Optical coherence tomography angiography manifestations of different degrees of nonproliferative diabetic retinopathy / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To investigate the differences in varying stages of non-proliferative diabetic retinopathy(NPDR)using optical coherence tomography angiography(OCTA).METHODS: Cross-sectional study. A total of 77 cases(77 eyes)of diabetic patients were included, and they were divided into non-diabetic retinopathy(NDR; 23 eyes)and non-proliferative diabetic retinopathy(NPDR; 54 eyes)groups, further subdivided into mild NPDR(20 eyes), moderate NPDR(20 eyes), and severe NPDR(14 eyes). Foveal avascular zone(FAZ)area, superficial and deep capillary plexus densities(SSP and DSP), and visual acuity(LogMAR)were compared between NDR and NPDR groups. Furthermore, the visual acuity, FAZ area and levels of SSP and DSP were compared in different degrees of NPDR. Correlation analysis were conducted to elucidate relationships between FAZ area, visual acuity, SSP, DSP, and severity of the disease.RESULTS: Compared with the NDR group, the visual acuity(LogMAR)and macular FAZ area increased, while SSP and DSP were decreased in the NPDR group(P<0.05); there were significant differences in visual acuity, FAZ area and SSP and DSP levels in different degrees of NPDR(P<0.05). Visual acuity(LogMAR)and FAZ area displayed a positive correlation with the severity of disease, while SSP and DSP showed a negative correlation.CONCLUSION: With the progression of NPDR, the visual acuity(LogMAR)and FAZ area increased, and the SSP and DSP decreased.

Application Value of Sevoflurane Combined with Brachial Plexus Block in Children with Humeral Fracture Surgery and its Effect on Hemodynamics: A Clinical and Anatomical Study

SUMMARY: To observe the effect of sevoflurane combined with brachial plexus block (BPB) in children with humeral fracture surgery and its effect on hemodynamics. 84 children who received surgical treatment of humeral fracture in our hospital from September 2019 to September 2022 were selected. According to different anesthesia methods, the children were divided into control group and study group. The control group only received laryngeal mask sevoflurane; the study group received laryngeal mask sevoflurane combined with BPB. The operation situation, hemodynamic indexes, stress level, pain and adverse reactions of children was observed. The postoperative awakening time in the study group was lower than control group, the postoperative pain onset time in the study group was higher than control group (P0.05). Postoperative 2h, the levels of serum cortisol, b-endorpin, norepinephrine and epinephrine in the study group were lower than control group (P0.05). Sevoflurane combined with BPB is helpful to shorten the postoperative awakening time of children with humeral fracture, reduce the degree of postoperative pain, improve hemodynamics, and reduce stress response, and has good safety.

El objetivo fue observar el efecto del sevoflurano combinado con bloqueo del plexo braquial (BPB) en niños con cirugía de fractura de húmero y su efecto sobre la hemodinámica. Se seleccionaron 84 niños que recibieron tratamiento quirúrgico de fractura de húmero en nuestro hospital desde septiembre de 2019 hasta septiembre de 2022. Según diferentes métodos de anestesia, los niños se dividieron en grupo control y grupo de estudio. El grupo control solo recibió sevoflurano en mascarilla laríngea; el grupo de estudio recibió sevoflurano con mascarilla laríngea combinado con BPB. Se observó la situación operatoria, índices hemodinámicos, nivel de estrés, dolor y reacciones adversas de los niños. El tiempo hasta el despertar postoperatorio en el grupo de estudio fue menor que el del grupo control, el tiempo de aparición del dolor postoperatorio en el grupo de estudio fue mayor que el del grupo control (P0,05). A las 2 horas postoperatorias, los niveles séricos de cortisol, β-endorfina, norepinefrina y epinefrina en el grupo de estudio fueron más bajos que los del grupo control (P 0,05). El sevoflurano combinado con BPB es útil para acortar el tiempo de despertar del posoperatorio de los niños con fractura de húmero, reduce el grado de dolor postoperatorio, mejora la hemodinámica y reduce la respuesta al estrés, además de tener buena seguridad.

