Single-shot intraoperative local anaesthetic infiltration does not reduce morphine consumption after total hip arthroplasty: a double-blinded placebo-controlled randomized study.

BACKGROUND: The infiltration of local anaesthetic (LA), ketorolac, and epinephrine has been suggested to be effective for analgesia after total hip arthroplasty (THA). The part of action of each component of the mixture remains unclear. We investigated the contribution of infiltration of ropivacaine alone on the morphine consumption during the first 24 h after surgery. METHODS: Sixty patients undergoing primary THA were included in this prospective randomized double-blinded placebo-controlled trial, after IRB approval and informed consent. Surgical and general anaesthetic management were standardized. At the end of surgery, 80 ml of ropivacaine 0.2% (160 mg) or saline was infiltrated. The primary endpoint was morphine consumption 24 h after surgery. The secondary endpoints were: visual analogue scale scores and opioid side-effects at H2, H4, H8, H12, H24, D1, D2, D3, D4, D5, rehabilitation programme progress, chronic pain level, analgesic consumption, and surgical result at 3 months and 1 yr after surgery. The observation period was 1 yr. RESULTS: Groups were similar for patient characteristic and perioperative characteristics. The ropivacaine wound infiltration did not reduce morphine consumption at 24 h [median (25th and 75th inter-quartile) 27 (17-37) mg in the ropivacaine group vs 24 (18-34) mg in the placebo group, P=0.51] or its side-effects. No effect was found on rehabilitation progress or chronic pain after 3 months or 1 yr, but these were not the main endpoints of the study. CONCLUSIONS: Ropivacaine infiltration alone did not reduce morphine consumption at 24 h after operation nor did it improve postoperative rehabilitation.

Preoperative fasting does not affect haemodynamic status: a prospective, non-inferiority, echocardiography study.

BACKGROUND: The link between preoperative fasting and hypovolaemia remains unclear. We tested the hypothesis that preoperative fasting does not significantly increase the proportion of patients with hypovolaemia according to transthoracic echocardiography (TTE) criteria. METHODS: Patients of ASA status I-III and without bowel preparation were included in a non-inferiority, prospective, single-centre trial. Patients underwent passive leg raising (PLR) test and TTE at admission (Day 0) and after 8 h fasting (Day 1). The primary hypothesis was that an 8 h preoperative fasting does not increase the proportion (margin=5%) of patients with a positive PLR test ('functional approach'). The secondary hypothesis was that echocardiographic filling pressures or stroke volume (margin 10%) are not affected by preoperative fasting ('static approach'). RESULTS: One hundred patients were included and 98 analysed. After an 8 h fasting, the change in the proportion of responders to PLR was -6.1% [95% confidence interval (CI)=-16.0 to 3.8] of responders to PLR test on Day 0 when compared with Day 1. Because 95% CI was strictly inferior to 5%, there was no significant increase in the proportion of PLR responders on Day 1 when compared with Day 0. The 95% CI changes of static variables were always fewer than 10%, meaning that preoperative fasting induced significantly no relevant changes in static variables. CONCLUSION: Preoperative fasting did not alter TTE dynamic and static preload indices in ASA I-III adult patients. These results suggest that preoperative fasting does not induce significant hypovolaemia. Clinical trial registration NCT 01258361.

Comparison of subgluteal sciatic nerve block duration in type 2 diabetic and non-diabetic patients.

BACKGROUND: Although animal studies demonstrated delayed recovery after nerve block in laboratory models of diabetes, the duration of the action of sciatic nerve blocks clinically in patients with diabetes remains to be determined. We studied the duration of a sciatic nerve block in type 2 diabetic patients compared with non-diabetic patients. METHODS: We prospectively included consecutive patients aged 50-80 yr, with type 2 diabetes with minor nerve injury (confirmed with 5.07 at 10 g monofilament test, n=23) and non-diabetic patients (n=49) scheduled for distal lower limb surgery. Before surgery, a subgluteal sciatic nerve block (20 ml of ropivacaine 4.75 mg ml(-1)) was performed with an ultrasound approach coupled with nerve stimulation. The primary endpoint was the sensory block duration. RESULTS: There was no significant difference between groups for age, but haemoglobin A1c and creatinine values were significantly higher in the diabetic group. There was no difference in 5.07 (10 g) monofilament testing, but the diabetic group had lower scores for the 0.4 and 0.07 g tests (P<0.01). There was no significant difference in the median onset time for the sensory block (25 vs 25 min, NS), but the median duration of the sensory block (21 vs 17 h, P<0.01) and the motor block (16 vs 12 h, P<0.01) were higher in the diabetic group. No complication occurred in either group. CONCLUSIONS: These findings demonstrate that diabetic patients with pre-existing incipient neuropathy exhibit delayed recovery from the block with ropivacaine, confirming animal studies. Clinical trial registration ClinicalTrials.gov, NCT01704612.

Oxidative stress intensity in lens and aqueous depending on age-related cataract type and brunescense.

