their capacity to reduce IOP over a 24-hour period. CONCLUSION: Assessing the effect of antiglaucomatous therapy on a 24-hour basis remains very difficult. However, in the next few Years, this could become an emerging focus point in the management of glaucoma.

[Tumescent local anesthesia in proctologic surgery]. / Tumeszenz-Lokalanästhesie bei proktologischen Eingriffen.

INTRODUCTION: Tumescent local anesthesia (TLA) was introduced to facilitate liposuction and other procedures mainly in plastic surgery. The aim of our study was to evaluate if this new technique can also be safely applied in proctologic surgery. METHODS: The following 50 proctologic procedures were performed using TLA as day surgery cases: perianal vein thrombectomy (n=15), subanodermal fistula resection (n=7), anal polyp resection (n=7), fissurectomy ( n=6), perianal abscess revision (n=6), excision of anal skin tags (n=3), hemorrhoidectomy for thrombosed piles (n=3), intersphincteric fistula extirpation (n=1), pilonidal sinus (n=1), and perianal tumor excision (n=1). The subcutaneously infused solution contained 200 ml of Ringer's solution, 50 ml of 2% Mepivacain, and 2.5 ml of epinephrine diluted 1:10,000. RESULTS: During an average application time of 14.3+/-4.9 min, a mean of 93.1+/-40.7 ml tumescent solution was infused. This dosage resulted in complete pain relief after 18.3+/-5.0 min. Local anesthesia was maintained up to 14 h postoperatively, with a mean duration of 6.7+/-1.9 h. Two patients developed moderate hematomas which required no further treatment. CONCLUSIONS: Our pilot study demonstrates that slow infusion tumescent local anesthesia can be widely and safely applied in proctologic surgery and enables the performance of these procedures on an outpatient basis.

Accidental injection of epinephrine from an autoinjector: invasive treatment not always required.

BACKGROUND: Individual case reports of accidental injection with epinephrine appear in the literature and seem to represent the worst case scenarios. We present a case series of 28 exposures to epinephrine via autoinjector. METHOD: All accidental parenteral injections of epinephrine by autoinjector reported to two regional poison information centers over a 2-year period were included. RESULTS: Injection sites included digits (23 cases), palm (4 cases), and thigh (1 case). Symptoms included swelling, pallor, pain, and erythema. Four patients reported no effect, and 9 required no treatment. Ten patients obtained relief with warm soaks, 1 patient had massage only, and 2 patients were lost to follow-up. Fourteen were examined in the emergency department, and 14 were treated at home. CONCLUSION: Although some injection injuries must be treated in an emergency facility, many can be treated at home. Immediate referral to a health care facility is not needed in all cases and at times is unwarranted.

The sympathomimetic agent, 6-hydroxydopamine, accelerates cutaneous wound healing.

Using pharmacological stimulation of sympathetic terminals, the present study examines the role of sympathetic post-ganglionic neurons in cutaneous wound healing. Effects of local stimulation of sympathetic post-ganglionic neurons with 0.2 mg/kg 6-hydroxydopamine were studied on the healing of full-thickness skin incisions in rats. Epidermal wound healing was measured by a novel non-invasive quantitative method based on the increasing electrical resistance of healing skin. Dermal healing was determined by measuring wound breaking strength using an Instron Universal Testing device. We report a 35% increase in the rate of epidermal wound healing (P < 0.05. n(e) = 21, n(c) = 18) and a 43% increase in dermal strength (P < 0.05, n(e) = 13, n(c) = 10) after 6-hydroxydopamine treatment. Thus, our results show that pharmacological stimulation of sympathetic post-ganglionic neurons markedly accelerates skin wound healing at both the epidermal and dermal levels. This is the first study to show that peripheral nerve stimulation and specifically sympathetic stimulation accelerates cutaneous wound healing. We discuss these results in relation to neurogenic inflammation.