Dexmedetomidine versus sufentanil as adjuvants to bupivacaine for brachial plexus block during upper extremity surgery: a randomized clinical trial

Abstract Background: Brachial plexus block (BPB) has been accepted as a reliable alternative for general anesthesia in upper limb surgeries. Adding adjuvant drugs like dexmedetomidine and sufentanil has been shown to have clinical and pharmacologic advantages. In this randomized parallel clinical trial, we aim to compare the effects of these two adjuvants for bupivacaine in BPB. Methods: In this double-blinded study, by using computer-assisted block randomization, 40 patients ranged from 20 to 65 years old and scheduled for elective upper limb surgeries were assigned to two equal study groups (n = 20), receiving 1 mL of 5 μg.mL-1 sufentanil (group S) or 1 mL of 100 μg.mL-1 dexmedetomidine (group D) in adjunction to 30 mL of 0.5% bupivacaine for supraclavicular BPB under the guidance of ultrasonography. Characteristics of local anesthesia and postoperative analgesia were evaluated (n = 40). Results: The duration of blocks significantly improved in group S (sensory: estimated median difference (EMD) [95%CI] = 100.0 [70.0~130.0], p < 0.001; motor: EMD [95%CI] = 120.0 [100.0~130.0], p < 0.001). Group S also had significantly longer postoperative analgesia and lower opioid consumption within 24 hours after the surgery (EMD [95%CI] = 4.0 [3.0~7.0], p < 0.001; EMD [95%CI] = -5.0 [-5.0~-5.0], p < 0.001; respectively). None of the patients showed adverse effects concerning vital signs, nausea, or vomiting. Conclusion: Our study showed that during ultrasound-guided supraclavicular BPB, sufentanil is a fairly better choice than dexmedetomidine as an adjuvant for bupivacaine and can provide preferable sensory and motor blocks. No significant side effects were seen in either of the study groups.

Perineural low dexamethasone dose as adjuvant in supraclavicular brachial plexus block for arteriovenous fistula creation in end stage renal disease: a randomized controlled trial

Abstract Background and aims: Dexamethasone as adjunct to local anesthetic solution improves the quality of brachial plexus block (BPB). However, evidence for its efficacy at low doses (< 4 mg) is lacking. This study was designed to evaluate the duration of analgesia attained with low dose dexamethasone as adjuvant to local anesthetic for creation of arteriovenous fistula (AVF) under BPB. Methods: Sixty-six patients scheduled for AVF creation were randomly allocated to receive either saline (control) or 2 mg dexamethasone, together with 0.5% ropivacaine and 0.2% lignocaine. The primary outcome was duration of analgesia, defined as time from performing the block to the first analgesic request. The secondary outcomes were time from injection to complete sensory block, time from injection to complete motor block, duration of motor block, postoperative analgesic consumption, and fistula patency at three months. Results: All the blocks were effective. In the group that received dexamethasone, the time to first analgesic request was significantly delayed (432 ± 43.8 minutes vs. 386.4 ± 40.2 minutes; p < 0.01). The onset of sensory and motor blockade occurred faster in dexamethasone group and overall analgesic consumption was also reduced. However, dexamethasone addition did not prolong the duration of motor block. There was no statistically significant difference in the patency of fistulas between the two groups at three months. (p = 0.34). Conclusion: Addition of low-dose perineural dexamethasone to local anesthetic solution significantly prolonged the duration of analgesia. Further trials are warranted to compare the adverse effects between dexamethasone doses of 4 mg and lower.

Endoscopic ultrasound-guided celiac plexus neurolysis in pancreatic cancer-associated pain: different technical approaches in three challenging cases

Abdominal pain is severe in the vast majority of patients with pancreatic cancer. In some cases, chronic use of analgesics markedly reduces quality of life due to side effects. Endoscopic ultrasound-guided celiac plexus neurolysis is a procedure that controls cancerassociated pain in this population and consists of injecting a neurolytic agent around or within the celiac plexus. In this report, we present three cases with different technical approaches for celiac plexus neurolysis.

El cáncer de páncreas se puede presentar con dolor abdominal intenso, siendo necesario el uso de analgésicos a largo plazo en muchos de los pacientes. Sin embargo, estos medicamentos pueden tener efectos adversos que finalmente reducen la calidad de vida de los pacientes. La neurólisis del plexo celíaco guiada por ecoendoscopia es un procedimiento que controla el dolor asociado a este tipo de neoplasia y consiste en inyectar un agente neurolítico en o alrededor del plexo celíaco. Presentamos tres casos en los cuales se realizan diferentes técnicas de abordaje terapéutico.

