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1.
Anaesthesia ; 74(11): 1397-1405, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31465115

RESUMO

We performed a randomised, blinded, controlled study with adult patients scheduled for primary total knee arthroplasty under spinal anaesthesia. The aim was to investigate the analgesic effects of adductor canal block using catheter-based repeated boluses, either through a new suture-method catheter or a standard perineural catheter, compared with a single-injection technique. All patients received an adductor canal block after surgery with an initial bolus of 20 ml ropivacaine 0.75%, followed by 20 ml of ropivacaine 0.2% every 8 h in the standard and suture-method catheter groups, and sham boluses for the single-injection group. The primary outcome measure was total opioid consumption (intravenous morphine equivalents) from the end of surgery until 12:00 on postoperative day 2. Secondary outcomes were pain, muscle strength and ambulation. We randomly assigned (1:1:1) and analysed 153 patients. Total opioid consumption was median (IQR [range]) 24 (11-37 [0-148]) mg in the suture-method group, 38 (17-51 [0-123]) mg in the standard catheter group and 37 (14-57 [0-158]) mg in the single-injection group (p = 0.049). Differences were not statistically significant after Bonferroni correction (α = 0.05/3). There were no differences between groups on postoperative day 1. On postoperative day 2, there were no differences between catheter groups, but muscle strength and ambulation were improved compared with the single-injection group. We conclude that providing repeated boluses via a catheter did not decrease opioid consumption or pain compared with a single injection, but improved muscle strength and ambulation on postoperative day 2. The two types of catheters were similar.


Assuntos
Anestésicos Locais/farmacologia , Bloqueio Nervoso/instrumentação , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Ropivacaina/farmacologia , Idoso , Analgesia/métodos , Anestésicos Locais/administração & dosagem , Artroplastia do Joelho , Cateteres , Feminino , Humanos , Injeções , Masculino , Ropivacaina/administração & dosagem , Método Simples-Cego , Suturas , Resultado do Tratamento
2.
JACC Clin Electrophysiol ; 5(1): 120-127, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30678776

RESUMO

OBJECTIVES: This study determined if radical plakophilin-2 (PKP2) variants might underlie some cases of clinically diagnosed catecholaminergic polymorphic ventricular tachycardia (CPVT) and exercise-associated, autopsy-negative sudden unexplained death in the young (SUDY). BACKGROUND: Pathogenic variants in PKP2 cause arrhythmogenic right ventricular cardiomyopathy (ARVC). Recently, a cardiomyocyte-specific PKP2 knockout mouse model revealed that loss of PKP2 markedly reduced expression of genes critical in intracellular calcium handling. The mice with structurally normal hearts exhibited isoproterenol-triggered polymorphic ventricular arrhythmias that mimicked CPVT. METHODS: A PKP2 gene mutational analysis was performed on DNA from 18 unrelated patients (9 males; average age at diagnosis: 19.6 ± 12.8 years) clinically diagnosed with CPVT but who were RYR2-, CASQ2-, KCNJ2-, and TRDN-negative, and 19 decedents with SUDY during exercise (13 males; average age at death: 14 ± 3 years). Only radical (i.e., frame-shift, canonical splice site, or nonsense) variants with a minor allele frequency of ≤0.00005 in the genome aggregation database (gnomAD) were considered pathogenic. RESULTS: Radical PKP2 variants were identified in 5 of 18 (27.7%) CPVT patients and 1 of 19 (5.3%) exercise-related SUDY cases compared with 96 of 138,632 (0.069%) individuals in gnomAD (p = 3.1 × 10-13). Cardiac imaging or autopsy demonstrated a structurally normal heart in all patients at the time of their CPVT diagnosis or sudden death. CONCLUSIONS: Our data suggested that the progression of the PKP2-dependent electropathy can be independent of structural perturbations and can precipitate exercise-associated sudden cardiac arrest or sudden cardiac death before the presence of overt cardiomyopathy, which clinically mimics CPVT, similar to the PKP2 knockout mouse model. Thus, CPVT and SUDY genetic test panels should now include PKP2.