PURPOSE: Cataract formation represents a serious problem in the elderly, and has a large impact on healthcare budget. The oxidative stress form and intensity might determine the cataract type and pigmentation, making efforts in the cataract prevention challenge more complex. METHODS: This is a retrospective cross-sectional review of 80 samples of aqueous humor and lens corticonuclear blocks. Aqueous samples were analyzed by the method of antioxidant activity estimation (%iMDA), while lipid peroxides (LP) and total sulfhydryl groups (TSH) were determined in lenses. RESULTS: Mixed and brunescent cataracts have statistically significant lower values of antioxidative %iMDA and TSH (p<0.001 for both parameters) and higher values of lipid peroxidation (p<0.001). No correlation between LP and TSH with maturity of cortical cataract was found, but there was a significant correlation with the %iMDA (p<0.05). CONCLUSIONS: The role of the oxidative stress in cataractogenesis could not be the same for all cataract types. High level of lipid peroxides in pigmented cataracts may point to the different nature of pigment source than proteins solely, whereas lipid peroxidation and SH groups consumption in cortical cataractogenesis might be of less importance.

Xanthine oxidase activity in patients with age-related cataract associated with hypertension.

Reactive oxygen species and lipid peroxidation are important factors that contribute to the development of age-related cataract. The study included 130 patients with age-related cataract, 69 of whom were diagnosed with hypertension (HT), 20 with hypertension and type 2 diabetes mellitus (DM), and 41 had no accompanying condition. The following parameters were measured in the serum of the examinees: products of lipid peroxidation malondialdehyde (MDA) and lipofuscin-like fluorophores (LLF), activity of prooxidative enzymes xanthine oxidase (XO) and myeloperoxidase (MPO), antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx), the concentration of thiol groups, and the ferric reducing activity of plasma. The activity of prooxidative enzymes XO and MPO was higher in the plasma of patients with HT (XO=9.0±1.2 U/L; MPO=77.3±8.4 U/L) and with HT and DM (XO=11.9±0.9 U/L; MPO=89.5±5.0 U/L) compared to patients with age-related cataract (XO=6.2±0.9 U/L; MPO=52.4±6.3 U/L; P<0.01). Our research has shown that patients with age-related cataract and hypertension were exposed to increased oxidative damage of biomolecules, based on the increased plasma LLF and MDA content and decreased levels of thiol groups. Oxidative changes of biomolecules in these patients were associated with increased activity of the XO, MPO, and GPx enzymes and a lower extracellular SOD activity and total ferric reductive ability of plasma.

Pseudoexfoliation syndrome and its antioxidative protection deficiency as risk factors for age-related cataract.

PURPOSE: Pseudoexfoliation syndrome (PES) seems to be a systemic condition. However, to an ophthalmologist it represents a continual challenge, due to unclear etiology and patho-genesis, and because of a potential for development of an aggressive glaucoma, and cataract surgery complications. According to some findings, PES could be a factor of hastened aging, which means that it could be considered as a secondary aging factor. METHODS: Frequencies of secondary aging diseases (non-insulin dependent diabetes mellitus, atherosclerotic myocardiopathy, chronic obstructive lung diseases, arterial hypertension, and PES) were investigated in 162 patients with age-related cataract and 55 age- and sex-matched control subjects, and analyzed by a logistic regression. The authors also determined elements of antioxidative protection in a group of sera from patients with cataract and PES, and compared them to those obtained from patients with cataract without PES (activity of catalase and peroxidase, glutathione, vitamins C and E), and total antioxidative protection (%iMDA). Antioxidant defense of aqueous humors, expressed as a rate of induced malondialdehyde (%iMDA), and total thiol groups in the lens corticonuclear blocks (TSH) were estimated in samples of 17 patients with PES and cataract and 55 patients with cataract only. RESULTS: Logistic regression showed the highest odds ratio for PES (OR=4.516; p<0.05). Catalytic activity of serum catalase had significantly lower values in patients with PES (p<0.05). Anti oxidative defense of aqueous humor and lens had lower values in patients with PES. CONCLUSIONS: The results indicate that PES might be a significant factor for cataractogenesis. At least a part of pathogenesis alterations in an eye with PES could be the result of higher intensity of oxidative stress.

Bilateral tuberculous abscesses on the face (eyelids) of a child.

PURPOSE: To report a rare case of tuberculosis with facial abscess. METHODS: A 4 1/2-year-old girl had an acute left upper eyelid abscess and a large, spherical tumescence involving the right upper eyelid, eyebrow, and forehead. The left upper eyelid abscess was drained, and the mass involving the right eyelid, eyebrow, and forehead was excised. RESULTS: Histopathologic and microbiologic examination established a human type of tuberculous mycobacterium as the cause of the bilateral facial lesions. CONCLUSION: Tuberculosis should be considered as a possible cause of abscess even when clinical features are not typical.

Influence of cataract maturity on aqueous humor lipid peroxidation markers and antioxidant enzymes.

