Anatomical proposal of local anesthesia injection for median nerve block in treating hyperhidrosis with botulinum neurotoxin.

INTRODUCTION: Hyperhidrosis, causing excessive sweat, can be treated with Botulinum neurotoxin injection. Botulinum toxin, an effective and safe treatment for hyperhidrosis, unfortunately involves significant pain due to multiple injections. This study aims to propose a more efficient and less painful approach to nerve blocks for relief, by identifying optimal injection points to block the median nerve, thereby enhancing palmar hyperhidrosis treatment. METHODS: This study, involving 52 Korean cadaver arms (mean age 73.5 years), measured the location of the median nerve relative to the transverse line at the pisiform level to establish better nerve block injection sites. RESULTS: In between the extensor carpi radialis and palmaris longus, the median nerve was located at an average distance of 47.39 ± 6.43 mm and 29.39 ± 6.43 mm from the transverse line at the pisiform level. DISCUSSION: To minimize discomfort preceding the botulinum neurotoxin injection, we recommend the optimal injection site for local anesthesia to be located 4 cm distal to the transverse line of the pisiform, within the tendons of the palmaris longus and flexor carpi radialis muscles.

Transcutaneous electrical nerve stimulation for pain during propofol injection: a randomized clinical trial.

Background: Propofol is a short-acting intravenous sedative widely used for procedural sedation and general anesthesia. However, pain during propofol injection is a distressing adverse effect. This study was designed to investigate whether transcutaneous electrical nerve stimulation (TENS) could reduce pain during propofol injection compared to sham TENS. Methods: In a randomized controlled trial, 80 patients were allocated to two groups: the active TENS group received electrical stimulation via two electrodes on the venous cannulation site, whereas the sham TENS group received no stimulus. After 20 min following TENS, propofol 0.5 mg/kg pain was injected intravenously and pain was evaluated using a four-point score (0 = none, 1 = mild, 2 = moderate, 3 = severe). Adverse effects associated with TENS were also recorded. Results: The overall incidence of pain during propofol injection was 47.5% in the TENS group and 87.5% in the sham group (P < 0.001). The incidence of moderate pain was significantly lower in the TENS group (7.5%) than in the sham TENS group (42.5%) (P < 0.001). There were no complications associated with TENS. Conclusion: Pre-treatment with TENS significantly reduced the incidence and intensity of pain during propofol injection.

Highly Flexible and Photo-Activating Acryl-Polyurethane for 3D Steric Architectures.

An acryl-functionalized polyurethane (PU) series was successfully synthesized using poly(tetramethylene ether) glycol-methylene diphenyl diisocyanate (PTMG-MDI) oligomer based on urethane methacrylates to control the flexibility of photo-cured 3D printing architectures. The mass ratio of acryl-urethane prepolymer: 1,4-butanediol (BD) chain-extender: diphenyl(2,4,6-trimethylbenzoyl) phosphine oxide (TPO) photoinitiator was 10:0.25:1. To produce suitably hard and precisely curved 3D architectures, the optimal UV absorbance and exposure energy of the acryl-PTMG-MDI resin were controlled precisely. Owing to the optimized viscosity of the acryl-PTMG-MDI resins, they could be printed readily by digital light processing (DLP) to form precisely curved 3D architectures after mixing with 1,6-hexanediol diacrylate (HDDA). The acryl-PTMG-MDI formulations showed much better flexural resolution than the neat resins. The printed 3D structure exhibited high surface hardness, good mechanical strength, and high elasticity for flexible applications in consumer/industrial and biomedical fields.

Efficiency of magnetic resonance imaging for diagnosing unstable ligament injuries around the thumb metacarpophalangeal joint: A comparison to arthroscopy.