3.
Circulation ; 137(25): 2705-2715, 2018 06 19.
Artigo em Inglês | MEDLINE | ID: mdl-29915097

RESUMO

BACKGROUND: Potentially lethal cardiac channelopathies/cardiomyopathies may underlie a substantial portion of sudden unexplained death in the young (SUDY). The whole-exome molecular autopsy represents the latest approach to postmortem genetic testing for SUDY. However, proper variant adjudication in the setting of SUDY can be challenging. METHODS: From January 2012 through December 2013, 25 consecutive cases of SUDY from 1 to 40 years of age (average age at death 27±5.7 years; 13 white, 12 black) from Cook County, Illinois, were referred after a negative (n=16) or equivocal (n=9) conventional autopsy. A whole-exome molecular autopsy with analysis of 99 sudden death-susceptibility genes was performed. The predicted pathogenicity of ultrarare, nonsynonymous variants was determined using the American College of Medical Genetics guidelines. RESULTS: Overall, 27 ultrarare nonsynonymous variants were seen in 16/25 (64%) victims of SUDY. Among black individuals, 9/12 (75%) had an ultrarare nonsynonymous variant compared with 7/13 (54%) white individuals. Of the 27 variants, 10 were considered pathogenic or likely pathogenic in 7/25 (28%) individuals in accordance with the American College of Medical Genetics guidelines. Pathogenic/likely pathogenic variants were identified in 5/16 (31%) of autopsy-negative cases and in 2/6 (33%) victims of SUDY with equivocal findings of cardiomyopathy. Overall, 6 pathogenic/likely pathogenic variants in 4/25 (16%) cases were congruent with the phenotypic findings at autopsy and therefore considered clinically actionable. CONCLUSIONS: Whole-exome molecular autopsy with gene-specific surveillance is an effective approach for the detection of potential pathogenic variants in SUDY cases. However, systematic variant adjudication is crucial to ensure accurate and proper care for surviving family members.


Assuntos
Autopsia/métodos , Canalopatias/genética , Canalopatias/mortalidade , Morte Súbita Cardíaca/epidemiologia , Patologia Molecular , Sequenciamento Completo do Exoma , Adolescente , Adulto , Causas de Morte , Canalopatias/patologia , Morte Súbita Cardíaca/patologia , Feminino , Predisposição Genética para Doença , Humanos , Illinois/epidemiologia , Masculino , Fenótipo , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Fatores de Risco , Adulto Jovem
4.
Br J Anaesth ; 119(4): 775-791, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29121288

RESUMO

Pregabalin has demonstrated anti-hyperalgesic properties and was introduced into acute pain treatment in 2001. Our aim was to evaluate the beneficial and harmful effects of pregabalin in postoperative pain management. We included randomized clinical trials investigating perioperative pregabalin treatment in adult surgical patients. The review followed Cochrane methodology, including Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and used trial sequential analyses (TSAs). The primary outcomes were 24 h morphine i.v. consumption and the incidence of serious adverse events (SAEs) defined by International Conference of Harmonisation Good Clinical Practice guidelines. Conclusions were based primarily on trials with low risk of bias. Ninety-seven randomized clinical trials with 7201 patients were included. The 24 h morphine i.v. consumption was reported in 11 trials with overall low risk of bias, finding a reduction of 5.8 mg (3.2, 8.5; TSA adjusted confidence interval: 3.2, 8.5). Incidence of SAEs was reported in 21 trials, with 55 SAEs reported in 12 of these trials, and 22 SAEs reported in 10 trials with overall low risk of bias. In trials with overall low risk of bias, Peto's odds ratio was 2.9 (1.2, 6.8; TSA adjusted confidence interval: 0.1, 97.1). Based on trials with low risk of bias, pregabalin may have a minimal opioid-sparing effect, but the risk of SAEs seems increased. However, the GRADE-rated evaluations showed only moderate to very low quality of evidence. Consequently, a routine use of pregabalin for postoperative pain treatment cannot be recommended.


Assuntos
Analgésicos/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Pregabalina/uso terapêutico , Doença Aguda , Analgésicos/efeitos adversos , Humanos , Pregabalina/efeitos adversos , Resultado do Tratamento
5.
Tex Heart Inst J ; 44(1): 39-42, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28265211

RESUMO

The cone reconstruction technique, first described by da Silva and modified by Dearani and by others, has become the repair method of choice in patients with Ebstein anomaly of the tricuspid valve. This report details the outcome of the modified cone reconstruction technique in 6 children who underwent surgical correction of Ebstein anomaly at the Tomsk Institute of Cardiology in Siberia. From 2012 through 2015, 4 boys and 2 girls (age range, 11 mo-12 yr) underwent surgery to correct Ebstein anomaly. All had presented with cyanosis, exertional dyspnea, fatigue, or new-onset atrial arrhythmia, and none had undergone previous cardiac surgery. All survived the operation. One patient needed tricuspid valve replacement with a bioprosthesis after early breakdown of the cone reconstruction. As of December 2016, all the patients had no symptoms, tricuspid stenosis, or arrhythmia. This series indicates that cone reconstruction-the most anatomic repair technique for the dysmorphic Ebstein tricuspid valve-can be successfully performed in pediatric heart centers with a large experience.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Anomalia de Ebstein/cirurgia , Procedimentos Cirúrgicos Reconstrutivos , Valva Tricúspide/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Criança , Pré-Escolar , Anomalia de Ebstein/diagnóstico por imagem , Anomalia de Ebstein/fisiopatologia , Ecocardiografia Doppler em Cores , Feminino , Humanos , Lactente , Masculino , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Recuperação de Função Fisiológica , Sibéria , Resultado do Tratamento , Valva Tricúspide/anormalidades , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/fisiopatologia
6.
JCI Insight ; 2(5): e91225, 2017 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-28289718

