Posteromedial quadratus lumborum block versus wound infiltration after caesarean section: A randomised, double-blind, controlled study.

BACKGROUND: Reducing pain and minimising the use of opioids after caesarean section are crucial to enhancing maternal recovery and promoting mother-newborn interaction. Various techniques have been implemented to improve analgesia. We compared the analgesic efficacy of posteromedial quadratus lumborum block with that of wound infiltration following elective caesarean section. OBJECTIVE: We hypothesised that within a multimodal analgesia approach, posteromedial quadratus lumborum block would, due to its potential to relieve visceral pain, result in a 15% reduction in 24-h postoperative opioid consumption compared with wound infiltration. DESIGN: A double-blind, randomised, placebo-controlled clinical study. SETTING: A single-centre study between August 2019 and May 2020. PATIENTS: One hundred and sixteen women were randomly allocated into two groups. In the quadratus lumborum group, 20 ml 0.9% saline was injected into the surgical wound followed by bilateral posteromedial quadratus lumborum block using 20 ml 0.25% levobupivacaine per side. In the wound infiltration group, 20 ml of 0.25% levobupivacaine was injected into the surgical wound followed by a bilateral posteromedial quadratus lumborum injection with 20 ml 0.9% saline per side. MAIN OUTCOME MEASURES: The primary outcome was opioid (piritramide) consumption at 24 h. Secondary outcomes were piritramide consumption at 48 h, time-to-first analgesic request, pain scores at rest and with movement, surgery-to-first-ambulation time, surgery-to-breastfeeding time, sedation, pruritus and complications. RESULTS: Piritramide consumption in 24 h was significantly lower with posteromedial quadratus lumborum block (1.5 ±â€Š1.8 mg) than with wound infiltration (2.2 ±â€Š1.7 mg) (P = 0.04), mean difference of -0.7 mg, (95% CI -1.3 to -0.03). In those who required piritramide, time-to-first analgesic request was significantly longer with posteromedial quadratus lumborum block 11 [7 to 14] h, than with wound infiltration 7 [5 to 11] h (P = 0.02). Pain scores were low, with no differences recorded at rest and with movement. There were no differences in time-to-ambulation and time-to-breastfeed between the groups. CONCLUSION: As a component of multimodal post-caesarean section analgesia, posteromedial quadratus lumborum block was associated with lower 24-h opioid consumption compared with wound infiltration. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04000308.

Analgesic efficacy of remifentanil patient-controlled analgesia versus combined spinal-epidural technique in multiparous women during labour.

OBJECTIVES: To compare the analgesic profile of remifentanil patient-controlled analgesia (RPCA) and combined spinal-epidural analgesia technique (CSEA) in multiparous women during the entire labour. We hypothesized that CSEA would provide a better and more sustained pain reduction than RPCA. MATERIAL AND METHODS: A prospective observational trial under ID NCT02963337 at a university hospital in Slovenia 2017-2018. Analgesic efficacy, satisfaction with pain-relief, adverse effects, labour progress, and outcomes between RPCA (80) and CSEA (81) were compared. RESULTS: CSEA provided significantly lower pain scores during the entire labour. Compared to baseline, significant pain reduction was recorded in both groups after 15 min. No difference was recorded compared to baseline with RPCA and CSEA after 45 and 90 mins, respectively. CSEA provided higher satisfaction than RPCA (5 [5-5] vs 5 [4-5], p < 0.0001). More patients with CSEA opted for the same technique for the next labour [CSEA; 77 (95%) vs RPCA; 65 (81%), p = 0.003]. No crossovers were observed. RPCA was associated with desaturation (34%), bradypnea (21%) and apnoea (25%), which were transitional and easily managed. None had severe sedation. No differences were recorded in labour progress and outcomes. Apgar scores were reassuring in all neonates (> 8). None had umbilical artery pH < 7.0. CONCLUSIONS: In multiparas, CSEA provided superior analgesia and satisfaction than RPCA. Nevertheless, RPCA provided a satisfactory experience, suggesting it could be used when neuraxial analgesia is not available, preferred, or contraindicated. In that case, constant presence of midwife is mandatory for management of clinically significant hypoventilation.

The effect of vitamin C on pulmonary oedema in patients with severe preeclampsia: A single-centre, randomised, placebo-controlled, double-blind trial.

OBJECTIVE: To determine whether vitamin C in the first three days postpartum reduces pulmonary oedema (PE) assessed by lung ultrasound in patients with severe preeclampsia. DESIGN: Randomised, placebo-controlled, double-blind trial. SETTING: Tertiary perinatal centre. POPULATION: Consecutively admitted patients with singleton pregnancies complicated by severe preeclampsia. METHODS: Thirty-four patients received vitamin C (1.5 g/6 h) (n = 17) or placebo (n = 17) at days 1, 2, and 3 postdelivery. Mann-Whitney-U test was used to compare vitamin C vs placebo groups. A p ≤ 0.05 was considered statistically significant. MAIN OUTCOME MEASURES: Lung ultrasound was performed once daily in the first three days following delivery. Echo Comet Score (ECS) on day 1 postdelivery was the primary outcome studied and was obtained using the 28-rib interspaces technique. ECS on days 2 and 3 postdelivery were secondary outcomes. RESULTS: There was no significant difference in ECS on day 1 (median 23 (inter-quartile range (IQR) 21-61) vs 18 (IQR 8-35); p = 0.31). All ultrasound examinations on day 1 were performed within six hours from delivery. On days 2 and 3, ECS was significantly lower in vitamin C group compared to placebo (8 (IQR 3-14) vs 35 (IQR 15-78); p = 0.03 and 5 (IQR 3-10) vs 18 (IQR 18-44); p = 0.04, respectively). CONCLUSION: A single dose of intravenous vitamin C did not reduce PE in postpartum patients with severe preeclampsia on day 1 after delivery. Repeated doses, however, seem to have a delayed effect with a reduction in PE detected on ultrasound on days 2 and 3 following delivery. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov: ID NCT03451266 (https://clinicaltrials.gov/ct2/show/NCT03451266?term=NCT03451266&draw=2&rank=1).