Posterior fossa choroidplexus papilloma in the pediatric population: case series and literature review / Papiloma de plexo coroide na fossa posterior na população pediátrica: série de casos e revisão da literatura

Abstract Choroid plexus papillomas (CPPs) are rare benign neoplasms which are particularly uncommon in the posterior fossa in children. We herein present a case series of five patients treated at a tertiary care hospital. A comprehensive literature review was also carried out. The patients treated at the tertiary care hospital were aged between 4 and 16 years. Gross total resection (GTR) was initially achieved in two patients. All patients showed clinical improvement. Moreover, 27 articles published between 1975 and 2021 were selected for the literature review, totaling 46 patients; with the 5 patients previously described, the total sample was composed of 51 cases, With a mean age was 8.2 years. The lesions were located either in the fourth ventricle (65.3%) or the cerebellopontine angle (34.7%). Hydrocephalus was present preoperatively in 66.7% of the patients, and a permanent shunt was required in 31.6% of the cases. The GTR procedure was feasible in 64.5%, and 93.8% showed clinical improvement. For CPPs, GTR is the gold standard treatment and should be attempted whenever feasible, especially because the role of the adjuvant treatment remains controversial. Neuromonitoring is a valuable tool to achieve maximal safe resection. Hydrocephalus is common and must be recognized and promptly treated. Most patients will need a permanent shunt. Though there is still controversy on its efficacy, endoscopic third ventriculostomy is a safe procedure, and was the authors' first choice to treat hydrocephalus.

Resumo Os papilomas do plexo coroide (PPCs) são neoplasias benignas raras e, na população pediátrica, são particularmente incomuns na fossa posterior. Apresentamos uma série de casos de cinco pacientes atendidos em um hospital terciário. Além disso, foi realizada uma ampla revisão da literatura. Os pacientes atendidos no hospital terciário tinham entre 4 e 16 anos. Ressecção macroscópica total (RMT) foi inicialmente realizada em dois pacientes. Todos os pacientes apresentaram melhora clínica. Além disso, 27 artigos publicados entre 1975 e 2021 foram selecionados para a revisão da literatura, totalizando 46 pacientes. Somados à série de casos atuais, encontramos 51 pacientes, com média de idade de 8,2 anos. As lesões localizavam-se no quarto ventrículo (65,3%) ou no ângulo pontocerebelar (34,7%). Hidrocefalia estava presente no pré-operatório em 66,7% dos pacientes, e derivação ventricular permanente foi necessária em 31,6% dos casos. A RMT foi possível em 64,5%, e 93,8% tiveram melhora clínica. Para os CPPs, a RMT é o tratamento padrão-ouro e deve ser tentado sempre que possível, especialmente porque ainda existem controvérsias quanto ao papel do tratamento adjuvante. A neuromonitorização é uma ferramenta importante para se atingir a máxima ressecção segura. A hidrocefalia é comumente vista nesses pacientes e deve ser identificada e tratada. A maioria dos pacientes irá precisar de uma derivação permanente. Apesar de persistirem controvérsias sobre sua eficácia, a terceiro-ventriculostomia endoscópica foi a primeira escolha para tratar a hidrocefalia na experiência dos autores e é uma opção segura.

Bloqueos Nerviosos. Bases Anatómicas del Dolor Somático Abdomino-Pélvico / Nerve Blocks. Anatomy of the Somatic Innervation of the Abdomino-Pelvic Cavity

El dolor abdominal es una de las sintomatologías que afectan con frecuencia la cavidad abdomino-pélvica. Dicha cavidad posee una inervación somática en la que intervienen del séptimo a doceavo nervios intercostales, ramos colaterales y terminales del plexo lumbar y el nervio pudendo; siendo objetivo de este trabajo la descripción anatómica del dolor abdominopélvico a través del plexo lumbar, nervios intercostales y nervio pudendo, sus diferentes patrones y variaciones de conformación, y las implicancias de éstas últimas en las distintas maniobras clínico-quirúrgicas. Se realizó un estudio descriptivo, observacional y morfométrico de la inervación somática de la cavidad abdomino-pélvica, en 50 preparaciones cadavéricas, fijadas en solución de formaldehído, de la Tercera Cátedra de Anatomía, Facultad de Medicina, Universidad de Buenos Aires, entre Agosto/2017-Diciembre/2019. La descripción clásica del plexo lumbar se encontró en 35 casos; la presencia del nervio femoral accesorio en ningún caso; así como también la ausencia del nervio iliohipogástrico en ningún caso; el nervio obturador accesorio se halló en 2 casos; el nervio genitofemoral dividiéndose dentro de la masa muscular del psoas mayor en 6 casos; el nervio cutáneo femoral lateral emergiendo únicamente de la segunda raíz lumbar en 6 casos y por último se encontró la presencia de un ramo del nervio obturador uniéndose al tronco lumbosacro en un caso. Los nervios intercostales y el nervio pudendo presentaron una disposición clásica en todos los casos analizados. Es esencial un adecuado conocimiento y descripción del plexo lumbar, nervios intercostales y nervio pudendo para un adecuado abordaje de la cavidad abdomino-pélvica en los bloqueos nerviosos.