RESUMO

Noonan syndrome (NS; MIM 163950) is an autosomal dominant disorder and a member of a family of developmental disorders termed "RASopathies," which are caused mainly by gain-of-function mutations in genes encoding RAS/MAPK signaling pathway proteins. Whole exome sequencing (WES) and trio-based genomic triangulation of a 15-year-old female with a clinical diagnosis of NS and concomitant cardiac hypertrophy and her unaffected parents identified a de novo variant in MRAS-encoded RAS-related protein 3 as the cause of her disease. Mutation analysis using in silico mutation prediction tools and molecular dynamics simulations predicted the identified variant, p.Gly23Val-MRAS, to be damaging to normal protein function and adversely affect effector interaction regions and the GTP-binding site. Subsequent ectopic expression experiments revealed a 40-fold increase in MRAS activation for p.Gly23Val-MRAS compared with WT-MRAS. Additional biochemical assays demonstrated enhanced activation of both RAS/MAPK pathway signaling and downstream gene expression in cells expressing p.Gly23Val-MRAS. Mutational analysis of MRAS in a cohort of 109 unrelated patients with phenotype-positive/genotype-negative NS and cardiac hypertrophy yielded another patient with a sporadic de novo MRAS variant (p.Thr68Ile, c.203C>T). Herein, we describe the discovery of mutations in MRAS in patients with NS and cardiac hypertrophy, establishing MRAS as the newest NS with cardiac hypertrophy-susceptibility gene.


Assuntos
Cardiomegalia/genética , Genes ras , Síndrome de Noonan/genética , Adolescente , Adulto , Sequência de Aminoácidos , Cardiomegalia/complicações , Criança , Pré-Escolar , Feminino , Células HEK293 , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Simulação de Dinâmica Molecular , Síndrome de Noonan/complicações , Homologia de Sequência de Aminoácidos , Sequenciamento Completo do Exoma , Adulto Jovem
7.
Br J Anaesth ; 117(5): 635-641, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27799178

RESUMO

BACKGROUND: Dexamethasone prolongs block duration. Whether this is achieved via a peripheral or a central mechanism of action is unknown. We hypothesized that perineural dexamethasone added as an adjuvant to ropivacaine prolongs block duration compared with ropivacaine alone, by a locally mediated effect when controlled for a systemic action. METHODS: We performed a paired, blinded, randomized trial, including healthy men. All subjects received bilateral blocks of the saphenous nerve with ropivacaine 0.5%, 20 ml mixed with dexamethasone 2 mg in one leg and saline in the other, according to randomization. The primary outcome was the duration of sensory block assessed by temperature discrimination in the saphenous nerve distribution. Secondary outcomes were sensory block assessed by mechanical discrimination, pain response to tonic heat stimulation, and warmth and heat pain detection thresholds. RESULTS: We included 20 subjects; one had a failed block and was excluded from the paired analysis. Block duration was not statistically significantly longer in the leg receiving dexamethasone when assessed by temperature discrimination (primary outcome, estimated median difference 1.5 h, 95% confidence interval -3.5 to 0, P=0.050). For all other outcomes, the duration was statistically significantly longer in the leg receiving dexamethasone, but the median differences were <2.0 h. Individual subject analysis revealed that only eight subjects had a block prolongation of at least 2 h in the leg receiving dexamethasone perineurally. CONCLUSION: Perineural administration of dexamethasone 2 mg showed a modest and inconsistent effect of questionable clinical relevance on block duration. CLINICAL TRIAL REGISTRATION: NCT01981746.


