Peripheral nerve block in ankle fracture surgery: a qualitative study of patients' experiences.

Peripheral nerve blocks are popular as a mode of anaesthesia for limb surgery and their beneficial effects are well documented in elective surgery. However, concerns have been raised about potential rebound pain outweighing the benefits in acute ankle fracture surgery. Furthermore, pain scores and morphine consumption do not provide a full picture, as pain is subjective. To evaluate the clinical usefulness of peripheral nerve blocks, we explored patients' expectations and experiences by means of semi-structured interviews analysed with systematic text condensation. We obtained ethical approval and informed consent and sampled purposively among adult patients scheduled for ankle surgery with nerve blocks as the primary mode of anaesthesia. Patients were interviewed within 48 h postoperatively. Data saturation was reached after 13 interviews. We found that, despite pre-emptive ibuprofen and paracetamol, some patients did experience excruciating rebound pain for up to 2 h, although most had little or no pain. The patients had doubts about what to do when the block wore off, which led to a risk of unnecessary pain levels or morphine overuse. Patients had difficulty understanding the effect and course of the nerve blocks. They had misunderstandings regarding the blocks' effect on sensation, resulting in fear of feeling pain during surgery and of permanent nerve damage after surgery. However, patients valued the mental alertness, ability to ambulate and efficient pain relief provided by the blocks. We recommend that patients be given thorough and repeated information as we feel this is crucial in preventing undesirable responses from patients, and is likely to increase the overall clinical usefulness of nerve blocks in acute limb surgery.

Prevalence of saphenous nerve injury after adductor-canal-blockade in patients receiving total knee arthroplasty.

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.

Effect of adductor-canal-blockade on established, severe post-operative pain after total knee arthroplasty: a randomised study.

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.

Impact of G-CSF Therapy on Leukopenia and Acute Rejection Following Kidney Transplantation.

BACKGROUND: Leukopenia is a common problem after kidney transplantation. The therapeutic approach typically includes a reduction of the immunosuppressive therapy, which is associated with an increased risk of rejection and allograft loss. Granulocyte colony-stimulating factor (G-CSF) is used as a therapeutic option to raise the leukocyte blood count; however, the effect on acute rejections is controversial. OBJECTIVE: The goal of this study is to examine the incidence of acute rejections following G-CSF therapy. METHODS: We retrospectively evaluated patients with leukopenia following kidney transplantation and GCSF therapy between January 2007 and December 2017 at our center compared to controls with matched minimal leucocyte blood count in a matched pair analysis. RESULTS: We identified 12 patients, who received G-CSF therapy with a cumulative dose of 10.74 µg/kg body weight over a time frame of 4.3 days. G-CSF therapy resulted in a significantly shorter time period with leucocytes <3,000/µL (9.5 vs. 16.6 days), but also trended towards an increased risk of rejection within the next 30 days with three patients in the G-CSF group and no patient in the control group (p=0.06) developing an acute biopsy-proven rejection. Infection and mortality rate in the subsequent year were not different between groups. CONCLUSION: G-CSF therapy decreases the duration of leukopenia post-kidney transplantation, but may also increase the risk of an acute rejection.

Cloning, sequencing and expression of the sialidase gene from Actinomyces viscosus DSM 43798.

Chromosomal DNA from Actinomyces viscosus was digested with restriction endonucleases and the fragments ligated with pUC-vectors were used to transform Escherichia coli cells. Clones bearing the required sialidase gene were detected by spraying the colonies with the fluorogenic sialidase substrate MU-Neu5Ac. The identity of the cloned sialidase was confirmed after the 5700-fold enrichment and comparison with the purified enzyme of A. viscosus. Both sialidases were identical with regard to molecular mass, substrate specificity tested with sialyllactoses, and the inhibition of their activity by heterologous antisialidase antibodies. The sequenced insert (EMBL accession number X62276) revealed a mol% G + C of 68.2, typical for A. viscosus. An open reading frame of 2739 bp follows a sequence with dyad symmetry and an AG-rich region, and codes for 913 amino acids representing a molecular mass of 113 kDa. The conserved amino acid sequence [Ser-X-Asp-X-Gly-X-Thr-Trp] typical for bacterial sialidases was found at five positions in the predicted amino acid sequence. The gene of this enzyme is expressed by E. coli, despite the low relatedness of both species.

Projection-simulated ametropia. A model for teaching subjective refraction.

Teaching subjective refraction techniques ("refractometry") is enhanced by having the student experience the effect of each lens change "through the eyes of the patient." A projector, positioned behind the phoropter, projects a visual acuity chart through the phoropter onto the far wall. "Unknown" refractive errors are simulated by attaching trial lenses to the lens barrel of the projector, and the student progressively clears the projected image as he learns the standard steps of subjective refractometry. The focus sensitivity of each lens change can be varied, if desired, by stopping down the projection system. This simulation, which uses equipment readily available in most ophthalmology offices, has proven useful for both demonstration and practice.

Genetic analysis of the maternally induced affinity enhancement in the non-Ox1 idiotypic antibody repertoire of the primary immune response to 2-phenyloxazolone.

The early phases of ontogeny are decisive for the development of the B-cell repertoire. Here, we demonstrate that maternal tertiary immunization of BALB/c mice with 2-phenyloxazolone (phOx) caused a drastic alteration of the primary antigen-specific repertoire of the offspring. Maternal tertiary immunization or quaternary antibodies, which exhibited an extremely weak cross-reactivity with the major Ox1 idiotype (IdOx1), induced a change in the proportion of IdOx1/non-IdOx1 antiphOx antibodies in the F1 and F2 primary repertoire. The observed variability in the level of IdOx1 expression (10-90%) exceeded even the seemingly genetically based differences between various mouse strains. In comparison with the non-IdOx1 of control mice, half of the non-IdOx1 antibodies showed a 5-100-fold enhanced affinity. Sixty per cent of these antibodies exhibited an affinity identical to that of IdOx1 antibodies, which are normally of the highest affinity, while the remaining 40% exceeded even that of IdOx1 by a factor of 10. The non-IdOx1 were encoded by VH/VL genes and/or combinations thereof which are either new, hitherto unobserved in the antiphOx response, or typical of memory responses in normal mice. The significance of these data is discussed with respect to the possibility that maternal antibodies, which are acquired through multiple immune maturation processes, may have an epigenetic (non-Mendelian) inheritable potential for the offspring.