SUMMARY: Abdominal pain is one of the symptoms that affect the abdominal-pelvic cavity. The abdominal-pelvic cavity has a somatic innervation involving the seventh to twelfth intercostal nerves, collateral and terminal branches of the lumbar plexus and the pudendal nerve. The objective of this work is the description of the lumbar plexus, intercostal nerves and pudendal nerve, its different patterns and structure variations, as well as its implications during pain management in patients. A descriptive, observational, and morphometric study of patterns and structure variations of the lumbar plexus, intercostal nerves and pudendal nerve was conducted in 50 formalin-fixed cadaveric dissections of the Third Chair of Anatomy at the School of Medicine in the Universidad de Buenos Aires from August 2017 to December/2019. The standard description of the lumbar plexus was found in 35 cases; accessory femoral nerve was not present in any of the cases; absence of the iliohipogastric nerve was also not found in any case, while the accessory obturating nerve was found in 2 cases; genitofemoral nerve dividing within the muscle mass of psoas in 6 cases; lateral femoral cutaneous nerve emerging only from the second lumbar root in 6 cases and finally, presence of a branch of the obturating nerve was found joining the lumbosacral trunk in one case. The pudendal and intercostal nerve patterns presented a typical pathway in all cases. Adequate knowledge and description of the lumbar plexus, intercostal nerves and pudendal nerve is essential for an adequate approach of the abdominal-pelvic cavity in nerve blocks.

Anatomy of the lower hypogastric plexus applied to endometriosis: a narrative review

ABSTRACT Objective The objective of the present study is to evaluate the anatomy of the inferior hypogastric plexus, correlating it with urological pathologies, imaging exams and surgeries of the female pelvis, especially for treatment of endometriosis. Material and Methods We carried out a review about the anatomy of the inferior hypogastric plexus in the female pelvis. We analyzed papers published in the past 20 years in the databases of Pubmed, Embase and Scielo, and we included only papers in English and excluded case reports, editorials, and opinions of specialists. We also studied two human fixed female corpses and microsurgical dissection material with a stereoscopic magnifying glass with 2.5x magnification. Results Classical anatomical studies provide few details of the morphology of the inferior hypogastric plexus (IHP) or the location and nature of the associated nerves. The fusion of pelvic splanchnic nerves, sacral splanchnic nerves, and superior hypogastric plexus together with visceral afferent fibers form the IHP. The surgeon's precise knowledge of the anatomical relationship between the hypogastric nerve and the uterosacral ligament is essential to reduce the risk of complications and postoperative morbidity of patients surgically treated for deep infiltrative endometriosis involving the uterosacral ligament. Conclusion Accurate knowledge of the innervation of the female pelvis is of fundamental importance for prevention of possible injuries and voiding dysfunctions as well as the evacuation mechanism in the postoperative period. Imaging exams such as nuclear magnetic resonance are interesting tools for more accurate visualization of the distribution of the hypogastric plexus in the female pelvis.

Influencia de posición del brazo en adultos para abordaje de plexo braquial costoclavicular: estudio observacional / Influence of arm position in costoclavicular approach for brachial plexus block in adult patient: observational study

Resumen: Introducción: el bloqueo de plexo braquial con abordaje costoclavicular, ofrece ventajas como sitio de inyección único, sitio adecuado para colocación de catéter de analgesia continua. Objetivo: identificar la visibilidad de los tres cordones del plexo braquial en el espacio costoclavicular según la angulación del brazo. Material y métodos: se realizó un estudio observacional descriptivo y transversal; se incluyeron 99 pacientes entre 18 a 90 años de edad, en un período de dos meses. Se describieron variables continuas, se aplicó la prueba no paramétrica de Friedman para K muestras relacionadas, una regresión lineal para confirmar la correlación entre la distancia de la piel a plexo braquial, peso e índice de masa corporal (IMC). Resultados: se encontró una menor profundidad en relación piel plexo bajo abducción del brazo a una angulación de 90o y 110o, que permite la visualización sonoanatómica del plexo braquial a nivel costoclavicular con significancia estadística. El peso es un factor independiente que determina la distancia entre la profundidad piel plexo. Conclusiones: se determinó que el abordaje del bloqueo costoclavicular ecoguiado es anatómicamente factible con elevada eficacia clínica, el cual concluye ser un sitio anatómico innovador y seguro.