Assuntos
Dexametasona/farmacologia , Glucocorticoides/farmacologia , Perna (Membro)/inervação , Bloqueio Nervoso/métodos , Dor/tratamento farmacológico , Adulto , Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Quimioterapia Combinada/métodos , Humanos , Masculino , Valores de Referência , Ropivacaina , Método Simples-Cego , Fatores de Tempo , Adulto Jovem
8.
Mayo Clin Proc ; 2016 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-27810088

RESUMO

We illustrate the work necessary to reverse course after identification of a KCNQ1 variant interpreted erroneously as causing long QT syndrome (LQTS) and to identify the true cause of a case of sudden death in the young. Surrogate genetic testing of a decedent's living brother identified a rare KCNQ1-V133I variant, which prompted an implantable cardioverter defibrillator and subsequent diagnosis of LQTS in other family members. Subsequently, this presumed LQT1 family came to our institution for further clinical evaluation and research-based investigations, including KCNQ1-V133I variant-specific analysis of the decedent, heterologous expression studies of KCNQ1-V133I, and a whole-exome molecular autopsy along with genomic triangulation using his unaffected parents' DNA. After evaluating several V133I-positive family members, clinical doubt was cast on the veracity of the previously levied diagnosis of LQT1, resulting in a re-opening of the case and an intense pursuit of the lethal substrate. Furthermore, the decedent tested negative for V133I, and heterologous expression studies demonstrated a normal cellular phenotype for V133I-containing Kv7.1 channels. Instead, after whole-exome molecular autopsy, a de novo pathogenic variant (p.R454W) in DES-encoded desmin was identified. As detailed herein, the forensic evaluation of sudden death in the young requires meticulous focus on the decedent followed by a careful and deliberate assessment of the decedent's relatives. Surrogate genetic testing can have disastrous consequences and should be avoided. Genetic test results require careful scrutiny to avoid unintended and potentially devastating repercussions. Although the root cause of the decedent's tragic death would have remained a mystery, the unintended consequences for the living relatives described herein might have been avoided based on clinical grounds alone. All family members had electrocardiograms with normal QT intervals, making the diagnosis of familial LQTS unlikely. As such, if the clinicians caring for these patients had focused solely on clinical data from the survivors, there might have been no reason to embark on a path of inappropriate treatment based on genetic testing.

9.
Congenit Heart Dis ; 11(5): 452-461, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27452334

RESUMO

OBJECTIVE: To use whole exome sequencing (WES) of a family trio to identify a genetic cause for polyvalvular syndrome. METHODS AND RESULTS: A male child was born with mild pulmonary valve stenosis and mild aortic root dilatation, and an atrial septal defect, ventricular septal defect, and patent ductus arteriosus that were closed surgically. Subsequently, the phenotype of polyvalvular syndrome with involvement of both semilunar and both atrioventricular valves emerged. His family history was negative for congenital heart disease. Because of hypotonia, myopia, soft pale skin, joint hypermobility, and mild facial dysmorphism, either Noonan syndrome- or William syndrome-spectrum disorders were suspected clinically. However, chromosomal analysis was normal and commercially available Noonan syndrome and William syndrome genetic tests were negative. Whole exome sequencing of the patient and both parents was performed. Variants were analyzed by sporadic and autosomal recessive inheritance models. A sporadic mutation, annotated as c.1491 T > A, in TAB2, resulting in a nonsense mutation, p.Y497X, in the TAB2-encoded TGF-beta activated kinase 1 (TAK1) was identified as the most likely disease-susceptibility gene. This mutation results in elimination of the terminal 197 amino acids, including the C-terminal binding motif critical for interactions with TRAF6 and TAK1. CONCLUSIONS: The combination of WES, genomic triangulation, and systems biology has uncovered perturbations in TGF-beta activated kinase 1 signaling as a novel pathogenic substrate for polyvalvular syndrome.


Assuntos
Proteínas Adaptadoras de Transdução de Sinal/genética , Códon sem Sentido , DNA/genética , Doenças das Valvas Cardíacas/genética , Metagenômica/métodos , Sequenciamento Completo do Exoma/métodos , Proteínas Adaptadoras de Transdução de Sinal/metabolismo , Análise Mutacional de DNA , Seguimentos , Previsões , Doenças das Valvas Cardíacas/congênito , Doenças das Valvas Cardíacas/enzimologia , Humanos , Recém-Nascido , Masculino , Linhagem , Síndrome
10.
Mater Sci Eng C Mater Biol Appl ; 58: 204-12, 2016 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-26478304

RESUMO

Investigation of an integrated supercritical fluid extraction and supercritical solvent impregnation process for fabrication of microporous polycaprolactone-hydroxyapatite (PCL-HA) scaffolds with antibacterial activity is presented. The HA content and particle size as well as the operating conditions of the integrated process is optimized regarding the amount of impregnated antibacterial agent (Usnea lethariiformis extract) in the PCL-HA matrix, scaffold morphology and antibacterial activity against methicillin resistant Staphylococcus aureus (MRSA) strains. High pressure differential scanning calorimetry (HP-DSC) assay reveals that an increasing amount of HA results in decreasing melting temperature as well as crystallinity at an operating pressure of 17 MPa. The PCL-HA composites with micrometric sizes of the HA particles are convenient for being processed by the integrated process due to the simple preparation, a good interaction between the PCL matrix and filler and the advantageous impact on sorption. The scaffold obtained from PCL-HA with 20% of the HA shows the highest impregnation yield at 17 MPa and 35 °C (5.9%) and subsequently also the best bactericidal effect on the tested MRSA strains at an initial bacterial inoculum of 2 × 10(-4)CFU/mL.


