Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA; formerly Wegener's granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten-year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1-year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.

Gastropulmonary fistula after bariatric surgery.

The Roux-en-Y gastric bypass is one of the most common operations for morbid obesity. Although rare, gastropulmonary fistulas are an important complication of this procedure. There is only one recently reported case of this complication. The present report describes the serious nature of this complication in a patient after an uneventful laparoscopic gastric bypass surgery.

Local opinion leaders: effects on professional practice and health care outcomes.

BACKGROUND: Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one innovative method that holds promise as a strategy to bridge evidence-practice gaps. OBJECTIVES: To assess the effectiveness of the use of local opinion leaders in improving the behaviour of health care professionals and patient outcomes. SEARCH STRATEGY: We searched MEDLINE, Health Star, SIGLE and the Cochrane Effective Practice and Organisation of Care Group Trials Register. We did not apply date restrictions to our search strategy. Searches were last updated in February 2005. In addition, we searched reference lists of all potential studies that were identified. SELECTION CRITERIA: Studies eligible for inclusion were randomized controlled trials that used objective measures of performance/provider behaviour and/or patient health outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data from each study and assessed its methodological quality. We calculated the absolute difference in the risk of 'non-compliance' with desired practice, adjusting for baseline levels of non-compliance where these data were available. MAIN RESULTS: Twelve studies met our eligibility criteria. The adjusted absolute risk difference of non-compliance with desired practice varied from -6% (favouring control) to +25% (favouring opinion leader intervention). Overall, the median adjusted risk difference (ARD) was 0.10 representing a 10% absolute decrease in non-compliance in the intervention group. AUTHORS' CONCLUSIONS: The use of local opinion leaders can successfully promote evidence-based practice. However the feasibility of its widespread use remains uncertain.

A double-blind randomized controlled trial showing the analgesic and anesthetic properties of lidocaine E to be equivalent to those of ropivicaine and bupivacaine in carpal tunnel release surgery.

In a three-phase trial, the anesthetic properties of lidocaine, bupivacaine and ropivicaine were compared in carpal tunnel release surgery. In phase I, two groups of 25 sequential patients were injected with either lidocaine plain 2% or lidocaine 2% with adrenaline 1:100,000 (E), as the local anesthetic for outpatient carpal tunnel release surgery. Subjective injection pain, postoperative pain at 2 h increments and the number of analgesic pills taken were recorded. During the first postoperative hours, outcome measures were superior in the lidocaine E group. In phase II, a double-blind randomized design compared 42 patients injected with either lidocaine E or a combination of lidocaine E and bupivacaine. Postoperative pain scores and analgesic pills taken were compared using nonparametric statistical tests. During the first 4 h there was a slight benefit in the duration of the anesthetic and fewer pain pills were used in the bupivacaine group. Phase III was a randomized double-blind comparison of ropivicaine and lidocaine E 2% in 72 patients. There was a slight decrease in pain scores and fewer analgesic pills required during the first 6 h in the ropivicaine group. Lidocaine plain 2% provided significantly inferior analgesic and anesthetic properties compared with lidocaine E 2%, bupivacaine or ropivicaine. Sequential randomized comparisons between lidocaine E and bupivacaine and ropivicaine showed clinical equivalence. The present study showed lidocaine E 2% to be a satisfactory and comparatively cost-effective anesthetic for outpatient carpal tunnel surgery.

Pendant un essai en trois phases, les propriétés anesthésiques de la lidocaïne, de la bupivacaïne et de la ropivicaïne ont été comparées dans le cadre du dégagement chirurgical du canal carpien. Pendant la phase I, deux groupes de 25 patients séquentiels ont reçu une injection de lidocaïne simple à 2 % ou de lidocaïne à 2 % associée à de l'adrénaline 1:100 000 (E), comme anesthésique local pour dégager leur canal carpien par voie chirurgicale sans hospitalisation. La douleur subjective à l'injection, la douleur postopératoire par intervalles de deux heures et le nombre de comprimés analgésiques consommés ont été consignés. Pendant les premières heures postopératoires, les mesures d'issue étaient supérieures au sein du groupe prenant de la lidocaïne E.Pendant la phase II, un essai aléatoire à double insu a permis de comparer 42 patients à qui on avait injecté soit de la lidocaïne E, soit une association de lidocaïne E et de bupivacaïne. Les indices de douleur postopératoire et les comprimés analgésiques consommés ont été comparés au moyen de tests statistiques non paramétriques. Pendant les quatre premières heures, on remarquait un léger avantage dans la durée de l'effet anesthésique et un moins grand nombre de comprimés utilisés au sein du groupe prenant de la bupivacaïne.La phase III était une comparaison aléatoire à double insu de la ropivicaïne et de la lidocaïne E à 2 % chez 72 patients. On remarquait une légère diminution des indices de douleur et un moins grand nombre de comprimés analgésiques nécessaires pendant les six premières heures au sein du groupe prenant de la ropivicaïne.La lidocaïne simple à 2 % avait des propriétés analgésiques et anesthésiques considérablement inférieures à la lidocaïne E à 2 %, à la bupivacaïne ou à la ropivicaïne. Des comparaisons aléatoires séquentielles entre la lidocaïne E, la bupivacaïne et la ropivicaïne démontraient une équivalence clinique. La présente étude révèle que la lidocaïne E à 2 % est un anesthésique satisfaisant et comparativement rentable pour le dégagement chirurgical du canal carpien sans hospitalisation.