Abstract: Introduction: the brachial plexus block with a costoclavicular approach offers advantages as a single injection site, being a suitable site for continuous analgesia catheter placement. Objective: to identify the visibility of the 3 brachial plexus cords in the costoclavicular space according to the angulation of the arm. Material and methods: a descriptive and cross-sectional observational study was carried out; 99 healthy patients between 18 and 90 years of age were included, in a period of two months. Continuous variables were described, the nonparametric Friedman test was applied for K related samples, a linear regression was performed to confirm the correlation between the distance from the skin to the brachial plexus, weight and body mass index (BMI). Results: a smaller depth was found in relation to the skin plexus under abduction of the arm at an angulation of 90o and 110o, which allows an adequate sonoanatomical visualization of the brachial plexus at the costoclavicular level with statistical significance. Weight is an independent factor that determine the distance between the skin plexus depth. Conclusions: it was determined that the ultrasound-guided costoclavicular block approach is anatomically feasible with greater clinical efficacy, which concludes to be an innovative and safe anatomical site.

Choroid plexus papilloma in a mature cystic teratoma of ovary: A rare case report

Mature cystic teratoma of the ovary is the most common type of germ cell tumor. It constitutes approximately 20% of all ovarian neoplasms. As a rare occurrence, however, several types of benign and malignant tumours developing secondarily in dermoid cysts have been reported. Those of central nervous origin are almost exclusively gliomas of astrocytic, ependymal or oligodendroglial lineage. Choroid plexus tumors are unusual intracranial tumors which comprised of only 0.4?0.6% of all brain tumors. These are neuroectodermal in origin and similar in structure to a normal choroid plexus in the form of multiple papillary fronds mounted on a well vascularized connective tissue stroma. The present case report highlights the presence of a choroid plexus tumor in a mature cystic teratoma of the ovary in a 27?year?old woman who came for safe confinement and cesarean section.

Bloqueo de plexo braquial con ultrasonido: estudio descriptivo de práctica clínica habitual en 283 niños / Brachial plexus block with ultrasound: a descriptive study of routine clinical practice in 283 children

Resumen: Introducción: en años recientes con el renacimiento de la anestesia regional a causa de los avances técnicos en equipamiento como el ultrasonido, estos han permitido llevar a cabo bloqueos de plexo braquial con varias técnicas de abordaje, alta eficacia de éxito y disminución de complicaciones. Objetivo: conocer la eficacia y seguridad del bloqueo de plexo braquial con ultrasonido, en anestesiólogos con especialidad en anestesia regional. Material y métodos: se realizó el estudio observacional, descriptivo y retrospectivo de la práctica clínica habitual en 283 pacientes de 0 a 15 años, programados para cirugía electiva de ortopedia y traumatología, de extremidad superior (húmero tercio distal, codo, antebrazo y mano), con manejo anestésico: sedación más bloqueo de plexo braquial con ultrasonido abordaje supraclavicular o infraclavicular. Durante dos años, de enero de 2018 a diciembre de 2019. Resultados: los bloqueos fueron realizados por 11 anestesiólogos con especialidad en anestesia regional. Se evaluó la eficacia con 99.65% de éxito. En cuanto a la seguridad no se registraron complicaciones. Conclusiones: el uso de ultrasonido en bloqueo de plexo braquial con abordaje supraclavicular e infraclavicular es una técnica con éxito alto y sin complicaciones; sin embargo, es necesario tener capacitación y experiencia.

Abstract: Introduction: in recent years with the revival of regional anesthesia due to technical advances in equipment such as ultrasound, have allowed to carry out brachial plexus blocks with several approach techniques with high efficiency of success and reduction of complications. Objective: to know the efficacy and safety of brachial plexus block with ultrasound, in anesthesiologists with a specialty in regional anesthesia. Material and methods: the observational, descriptive, retrospective study of the usual clinical practice was carried out in 283 patients from 0 to 15 years old, scheduled for elective orthopedic surgery and traumatology, of the upper extremity (distal third humerus, elbow, forearm and hand), with anesthetic management: sedation plus brachial plexus block with ultrasound supraclavicular or infraclavicular approach. For two years from January 2018 to December 2019. Results: the blocks were performed by 11 anesthesiologists specializing in regional anesthesia. Efficacy was evaluated with 99.65% success. In terms of safety, there were no complications. Conclusions: the use of ultrasound in brachial plexus block with supraclavicular and infraclavicular approach is a technique with high success and without complications however it is necessary to have training and experience.