Most common clinical presentations of cutaneous mastocytosis.

The term mastocytosis is referred to as an array of uncommon, usually sporadic, heterogeneous clinical illnesses that result from the hyperplasia of tissue mast cells. It comprises many different clinical manifestations varying from indolent cutaneous forms to systemic and malignant conditions. The characteristic presentation of mastocytosis consists of cutaneous manifestations: either a solitary mastocytoma, urticaria pigmentosa, or less commonly, diffuse cutaneous mastocytosis. Urticaria pigmentosa is the most common manifestation of cutaneous mastocytosis that manifests as a generalized eruption of round or oval erythematous macules, papules and plaques with variable amounts of brown pigment, usually on the trunk, but may also occur in all regions of the body including face and mucous membranes. Pruritus, dermographism and Darier's sign are additional features of these eruptions. Mastocytosis may also be manifested as mastocytoma, a rare, benign, pediatric tumor that results from hyperplasia of mast cells in papillary dermis in the first few weeks of life. The clinical course of mastocytosis is variable. The prognosis for the majority of pediatric patients with urticaria pigmentosa is extremely good, and over half of cases clear completely by adolescence, while those with aggressive systemic mastocytosis or mast cell leukemia show a progressive course, usually with a fatal outcome.

Epidemiological data on melanoma from the referral centre in croatia (2002-2007).

Melanoma is considered to be one of the most aggressive skin tumors. Various studies have shown that the incidence rate for this malignancy is rising rapidly all over the world. Incidence rates vary substantially worldwide with New Zealand and Australia having the highest rates. In the past 40 years in Croatia the incidence of melanoma is also in rise for more than 300%. Women and men are almost equally affected. According to anatomical site in most populations the rise is the greatest for the male trunk, and extremities in both sexes. There has been little change in rates for the head and neck. In the last decades, melanoma often occurs in relatively younger people, between the age of 25 and 40, rarely in the childhood. However, survival in patients with melanoma in Western European countries has increased markedly in recent years, due to timely recognition of the disease. Unfortunately, in Croatia the mortality remains higher even though the incidence is lower than those in some Western European countries. The authors are presenting epidemiological data on melanoma during the last 6 years (for the period 2002-2007) from the Croatian Referral Centre for Melanoma which is placed in the University Hospital "Sestre milosrdnice" in Zagreb.

Psychological status and illness perceptions in patients with melanoma.

A diagnosis of cancer and its treatment can create considerable distress, anxiety and depression for both patients and their families. The emotional impact of melanoma can be long lasting and profound, although the data in this field is inconsistent. Our last study showed that melanoma has a medium influence on patients' psychological status and quality of life. The aim of this paper was to investigate illness perceptions in patients with melanoma and its correlations with quality of life and emotional status. 60 patients suffering from malignant melanoma were included in the study. Results of this study show that patients perceive melanoma as a relatively long lasting illness, relatively easy to control, but hard to cure; and as an illness with not many consequences to their health. The causes of melanoma as perceived by patients are exposure to sun, heredity, immunity and stress. Illness perceptions are correlated with patients'quality of life, the influence illness has on the quality of life and depression.

Trends, habits and attitudes towards suntanning.

Epidemiological studies suggest a relationship between suntanning habits and high risk of malignant melanoma (MM). The incidence of MM is increased during the last 40 years. Sun exposure is highly prevalent in all age groups, especially among young and it is influenced by certain believes and attitudes towards suntanning and stimulated by peer pressure and aesthetic references. What is the cause of higher incidence of MM? Is it only trend and attitudes towards suntanning? A prototype of a young female of 21st century is attractive, slim, with bronze complexion, dresses in the bathing suit, whereas the lady of the 19th is pale, dressed in white dress and with hat or sunshade that protects face and hair from the sun. When did social mores and medical knowledge about sun exposure change? A critical interplay occurred between the end of 19th century and the start of the 20th century with significant success of phototherapy and the growing popularity of sunbathing which reflected number of social changes. During the same time of invigoration of sun exposure, appeared the first reports about correlation between sunlight and skin cancer, but without significant repercussion on medical profession and therefore without knowledge of the public. The 1920s and 1930s were highlighted with the great discovery that ultraviolet wavelengths less than 313 nm played the role in vitamin D synthesis which prevents rickets. Numerous other medical benefits were soon attributed to the sunlight. Finally, the cancerogenity of UV light came to attention when scientist succeeded in induction of skin cancer in rodents after UV light exposure. The etiology of sunlight in development of skin cancer was mentioned in scientific articles and public magazines in 1940s and 1950s. Over the decades the message that sunlight exposure leads to increased risk of skin cancer, reach the public. But despite the knowledge, even at present people believe that tan person looks healthier. Additional and continuous educational campaigns are needed for changing people's behavior.