Ultrasound-guided pudendal nerve block in children: A new technique of ultrasound-guided transperineal approach.

BACKGROUND: Transperineal pudendal nerve block guided by nerve stimulator is used in pediatric anesthesia as an alternative to caudal analgesia in perineal surgery. The risk of rectal puncture or intravascular injection is inherent to this blinded technique. We described a new technique of transperineal pudendal nerve block, with ultrasound guidance, to improve safety of the technique. AIMS: The first goal of this study was to describe this new technique and to test its feasibility. The second objective was to evaluate intra operative effectiveness and postoperative pain control. METHODS: After parental and children consent, this prospective descriptive study included children aged 1-15 years, ASA status I-III, scheduled for general anesthesia associated with bilateral pudendal nerve block for an elective perineal surgery. After standardized general anesthesia, the anesthesiologist performed pudendal nerve block under ultrasound guidance with "out of plane" approach and evaluated the visualization of anatomical structures (ischial tuberosity, rectum, and pudendal artery), of the needle and of the local anesthetic spread. Pudendal nerve block failure was defined as an increase in mean arterial blood pressure or heart rate more than 20% compared to baseline values after surgical incision. In the postoperative period, the need for rescue analgesia was noted. RESULTS: During the study period, 120 blocks were performed in 60 patients, including 59 boys. Quality of the ultrasonographic image was good in 81% of blocks, with easy visualization of ischium and rectum in more than 95% of cases. Localization of the tip of the needle was possible for all pudendal nerve blocks, directly or indirectly. The spread of local anesthetic was seen in 79% of cases. The block was effective in 88% of cases. CONCLUSION: The new technique of ultrasound-guided pudendal nerve block, described in this study, seems to be easy to perform with a good success rate, and probably improves safety of the puncture and of the injection by real-time visualization of anatomical structures and local anesthetic spread.

Alcohol use disorders in the emergency ward: choice of the best mode of assessment and identification of at-risk situations.

BACKGROUND: This study aims to identify the prevalence and at-risk situations of alcohol use disorders among patients examined in the emergency department and to compare the scales commonly used to identify alcohol use disorders. METHODS: We used the CAGE and AUDIT questionnaires and a structured interview, the MINI. FINDINGS: Of the presenting patients, 9.5% met the DSM-IV criteria for alcohol use disorders. The CAGE questionnaire was less sensitive (75%) and more specific (92%) than the AUDIT (87 and 80%, respectively). The typical alcohol-dependent patient is a young man who is unemployed and brought to the emergency department by the police. During the past 24 h, he has consumed alcohol, nicotine, cocaine, sedatives or cannabis. CONCLUSION: Of the patients, 9.5% examined in the emergency department present with alcohol abuse or dependence without asking spontaneously for treatment for their addiction. These results support the importance of systematically identifying alcohol use disorders with a simple and rapid questionnaire such as the CAGE questionnaire.

Access to care of patients with chronic hepatitis C virus infection in a university hospital: Is opioid dependence a limiting condition?

BACKGROUND: We aimed to examine access to care of opioid-dependent patients with chronic hepatitis C. METHODS: A standardized form was used to conduct a retrospective survey from 1999 to 2003 in a French university hospital. All HCV RNA positive in- or outpatients who had not had a liver biopsy or anti-HCV treatment were included. Opioid-dependence was defined as active opioid drug use or being on opioid substitution treatment. RESULTS: The survey included 580 patients; 137 (23.6%) were opioid-dependent. Fewer patients with than without current opioid dependence had had genotyping (40.1% versus 67.7%, p<0.001), liver biopsy (51.8% versus 62.8%, p=0.022), and anti-HCV treatment (8.8% versus 18.3%, p=0.008). Genotyping was independently, negatively, associated with: (1) current opioid-dependence (OR=0.3, 95%CI=0.2-0.5), (2) former opioid-dependence (OR=0.5, 95%CI=0.3-0.9), (3) unemployment (OR=0.5, 95%CI=0.3-0.7), and (4) HCV infection discovered by screening (OR=0.5, 95%CI=0.3-0.7). Access to liver biopsy was independently, negatively associated with current opioid-dependence (OR=0.6, 95%CI=0.4-0.9), but positively associated with alcohol consumption (OR=2.0, 95%CI=1.2-3.4) and abnormal ALT level (OR=2.2, 95%CI=1.5-3.2). Access to anti-HCV treatment was independently, negatively associated with HCV infection discovered by screening (OR=0.5, 95%CI=0.3-0.9), but positively associated with moderate hepatitis (OR=6.8, 95%CI=2.8-16.8), extensive fibrosis or cirrhosis (OR=12.3, 95%CI=5.5-27.5), abnormal ALT level (OR=2.1, 95%CI=1.3-3.6) and age (40-64 years) (OR=1.9, 95%CI=1.0-3.4). CONCLUSIONS: Genotyping and liver biopsies were performed less frequently on current opioid dependent patients. Absence of genotyping was also independently associated with unemployment and former opioid-dependence. Alcohol consumption or abnormal ALT levels favored access to biopsy. Histological grade strongly conditioned access to anti-HCV treatment.

Evaluation of depression and anxiety in patients with systemic sclerosis.

OBJECTIVE: To determine the prevalence of depression and anxiety in patients receiving follow-up in France for systemic sclerosis. PATIENTS: We prospectively evaluated 42 patients admitted for a follow-up evaluation of systemic sclerosis, including 18 with diffuse cutaneous scleroderma and 24 with limited cutaneous scleroderma. Patients admitted for recent organ involvement were excluded. Mean age was 57 +/- 13 years, mean disease duration was 10.2 +/- 8 years, and the mean functional Health Assessment Questionnaire score was 0.682 +/- 0.649. Only four patients had a history of antidepressive drug therapy. We used the Montgomery-Asberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Rating Scale to evaluate depression and anxiety, respectively. RESULTS: Eighteen (43%) patients met criteria for depression and 11 (26%) had scores above the cutoff usually taken to define moderate-to-severe depression. Twenty-seven (64%) patients met criteria for minor anxiety and eight (19%) for major anxiety. Depression and anxiety were strongly correlated with each other (r = 0.89; P < 0.0001). The MADRS score was significantly higher in the patients with pulmonary restrictive disease (P = 0.009) but was not associated with the extent of skin involvement, organ involvement, or disability. CONCLUSION: Systemic scleroderma is associated with a high prevalence of depression and anxiety. These disorders should be looked for routinely and the need for specific treatment evaluated.

[Current drugs. New clinical problems]. / Drogues actuelles. Nouveaux problèmes cliniques.

The last decade has been marked by important changes in the way people use drugs. Psychostimulants and psychodysleptics are second in the list of drugs young people like the most, before heroin. Cannabis is most frequently used. The development of the "designer drugs" is included in the abusive context of research of molecules able to facilitate and reinforce relation-ships. They are almost always used with alcohol and cannabis and sometimes other psychotropic drugs.