Infratentorial atypical choroid plexus papilloma in an adult: A case report and literature review

Atypical choroid plexus papilloma is classified as WHO (World Health Organization) Grade II subtype of choroid plexus tumor, and it has intermediate pathological features, prognosis, and clinical outcome rates between choroid plexus papilloma and choroid plexus carcinoma. These tumors are more common in children compared with adults and are usually located in the lateral ventricles. We present a case of an adult with atypical choroid plexus papilloma located in the infratentorial region. A 41?year?old woman underwent evaluation for headache and dull aching neck pain. Magnetic resonance imaging (MRI) of the brain revealed a well?defined intraventricular mass lesion in the fourth ventricle and foramen of Luschka. She underwent craniotomy and gross total excision of the lesion. Histopathological and immunohistochemical findings confirmed the diagnosis of atypical choroid plexus papilloma (WHO Grade II). We discuss the various treatment options for this condition and review the relevant literature.

A rare variation of radial nerve coexisting with the intercalated ectopic muscle from latissimus dorsi muscle / Una rara variación del nervio radial que coexiste con el músculo ectópico intercalado del músculo latísimo del dorso

SUMMARY: The axilla is the main communication channel connecting the upper limbs, the neck and chest. Stabilization of the internal structure is essential for upper limb and shoulder mobility. In this case, we observed and recorded the characteristics of the variation of the radial nerve as well as the intercalated ectopic muscle from latissimus dorsi muscle. The position relationship between both, was also particularly noted by us. In view of the presence of the variation we reported, related clinical research, surgery and disease diagnosis are expected to take this case into account.

La axila es el principal canal de comunicación que conecta los miembros superiores, el cuello y el tórax. La estabilización de la estructura interna es fundamental para la movilidad del miembro superior y del hombro. En este caso observamos y registramos las características de la variación del nervio radial así como del músculo ectópico intercalado del músculo latísimo del dorso. La relación de posición entre ambas también fue significativa en este estudio. En vista de la presencia de la variación que informamos, se espera que la investigación clínica relacionada con la cirugía y el diagnóstico de la enfermedad tengan en cuenta este caso.

Debridement of axillary necrotizing fasciitis under anesthetic blocks of the serratus plane and supraclavicular brachial plexus: a case report

Abstract The regional techniques for axillary analgesia are well established. However, few studies have investigated surgical anesthesia. In this report, extensive debridement of axillary necrotizing fasciitis, including the posteromedial region of the right arm, performed under exclusive regional anesthesia in a patient with probable difficult airway is described. The procedure was accomplished under a Serratus Plane Block (SPB) and supraclavicular brachial plexus block, guided by ultrasound, and with venous sedation. We observed satisfactory anesthesia 15 minutes after the intervention, efficient intraoperative pain control and within the following 24 hours. Surgical axilla anesthesia is feasible with the described blocks.

Dexmedetomidine versus clonidine as an adjuvant to local anaesthetic in brachial plexus blocks: a metaanalysis of randomised controlled trials

Abstract Objective: This meta-analysis aimed to compare the efficacy and safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. Methods: Two investigators independently searched databases to identify all RCTs comparing the efficacy and/or safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. All outcomes were pooled using the inverse variance method with a random-effect model. An I2 test was used to assess heterogeneity. The source of heterogeneity was explored through meta-regression. The quality of the evidence was assessed using the GRADE approach. Results: Out of 123 full texts assessed, 24 studies (1448 patients) were included in the analysis. As compared to Clonidine, dexmedetomidine groups showed significantly longer sensory block duration (MD = 173.31; 95% CI 138.02-208.59; I2 = 99%; GRADE approach evidence: high); motor block duration (MD = 158.35; 95% CI 131.55-185.16; I2 = 98%; GRADE approach evidence: high), duration of analgesia (MD = 203.92; 95% CI 169.25-238.58; I2 = 99%; GRADE approach evidence-high), and provided higher grade quality of block (RR = 1.97; 95% CI 1.60-2.41 ; I2 = 0%; GRADE approach evidence: moderate). The block positioning technique (regression coefficient: 51.45, p = 0.005) was observed as a significant predictor of the heterogeneity in the case of sensory block duration. No significant difference was observed for the risk of hypotension (RR = 2.59; 95% CI 0.63-10.66; I2 = %). Conclusion: Moderate to high-quality evidence suggests dexmedetomidine is a more efficacious adjuvant to local anesthetic in BPBs than Clonidine.