Assuntos
Antibacterianos/química , Cromatografia com Fluido Supercrítico , Durapatita/química , Poliésteres/química , Usnea/química , Antibacterianos/isolamento & purificação , Antibacterianos/farmacologia , Varredura Diferencial de Calorimetria , Dióxido de Carbono/química , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Microscopia Eletrônica de Varredura , Pressão , Temperatura de Transição , Usnea/metabolismo
11.
Br J Anaesth ; 115(6): 920-6, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26582853

RESUMO

BACKGROUND: Theoretically, the ideal volume of local anaesthetic for adductor canal block (ACB) would ensure sufficient filling of the canal and avoid proximal spread to the femoral triangle. In this dose-finding study, we aimed to investigate the minimal effective volume for an ACB needed to fill the adductor canal distally in at least 95% of patients (ED95). METHODS: We performed a blinded trial, enrolling 40 healthy men. All subjects received an ACB with lidocaine 1%. Volumes were assigned sequentially to the subjects using the continual reassessment method followed by Bayesian analysis to determine the ED95. Distal filling of the adductor canal was assessed by magnetic resonance imaging (primary outcome). Secondary outcomes were the effect of volume on proximal spread to the femoral triangle (also assessed by magnetic resonance imaging), quadriceps muscle weakness (decrease by ≥25% from baseline) and sensory block. RESULTS: The ED95 was 20 ml, with an estimated probability of sufficiently filling the canal of 95.1% (95% credibility interval: 0.91-0.98). Proximal spread to the femoral triangle was seen in 0/4 (0%), 7/12 (58%), 4/8 (50%), and 8/16 (50%) subjects with the 5, 10, 15, and 20 ml doses, respectively (P=0.25). Seven subjects had a reduction in muscle strength, but there was no difference between groups (P=0.85). CONCLUSIONS: For an ACB, the dose closest to the ED95 needed to fill the adductor canal distally was 20 ml. There was no significant correlation between volume and proximal spread or muscle strength. CLINICAL TRIAL REGISTRATION: NCT02033356.


Assuntos
Anestésicos Locais/administração & dosagem , Lidocaína/administração & dosagem , Bloqueio Nervoso/métodos , Adolescente , Adulto , Anestésicos Locais/farmacocinética , Anestésicos Locais/farmacologia , Relação Dose-Resposta a Droga , Método Duplo-Cego , Esquema de Medicação , Humanos , Lidocaína/farmacocinética , Lidocaína/farmacologia , Imagem por Ressonância Magnética/métodos , Masculino , Força Muscular/efeitos dos fármacos , Bloqueio Nervoso/efeitos adversos , Estudos Prospectivos , Adulto Jovem
12.
Acta Anaesthesiol Scand ; 58(10): 1220-7, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25307707

RESUMO

BACKGROUND: The analgesic effect of the adductor canal block (ACB) after knee surgery has been evaluated in a number of trials. We hypothesized that the ACB would provide substantial pain relief to patients responding with moderate to severe pain after arthroscopic knee surgery. METHODS: Fifty subjects with moderate to severe pain after arthroscopic knee surgery were enrolled in this placebo-controlled, blinded trial. All subjects received two ACBs; an initial ACB with either 30 ml ropivacaine 7.5 mg/ml (n = 25) (R group) or saline (n = 25) (C group) and after 45 min a second ACB with the opposite study medication, according to randomization. Primary outcome was pain during 45 degrees active flexion of the knee at 45 min after the first block, assessed on a 0-100 mm visual analogue scale. Secondary outcome measures were: pain at rest and during flexion of the knee, worst pain experienced during a 5-m walk, patient's evaluation of muscle strength during walk, and amount of sufentanil administered during the 90-min study period. RESULTS: Regarding primary outcome, mean pain score difference between groups was 34 (95% CI: 25 to 44) mm, P < 0.001, in favour of the R group. At rest, mean pain score difference was 32 (23 to 41) mm, P < 0.001, and during walk: 21 (6 to 36) mm, P = 0.01 in favour of the R group. There were no differences between groups regarding other secondary outcome measures. CONCLUSION: The ACB is a relevant option for patients with moderate to severe pain after arthroscopic knee surgery.