PURPOSE: The impact of cataract maturity on the aqueous humor (AH) oxidant/antioxidant balance is largely controversial. This study was aimed at assessing the relationships between cataract maturity and AH lipid peroxidation markers and enzymatic antioxidants. PATIENTS AND METHODS: The concentrations of conjugated dienes (CD), lipofuscin-like fluorescent end-products (LLF), soluble proteins, as well as the activities of superoxide dismutase (SOD) and catalase (CAT) were measured in AH samples from nondiabetic patients with either immature (n=15) or mature (n=15) cataract. RESULTS: In the overall AH sample, the mean values of CD, LLF, SOD, and CAT were 0.160 ± 0.024 (OD234), 166 ± 27 RFU, 24.5 ± 7.1 U/ml, and 31.9 ± 3.9 pmol/ml, respectively. CD was positively correlated with SOD (r=0.647; P<0.001), CAT (r=-0.394; P=0.031), and LLF (r=-0.399; P=0.029). The LLF was negatively correlated with SOD (r=-0.461; P=0.010). In samples adjusted for confounding factors, differences between immature and mature cataract groups regarding SOD, CD, LLF, and total proteins were significant (P<0.05; for all variables). The multiple logistic regression analysis identified LLF (OR=4.08; P=0.038) and SOD (OR=4.99; P=0.031) as independent predictors of cataract maturity. CONCLUSIONS: These results suggest that AH lipid peroxidation markers and antioxidants may significantly depend on the cataract maturity stage.

Xanthine oxidase activity in patients with age-related cataract associated with hypertension

Reactive oxygen species and lipid peroxidation are important factors that contribute to the development of age-related cataract. The study included 130 patients with age-related cataract, 69 of whom were diagnosed with hypertension (HT), 20 with hypertension and type 2 diabetes mellitus (DM), and 41 had no accompanying condition. The following parameters were measured in the serum of the examinees: products of lipid peroxidation malondialdehyde (MDA) and lipofuscin-like fluorophores (LLF), activity of prooxidative enzymes xanthine oxidase (XO) and myeloperoxidase (MPO), antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx), the concentration of thiol groups, and the ferric reducing activity of plasma. The activity of prooxidative enzymes XO and MPO was higher in the plasma of patients with HT (XO=9.0±1.2 U/L; MPO=77.3±8.4 U/L) and with HT and DM (XO=11.9±0.9 U/L; MPO=89.5±5.0 U/L) compared to patients with age-related cataract (XO=6.2±0.9 U/L; MPO=52.4±6.3 U/L; P<0.01). Our research has shown that patients with age-related cataract and hypertension were exposed to increased oxidative damage of biomolecules, based on the increased plasma LLF and MDA content and decreased levels of thiol groups. Oxidative changes of biomolecules in these patients were associated with increased activity of the XO, MPO, and GPx enzymes and a lower extracellular SOD activity and total ferric reductive ability of plasma.

[Patient's relatives wishes concerning the visiting hours in an intensive care unit]. / Elargissement des plages horaires de visites dans une unité de réanimation : l'avis des proches.

OBJECTIVE: The present study was aimed at assessing the opinion of the patient's relatives concerning the visiting hours in the ICU. METHOD: The visiting relatives were questioned about the information delivered in the Unit (assessed as 0 for minimal and 10 for maximal assessments, respectively) and the hypothesis to extend the Unit's visiting hours. The responses were given independently by the relatives. RESULTS: Eighty-seven out of 64 relatives responded (63% females). The delivered information was assessed by a median note=10 (interquartile: [8-10]). The current visiting times (2h per day during the week, 6h in weekend) were assessed as sufficient by 48 closest (58%). Fifty-four (67%, CI95%=[56-77]) requested more liberal visiting times and 38 (46%, CI95%=[36-57]) requested 24h visiting policy. Five relatives (6%, CI95%=[1-11]) would like to be present during patient's care. Most relatives do not wish to assist to patient's care to avoid interfering with caregiver's workload (81%), to respect the patient's intimacy (49%) and by fear of being impressed by the care (23%). Forty percent of the relatives would like to help feeding the patient. CONCLUSION: Most of the relatives wish for more liberal visiting times without interfering with patient's care.

[Stress ulcer in a patient with a subacute subdural hematoma]. / Stres ulkus kod bolesnika sa subakutnim subduralnim hematomom.

During the onset and development of pathologic events, numerous changes occur in the body as the result of an attempt of dynamic equilibrium maintenance. Results of such sequence of events may lead to organic, as well as psychic impairment of the body that is often referred to as the onset of psychosomatic disease. This paper deals with the disorder that could provide better insight in the possible physiopathologic mechanisms of psychosomatic disease or disorders. In a patient, chronic alcoholic subdural hematoma was diagnosed. Peptic ulcer hemorrhage occurred after surgical removal of the hematoma. Possible physiopathologic mechanisms in the origin of this disorder have been described.