Protocolo de recuperación intensificada durante la cirugía del plexo braquial (RIPLEX) / ntensified Recovery Protocol during Brachial Plexus Surgery (RIPLEX)

La restauración de la función del miembro superior en los pacientes que sufren lesiones del plexo braquial para favorecer la mejoría en su calidad de vida. Así como su reinserción social y laboral, se puede optimizar mediante la implementación de programas de recuperación intensificada o mejorada, multimodales, multidisciplinarios, y de elevados estándares cualitativos, denominados protocolos ERAS (Enhanced Recovery After Surgery), se recomienda la utilización de métodos fundamentados en la mejor evidencia científica disponible. El protocolo que se expone, aplicado en el Complejo Científico Ortopédico Internacional "Frank Paísˮ, derivado de una investigación institucional en curso. Objetivos: Contribuir en el desarrollo del conocimiento científico imprescindible para favorecer la introducción y sistematización de los cuidados perioperatorios multimodales durante las intervenciones quirúrgicas del plexo braquial.

Introduction: Restoration of upper limb function in patients suffering from brachial plexus injuries, in view of favoring improvement in their quality of life or their social and labor reinsertion, can be optimized by means of implementing multimodal, multidisciplinary, intensified or enhanced recovery programs with high qualitative standards, called ERAS (enhanced recovery after surgery) protocols. The use of methods based on the best available scientific evidence is recommended. The protocol presented here is applied at Complejo Científico Ortopédico Internacional "Frank Paísˮ and derived from an ongoing institutional research. Objective: To contribute to the development of scientific knowledge essential to favor the introduction and systematization of multimodal perioperative care during brachial plexus surgical interventions.

Lumbar plexus block combined with general anesthesia in treating postoperative delirium of hip fracture in elderly patients / 中国骨伤

OBJECTIVE@#To explore lumbar plexus nerve block combined with general anesthesia in elderly patients undergoing hip operation could improve analgesia effect, reduce consumption of analgesics, prevent inflammatory reaction, and avoid postoperative delirium(POD).@*METHODS@#Totally 200 elderly patients underwent hip fracture surgery from February 2020 to September 2021 were selected and were divided into observation group and control group according to different anesthesia methods. There were 97 patients in observation group including 66 males and 33 females; aged (70.23±6.60) years old;body mass index (BMI) was (23.13±1.94) kg·m-2;19 patients with hemi arthroplasty, 46 patients with total hip arthroplasty, and 32 patients with femur intertrochanteric fixation;treated with lumbar plexus block combined with general anesthesia. There were 94 patients in control group, including 66 males and 33 females;aged (68.80±6.24) years old;BMI was (22.88±1.85) kg·m-2;14 patients with hemi arthroplasty, 39 patients with total hip arthroplasty, and 41 patients with femur intertrochanteric fixation;treated with only general anesthesia. Nine patients were separated due to the change of surgical protocol or chronic disease. The incidence of POD at 1, 2 and 3 days after surgery, mini-mental state examination (MMSE) score, visual analogue scale (VAS) in resting state, serum inflammatory factors levels [such as C-reactive protein(CRP), interleukin-1β(IL-1β), interleukin-6(IL-6), tumor necrosis factor-α(TNF-α)] at 1 d before operation, 1 and 6 h after surgery, consumption of sufentanil between two groups were compared.@*RESULTS@#The incidences of POD in observation group were lower than control group at 1, 2 and 3 days of operation (P<0.05), MMSE score in observation group was higher than that of control group (P<0.05), VAS in observation group was lower than that of control group (P<0.01). The incidences of POD decreased and MMSE score were increaed in both groups day by day (P<0.01). The levels of CRP, IL-1β, IL-6 and TNF-α in observation group were lower than that of control group at 1 h after operation (P<0.01). The levels of CRP, IL-6 and TNF-α in observation group were lower than that of control group at 6 h after operation (P<0.01), while no statisitical difference in IL-1β between two groups(P>0.05). The consumption of sufentanil in observation group was lower than that of control group (P<0.01).@*CONCLUSION@#Compared with general anesthesia, lumbar plexus nerve block combined with general anesthesia for the operations of hip fracture in elderly patients has better analgesic effect, has advantages of slight inflammatory reaction, and could decrease consumption of opioid and incidence of POD.