Assuntos
Artroscopia/métodos , Joelho/cirurgia , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Adulto , Amidas , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Anestésicos Locais , Artroscopia/efeitos adversos , Feminino , Humanos , Masculino , Força Muscular , Medição da Dor , Ropivacaina , Coxa da Perna , Resultado do Tratamento
13.
Rev Med Suisse ; 9(375): 456-61, 2013 Feb 27.
Artigo em Francês | MEDLINE | ID: mdl-23539812

RESUMO

Nephrolithiasis is a highly prevalent pathology with a 10% lifetime risk in the Western population. Although it is often minimized and qualified as "idiopathic" significant comorbidities are frequently observed, e.g. the metabolic syndrome, type 2 diabetes mellitus, hypertension and bone fragility. Therefore nephrolithiasis can be regarded as a systemic disorder. A specialized diagnostic and therapeutic approach should be offered to such patients with active kidney stone disease in order to prevent stone recurrence and favor early diagnosis of said comorbidities.


Assuntos
Comportamento Cooperativo , Cálculos Renais/terapia , Nefrologia/organização & administração , Médicos/organização & administração , Atenção Primária à Saúde/organização & administração , Humanos , Cálculos Renais/classificação , Cálculos Renais/etiologia , Equipe de Assistência ao Paciente/organização & administração , Especialização
14.
Acta Anaesthesiol Scand ; 57(1): 112-7, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23074997

RESUMO

BACKGROUND: Adductor-canal-blockade is a new technique for pain relief after knee surgery. This block could cause nerve injury and the aim of this follow-up study was to determine the prevalence of saphenous nerve injury in patients receiving adductor-canal-blockade for pain treatment after total knee arthroplasty. METHODS: All patients included in two former studies of adductor-canal-blockade following total knee arthroplasty were invited to participate in this follow-up study 3-6 months after surgery. We examined the cutaneous area on the medial aspect of the lower leg (medial crural branch of the saphenous nerve), as well as the anterior, posterior, lateral and infrapatellar part of the affected and contralateral lower leg. Sensory function was tested with pinprick (sharp and blunt needle), temperature discrimination (cold disinfectant swabs) and light brush. RESULTS: We included 97 patients. None of the patients [0-5.3% (99% confidence interval)] had sensory changes related to temperature or light brush corresponding to the medial crural branch of the saphenous nerve, but 10 patients could not discriminate between blunt and sharp stimulation with a needle. In the infrapatellar area of the operated knee, 76 patients could not discriminate between blunt and sharp stimulation with a needle, 81 patients could not discriminate between cold and warmth, and 82 patients displayed an altered sensation to light brush. CONCLUSION: We found no indications of saphenous nerve injury caused by the adductor-canal-blockade at the mid-thigh level. However, 84% of the patients had signs of injury to the infrapatellar branch of the saphenous nerve in the operated leg. Such findings are well-known complications to the surgical procedure.


Assuntos
Artroplastia do Joelho/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Traumatismos dos Nervos Periféricos/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Lateralidade Funcional/fisiologia , Humanos , Perna (Membro)/inervação , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Medição da Dor/métodos , Estimulação Física , Sensação , Pele/inervação , Sensação Térmica , Resultado do Tratamento
15.
Acta Anaesthesiol Scand ; 56(8): 1013-9, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22834681

RESUMO

BACKGROUND: In this proof-of-concept study, we investigated the effect of the predominantly sensory adductor-canal-blockade on established pain in the early post-operative period after total knee arthroplasty (TKA). We hypothesised that the adductor-canal-blockade would reduce pain during flexion of the knee (primary end point) and at rest, as well as reducing morphine consumption and morphine-related side effects (secondary outcomes) compared with placebo. METHODS: We enrolled patients scheduled for elective TKA into this double-blind, placebo-controlled, randomised study. During general anaesthesia, we placed a catheter in the adductor canal, and after obtaining pre-block pain scores 30 min post-operatively, we injected 30 ml of ropivacaine 0.75% (n = 21) or saline (n = 20) according to randomisation. Clinicaltrials.gov Identifier: NCT01261897. RESULTS: Forty-two patients were randomised, and 41 were analysed. Mean (standard deviation) pain scores during flexion of the knee at 1 h post-operatively were 58 (22) mm and 67 (29) mm, ropivacaine and placebo group, respectively (P = 0.23) but was significantly reduced in the ropivacaine group when calculated as area under the curve for the interval 1-6 h (P = 0.02). There were no statistically significant differences regarding pain at rest (P = 0.08), morphine consumption (P = 0.06), nor morphine-related side effects, apart from nausea (P = 0.04). CONCLUSION: This proof-of-concept study shows promising results regarding the analgesic efficacy of adductor-canal-blockade in post-operative pain treatment after TKA, with a significant reduction in pain during flexion of the knee in the early post-operative period compared with placebo. However, the study was not sufficiently powered to permit final conclusions.


