Comparing cold-air analgesia, systemically administered analgesia and scalp nerve blocks for pain management during photodynamic therapy for actinic keratosis of the scalp presenting as field cancerization: a randomized controlled trial.

BACKGROUND: Photodynamic therapy (PDT) using methyl aminolaevulinate (MAL) is an effective treatment for extensive actinic keratosis (AK). However, pain is a major side-effect of this therapy. OBJECTIVES: To investigate whether scalp nerve blocks (group 1) provide adequate pain relief during MAL-PDT of the scalp and forehead in 32 men with baldness. METHODS: The patients received intravenous (IV) analgesia [piritramide 7.5 mg IV, plus oral metamizole (40 drops 30 min prior to PDT)] in combination with cold-air analgesia (group 2; IV analgesia) and cold-air analgesia alone (group 3). Maximum pain was evaluated by means of a visual analogue scale (VAS) during and up to 300 min after PDT. Pain during PDT was further analysed according to a pain perception scale. Furthermore, we measured haemodynamics and investigated stress hormone levels in blood samples at different time points. RESULTS: Maximum pain during PDT (primary end point) was significantly reduced in the treatment group receiving scalp nerve blocks (VAS 2.1 ± 1.3) compared with the treatment groups receiving IV analgesia (VAS 7.3 ± 1.1) and cold-air analgesia (VAS 8.4 ± 2.0; P < 0.05). No significant difference was found between groups 2 and 3 with regard to pain relief (P = 0.32). The increase in systolic blood pressure during the first 3 min of PDT was significantly lower for group 1 than for groups 2 and 3 (P < 0.001). No correlation between stress hormone levels and pain were found. CONCLUSIONS: Scalp nerve blocks provide an effective method for pain management during PDT for patients with extensive AK.

[Patients with implanted ventricular assist devices : Challenge for emergency medicine]. / Patienten mit implantierten Herzunterstützungssystemen : Herausforderung in der Notfallmedizin.

Due to a huge increase in the implantation of ventricular assist devices (VAD) over the last few years and the enormous technical advances in functional safety, a growing number of patients with VAD are discharged from hospital, who are still considered to be severely ill. This results in an increased probability of these patients interacting with emergency services where personnel are unaware of the presence of a VAD, creating anxiety and uncertainty regarding how to treat these patients. This article presents an overview of the most common problems and pitfalls regarding VADs. It also presents an algorithm for dealing with emergencies involving these patients including the diagnostics, treatment and primary transport.

[Scalp blocks. A useful technique for neurosurgery, dermatology, plastic surgery and pain therapy]. / Kraniale Leitungsanästhesien. Hilfreiche Techniken für Neurochirurgie, Dermatologie, plastische Chirurgie und Schmerztherapie.

Safe and effective cranial analgesia can be achieved by blocking the sensitive nerves of that region. These include the supraorbital nerve, the supratrochlear nerve, the zygomaticotemporal nerve, the auriculotemporal nerve and the greater and lesser occipital nerves which are accessible at typical and most proximal points. Preferably long acting local anesthetics such as ropivacaine 0.75% or levobupivacaine 0.5% are used supplemented with 5 microg/ml epinephrine to reduce systemic resorption and to elongate the duration. Scalp blocks are useful for intraoperative neurologic testing of the patient during awake craniotomy or for supplementation of general anesthesia for other forms of craniotomy. Other applications are minimally invasive and stereotactic neurosurgery including deep brain stimulation, photodynamic therapy of actinic ceratosis, cranial plastic surgery and pain therapy.

Expression of rat kidney anion exchanger 1 in type A intercalated cells in metabolic acidosis and alkalosis.

By enzyme-linked in situ hybridization (ISH), direct evidence is provided that acid-secreting intercalated cells (type A IC) of both the cortical and medullary collecting ducts of the rat kidney selectively express the mRNA of the kidney splice variant of anion exchanger 1 (kAE1) and no detectable levels of the erythrocyte AE1 (eAE1) mRNA. Using single-cell quantification by microphotometry of ISH enzyme reaction, medullary type A IC were found to contain twofold higher kAE1 mRNA levels compared with cortical type A IC. These differences correspond to the higher intensity of immunostaining in medullary versus cortical type A IC. Chronic changes of acid-base status induced by addition of NH(4)Cl (acidosis) or NaHCO3 (alkalosis) to the drinking water resulted in up to 35% changes of kAE1 mRNA levels in both cortical and medullary type A IC. These experiments provide direct evidence at the cellular level of kAE1 expression in type A IC and show moderate capacity of type A IC to respond to changes of acid-base status by modulation of kAE1 mRNA levels.