PURPOSE: This study aimed to assess the accuracy of MRI in identifying ulnar collateral ligament (UCL), radial collateral ligament (RCL), and volar plate (VP) injuries of the metacarpophalangeal joint (MCPJ) of the thumb by comparing with diagnostic arthroscopy. METHODS: A total of 56 consecutive patients (56 thumbs) who underwent arthroscopy of MCPJ of thumb were enrolled. MRI findings reviewed by consensus reading of two blinded radiologists were compared with arthroscopic examination. Statistical data, including sensitivity, specificity, accuracy, were analyzed. Additionally, the performance characteristics between 3.0-tesla (39 thumbs) and 1.5-tesla (17 thumbs) MRI and acute (≤4 weeks after injury) and chronic (>4 weeks) injuries were compared. RESULTS: Of the 56 thumbs, 38 thumbs (67.9%) showed complete correspondence between MRI and arthroscopic findings. The sensitivity, specificity and accuracy of MRI for detecting UCL injuries were 78.8%, 87.0%, and 82.1%, respectively. The sensitivity, specificity and accuracy of MRI for detecting RCL injuries were 85.7%, 91.4%, and 85.7%, respectively. The sensitivity, specificity, and accuracy of MRI for detecting VP injuries were 89.5%, 89.2%, and 81.0%, respectively. 3.0-tesla MRI showed higher correspondence with arthroscopic observation (76.9%) than 1.5-tesla MRI (47.1%) (p = 0.028). For acute injuries, 78.4% showed complete correspondence between MRI and arthroscopic findings, whereas 47.4% with chronic injuries revealed complete agreement (p = 0.019). CONCLUSION: Overall, MRI is moderately effective in evaluating ligamentous lesions around MCPJ of thumb, but MRI is more sensitive in diagnosing acute injuries. Furthermore, 3.0-tesla MRI can provide results with better accuracy for diagnosing ligamentous lesions around MCPJ of thumb. However, the sensitivity and the specificity are not applicable to all ligament injuries, but only the severe one which would agree for surgical options.

Tendon Subluxation After Surgical Release of the First Dorsal Compartment in De Quervain Disease.

We aimed to determine whether dorsoulnar incision elevating radial flap and immobilization for the treatment of de Quervain disease have an advantage over simple midline incision and early mobilization, respectively, in terms of tendon subluxation and clinical outcomes. Forty-six patients with de Quervain disease were randomly divided into 2 groups (midline incision vs dorsoulnar incision) and 2 subgroups (immobilization vs early mobilization). Subluxation of intracompartmental tendons was measured in dynamic wrist positions at 12 and 24 weeks using ultrasonography. The DASH (Disabilities of the Arm, Shoulder, and Hand) and visual analog scale scores and grip and pinch strengths were evaluated. At 24 weeks, the tendons were displaced voloradially in wrist volar flexion (1.25 mm in midline incision vs 0.36 mm in dorsoulnar incision, P = 0.001), whereas the tendons were displaced dorsoulnarly in wrist extension (0.95 mm in midline incision vs 1.78 mm in dorsoulnar incision, P = 0.041). There were no significant differences in tendon displacement between early mobilization and immobilization groups. Clinical outcome measures showed no variation between the groups, and no significant correlation occurred with tendon subluxation. Dorsoulnar incision and postoperative immobilization do not have advantage over midline incision and early mobilization, respectively. However, tendon subluxation after release of the first dorsal compartment for de Quervain disease does not affect clinical outcomes.

False localizing sign caused by schwannoma in cervical spinal canal at C1-2 level: A case report.

RATIONALE: False localizing sign means that the lesion, which is the cause of the symptom, is remote or distant from the anatomical site predicted by neurological examination. This concept contradicts the classical clinicoanatomical correlation paradigm underlying neurological examinations. PATIENT CONCERNS: A 54-year-old man consulted for the right sciatica-like leg pain that had aggravated 1 year ago. Radiological examinations revealed degenerative spondylolisthesis with instability and right-sided recess stenosis at the L4-5 level. After initial improvement following 3 transforaminal epidural steroid injections with gabapentin and antidepressant medication, there was a recurrence of the symptoms a year later, along with wasting of the right leg for several months. Physical examination revealed difficulty in heel-walking and a weakness of extension of the right big toe; tendon reflexes were normal. Lumbar spine radiographs revealed no new findings. The initial course of treatment was repeated, but was ineffective. DIAGNOSES: Further cervicothoracic spine evaluations revealed a right-sided intradural-extramedullary mass and myelopathy at the C1-2 level. INTERVENTIONS: The cervical mass was surgically resected and identified histopathologically as a schwannoma. OUTCOMES: Immediately after surgery, sciatica-like pain and weakness of right leg were completely resolved. LESSONS: It is difficult to make an accurate diagnosis if there are symptoms caused by false localizing sign. Additionally, it is even more difficult to diagnose false localizing sign accurately when there is a co-existing lumbar lesion that can cause the similar symptoms.

Misinterpretation of carbon dioxide monitoring because of deadspace of heat and moisture exchanger with a filter in pediatric anesthesia: A case report.