Assuntos
Artroplastia do Joelho , Bloqueio Nervoso/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Acetaminofen/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgesia Controlada pelo Paciente , Analgésicos não Entorpecentes/uso terapêutico , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Anestesia Geral , Área Sob a Curva , Método Duplo-Cego , Determinação de Ponto Final , Feminino , Humanos , Ibuprofeno/uso terapêutico , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Morfina/efeitos adversos , Morfina/uso terapêutico , Medição da Dor , Náusea e Vômito Pós-Operatórios/epidemiologia , Tamanho da Amostra , Resultado do Tratamento
16.
Acta Anaesthesiol Scand ; 56(3): 357-64, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22221014

RESUMO

BACKGROUND: Total knee arthroplasty (TKA) is associated with intense post-operative pain. Besides providing optimal analgesia, reduction in side effects and enhanced mobilization are important in this elderly population. The adductor-canal-blockade is theoretically an almost pure sensory blockade. We hypothesized that the adductor-canal-blockade may reduce morphine consumption (primary endpoint), improve pain relief, enhance early ambulation ability, and reduce side effects (secondary endpoints) after TKA compared with placebo. METHODS: Patients aged 50-85 years scheduled for TKA were included in this parallel double-blind, placebo-controlled randomized trial. The patients were allocated to receive a continuous adductor-canal-blockade with intermittent boluses via a catheter with either ropivacaine 0.75% (n = 34) or placebo (n = 37) (http://www.clinicaltrials.gov Identifier: NCT01104883). RESULTS: Seventy-five patients were randomized in a 1 : 1 ratio and 71 patients were analyzed. Morphine consumption from 0 to 24 h was significantly reduced in the ropivacaine group compared with the placebo group (40 ± 21 vs. 56 ± 26 mg, P = 0.006). Pain was significantly reduced in the ropivacaine group during 45 degrees flexion of the knee (P = 0.01), but not at rest (P = 0.06). Patients in the ropivacaine group performed the ambulation test, the Timed-Up-and-Go (TUG) test, at 24 h significantly faster than patients in the placebo group (36 ± 17 vs. 50 ± 29 s, P = 0.03). CONCLUSION: The adductor-canal-blockade significantly reduced morphine consumption and pain during 45 degrees flexion of the knee compared with placebo. In addition, the adductor-canal-blockade significantly enhanced ambulation ability assessed by the TUG test.


Assuntos
Artroplastia do Joelho , Bloqueio Nervoso , Dor Pós-Operatória/epidemiologia , Caminhada/fisiologia , Idoso , Idoso de 80 Anos ou mais , Amidas , Analgesia Controlada pelo Paciente , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Anestésicos Locais , Método Duplo-Cego , Determinação de Ponto Final , Feminino , Humanos , Perna (Membro)/inervação , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Morfina/efeitos adversos , Morfina/uso terapêutico , Medição da Dor/efeitos dos fármacos , Dor Pós-Operatória/tratamento farmacológico , Satisfação do Paciente , Medicação Pré-Anestésica , Estudos Prospectivos , Ropivacaina , Resultado do Tratamento
17.
Acta Anaesthesiol Scand ; 55(1): 14-9, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21039357

RESUMO

Because both the saphenous nerve and in part the obturator nerve are traversing the adductor canal of the thigh, we hypothesised that repeated administration of a local anaesthetic (LA) into this aponeurotic space could be a useful option for post-operative analgesia after knee replacement surgery. A systematic search of the literature pertinent to the blockade of the saphenous and/or obturator nerves for pain relief after knee surgery was conducted. Further, pain and opioid requirements were evaluated in eight patients receiving a continuous blockade of the saphenous and obturator nerve (adductor-canal-blockade) after total knee arthroplasty (TKA). Finally, we performed cross-sectional MR scans of the adductor canal after injection of ropivacaine 30ml in one patient. The systematic literature search revealed only one controlled study, where selective blockade of the saphenous nerve was investigated for the purpose of clinical pain relief after knee arthroscopy. We located no studies reporting on saphenous and/or obturator nerve block for pain relief after TKA. Preliminary findings in eight patients demonstrated that a continuous adductor-canal-blockade for 48h after TKA was associated with low mean pain scores at rest and low mean requirements for supplemental morphine. MR scans in one patient demonstrated that 30ml of LA filled the adductor canal, including the distal part, where the posterior branch of the obturator nerve joins the vessels and the saphenous nerve. Continuous adductor-canal-blockade may be a valuable adjunct for post-operative analgesia after major knee surgery. These preliminary results should be confirmed in randomised, controlled trials.


Assuntos
Artroplastia do Joelho , Joelho/cirurgia , Bloqueio Nervoso , Nervo Obturador , Procedimentos Ortopédicos , Dor Pós-Operatória/tratamento farmacológico , Amidas , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Anatomia Transversal , Anestésicos Locais , Humanos , Joelho/inervação , Imagem por Ressonância Magnética , Morfina/administração & dosagem , Morfina/uso terapêutico , Medição da Dor , Ropivacaina
18.
Urologe A ; 48(11): 1352-5, 2009 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-19705095

RESUMO

We report on a remarkable diagnostic work up of suspect rectal palpation results in a 54-year-old patient. According to a transrectal ultrasound-guided punch biopsy the patient was suspected of having a carcinoma of the seminal vesicles and an aggressive operational approach was considered. After a median laparotomy a generalized peritoneal carcinomatosis was found. A goblet cell carcinoid of the vermiform appendix was identified as the primary tumor. This case report deals with metastazation of a primary goblet cell carcinoma into the seminal vesicles on both sides as an extremely rare reason for suspicious rectal palpation results. The tumor valency, diagnostic work up, therapy and further differential diagnoses are described.


Assuntos
Neoplasias do Apêndice/patologia , Tumor Carcinoide/patologia , Tumor Carcinoide/secundário , Neoplasias dos Genitais Masculinos/patologia , Neoplasias dos Genitais Masculinos/secundário , Glândulas Seminais/patologia , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Apendicectomia , Neoplasias do Apêndice/cirurgia , Apêndice/patologia , Biomarcadores Tumorais/análise , Biópsia , Tumor Carcinoide/cirurgia , Terapia Combinada , Diagnóstico Diferencial , Exame Retal Digital , Fluoruracila/administração & dosagem , Fluoruracila/efeitos adversos , Neoplasias dos Genitais Masculinos/cirurgia , Humanos , Leucovorina/administração & dosagem , Leucovorina/efeitos adversos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Compostos Organoplatínicos/administração & dosagem , Compostos Organoplatínicos/efeitos adversos , Cuidados Paliativos , Equipe de Assistência ao Paciente , Neoplasias Peritoneais/patologia , Neoplasias Peritoneais/secundário , Glândulas Seminais/cirurgia , Sinaptofisina/análise
19.
Rev Med Suisse ; 5(207): 1314-7, 2009 Jun 10.
Artigo em Francês | MEDLINE | ID: mdl-19626931

RESUMO

Idiopathic calcium stone formation affects 10% of the adult western population in a lifetime and is, consequently, a real public health problem in these countries. Abnormalities of bone metabolism with osteopenia have been found in patients with idiopathic hypercalciuria. The type of diet (high protein intake, calcium restriction) and some mediators (cytokines, calcitriol) are involved in the pathophysiology of bone alterations. The purpose of this article is to discuss the link between calcium nephrolithiasis and bone density, factors implicated in bone loss and how to treat this pathology.


Assuntos
Densidade Óssea , Doenças Ósseas Metabólicas/metabolismo , Nefrolitíase/metabolismo , Adulto , Doenças Ósseas Metabólicas/complicações , Doenças Ósseas Metabólicas/epidemiologia , Doenças Ósseas Metabólicas/terapia , Osso e Ossos/metabolismo , Cálcio/metabolismo , Cálcio na Dieta/administração & dosagem , Proteínas na Dieta , Comportamento Alimentar , Humanos , Hipercalciúria/metabolismo , Incidência , Metanálise como Assunto , Nefrolitíase/epidemiologia , Nefrolitíase/etiologia , Nefrolitíase/terapia , Osteoporose/metabolismo , Fatores de Risco , Suíça/epidemiologia , Resultado do Tratamento
20.
J Colloid Interface Sci ; 320(1): 268-74, 2008 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-18255090

RESUMO

In the Young equation, only two of the four unknowns are measurable. They are the liquid interfacial tension sigma lv and the contact angle theta. To solve this equation, another correlation is required. In solving this equation, a better understanding of the magnitude of the solid interfacial tension sigma sv and the solid-liquid interfacial tension sigma sl is expected. The possibility of a theoretical estimation of the contact angle theta is sought as an alternative to the experimental method. In this paper, an attempt to calculate the solid interfacial tension sigma sv is reported. It is based on the intermolecular interaction which is mathematically described in the parameter Phi sl according to Good. The calculated sigma sv values for PTFE, steel, and glass surrounded by dense carbon dioxide are verified by comparing those values obtained from aqueous and ethanolic systems. Furthermore, the solid interfacial tension sigma sv is also used to forecast the water drop contact angle theta. The calculated values are compared with the experimental measured ones.

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