RATIONALE: When patients are intubated and treated with mechanical ventilation, the upper respiratory tract is bypassed by the flow of dry and cold air. To prevent disturbances of airway homeostasis, a heat and moisture exchanger filter (HMEF) has been applied to breathing circuit. PATIENT CONCERNS: A 4-month-old male infant was ventilated with the pediatric HMEF. We report the impact of ignoring the direct influence of a filter containing deadspace in pediatric mechanical ventilation. DIAGNOSES: The breathing circuit with HMEF leads to unexpected complications such as mechanical obstructions owing to respiratory secretions, bleeding, inhaled drugs, and moisture. Besides these complications, we generally ignored the deadspace as the internal volume of the filters in breathing circuit for pediatric patients. INTERVENTIONS: After we noticed the influence of filter deadspace for pediatric patient, we removed the filter for effective respiratory circulation. OUTCOMES: The operation was completed without any specific incidents and the patient's voluntary breathing was well-maintained. The patient was discharged without any other complications. LESSONS: The increase in breathing apparatus deadspace should be minimized, and the clinicians should keep in mind that HMEF can causes respiratory acidosis with hypercapnia by apparatus deadspace rebreathing, especially for infants.

Intraoperative venesection and isosorbide dinitrate for postreperfusion syndrome during liver transplantation: A case report.

RATIONALE: Postreperfusion syndrome is the most severe cardiovascular and metabolic alteration which typically occurs after the declamping of the portal vein of the grafted liver during liver transplantation, and it could affect the mortality and morbidity of the patient. PATIENT CONCERNS: We report the case of ischemic change in electrocardiogram with substantial increase of central venous pressure, from 6 to 16 mmHg, that developed immediately after reperfusion. DIAGNOSES: Based on his hemodynamic parameters, it was suspected that this event was caused by sudden volume overload in the right ventricle after reperfusion rather than hypovolemic status, thromboembolism, or any other possibilities. INTERVENTIONS: He was treated with active venesection of 300 mL and isosorbide dinitrates infusion at the rate of 30 µg/min. OUTCOMES: The parameter values were restored to normal within 15 to 20 minutes after treatment, and the patient was discharged postoperatively without any significant cardiac sequelae. LESSONS: Although ischemic ST change during reperfusion reported without any previous cardiac complication is limited, the patient could recover rapidly with careful identification of the cause of PRS and immediate treatment.

The effect of preoperative nefopam treatment on postoperative catheter-related bladder discomfort in patients undergoing transurethral bladder tumor resection: a randomized double-blind study.

BACKGROUND: Catheter-related bladder discomfort (C.R.B.D.) is a risk factor for emergence agitation and delirium in postoperative phase. It may be resistant to conventional analgesic therapy such as opioids. This study evaluated the role of preoperative treatment using intravenous 20 mg nefopam in reducing the incidence and severity of C.R.B.D. during the first postoperative 24 h after urinary catheterization when compared with placebo. METHODS: Seventy adult males undergoing elective transurethral resection of bladder tumor requiring urinary bladder catheterization intraoperatively were randomly divided into two groups of 35 patients. In the intervention group (Group N), intravenous 20 mg nefopam in 100 mL normal saline was administered before spinal anesthesia. The placebo group (Group P) received intravenous normal saline 100 mL instead. The incidence and severity of side-effects, including C.R.B.D. at 1, 2, 6, and 24 h after surgery, was evaluated. RESULTS: The incidence of C.R.B.D. was reduced in Group N compared with Group P during the first postoperative 24 h (6/33 [18.2%] vs 22/35 [62.9%], Group N vs Group P, p = .000). The severity of C.R.B.D. also varied significantly at postoperative 1, 2, and 6 h. The use of postoperative analgesics was reduced in Group N compared with Group P (8/33 [24.2%] vs 25/35 [71.4%], Group N vs Group P, p = .000). CONCLUSIONS: The preoperative administration of single-dose intravenous nefopam reduced the incidence and severity of C.R.B.D. in the early postoperative period in patients undergoing T.U.R.-B. under spinal anesthesia.

Arthroscopically assisted mini-deltopectoral rotator cuff repair.

This study examined the technique and outcome of arthroscopically assisted mini-deltopectoral rotator cuff repair. The mini-deltopectoral approach enables the repair of large or massive rotator cuff tears while preventing injury to the deltoid muscle and axillary nerve often caused by splitting and excessive traction during conventional mini-open repair. This technique also is useful in the repair of subscapularis tears and thus could extend the indications for mini-open repair.