Value of the imaging features of extrapancreatic nerve plexus in predicting the early postoperative recurrence of ductal adenocarcinoma of pancreatic head / 中华肝胆外科杂志

Objective:To study the value of imaging features of extrapancreatic nerve plexus in predicting early postoperative recurrence of ductal adenocarcinoma of pancreatic head.Methods:The clinical, imaging and pathological data of patients with ductal adenocarcinoma of pancreatic head undergoing pancreati-coduodenectomy at the Hepatobiliary Pancreatic Center of Beijing Tsinghua Changgung Hospital, Tsinghua University from January 2014 to April 2022 were retrospectively analyzed. A total of 73 patients were included, including 51 males and 22 females, aged (66.1±9.0) years old. The patients were followed up by telephone or outpatient review, who were divided into two groups according to the recurrence within 6 months after surgery: the recurrence group ( n=26) and the non-recurrence group ( n=47). Streaks or soft-tissue densities in the distribution area of extrapancreatic nerve plexus, difference in CT values between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus, maximum tumor diameter, and regional lymph node enlargement were compared between the two groups. Results:The incidences of streaks or soft-tissue densities showing in the distribution area of extrapancreatic nerve plexus were 80.8%(21/26) in the recurrence group and 51.1%(24/47) in the non-recurrence group, respectively. A CT value difference ≥15 HU between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus occurred in 50.0%(13/26) patients of the recurrence group and 25.5%(27/47) of the non-recurrence group, respectively. Maximum tumor diameter ≥25 mm were found in 80.8% (21/26) patients of the recurrence group and 57.4% (27/47) of the non-recurrence group, respectively. ≥3 reginal lymph node enlargement showed in 65.4% (17/26) patients of the recurrence group and 31.9% (15/47) of the non-recurrence group, respectively (all P<0.05). The risk of early postoperative recurrence increased in patients with a CT value difference ≥15 HU between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus ( OR=3.609, 95% CI: 1.099-11.855), and regional lymph node enlargement ≥ 3 ( OR=4.665, 95% CI: 1.400-15.545) (all P<0.05). And these two independent risk factors were combined to predict early postoperative recurrence of ductal adenocarcinoma of pancreatic head with an area under receiver operating characteristic curve of 0.748, sensitivity of 92.3%, and specificity of 48.9% ( P<0.001). Conclusion:≥ 15 HU CT value difference between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus and ≥ 3 regional lymph node enlargement are independent risk factors for the early postoperative recurrence of pancreatic head ductal adenocarcinoma, which could provide more predictive information preoperatively.

Clinical analysis of 11 cases of iliopsoas muscle hematoma compressing lumbar plexus nerve / 中国基层医药

Objective:To investigate the etiology, clinical manifestations, treatment methods, and prognosis of patients with iliopsoas muscle hematoma compressing the lumbar plexus.Methods:The clinical data of 11 cases of iliopsoas muscle hematoma oppressing the lumbar plexus nerve admitted to The Affiliated Hospital of Southwest Medical University between March 2014 and May 2018 were analyzed.Results:Eleven patients, consisting of 10 men and 1 woman, aged (36.36 ± 6.74) years were analyzed. Causes of iliopsoas muscle hematoma oppressing the lumbar plexus nerve included coagulation abnormality ( n = 8) and trauma ( n = 3). Iliopsoas muscle hematoma occurred on the left side in 7 cases and on the right side in 4 cases. Among them, 11 cases had bleeding in the middle area, 8 cases in the lower area, and 2 cases in the upper area. The involved lumbar plexus nerve included the femoral nerve ( n = 11), lateral femoral cutaneous nerve ( n = 6), and obturator nerve ( n = 2). Eleven cases underwent causative treatment ( n = 11). Three-month follow-up results showed that the hematomas were completely absorbed in 11 cases, and the bone and joint activities were normal. The sensory and motor functions were restored in 10 cases. The sensory function was restored, but the recovery of motor function was poor in 1 patient. All 11 cases returned to normal after 1 year. Conclusion:The main causes of iliopsoas muscle hematoma are coagulation dysfunction and trauma. The femoral nerve and lateral femoral cutaneous nerve in the lumbar plexus are easily affected, which can cause lower limb sensory and motor disorders. As for iliopsoas muscle hematoma caused by coagulation abnormality, coagulation factors should be supplemented to correct coagulation function. As for iliopsoas muscle hematoma caused by trauma, early surgical treatment should be performed to relieve nerve compression. Timely treatment of iliopsoas muscle hematoma can generally acquire a good prognosis.

The expression of adhesion molecules in Z310 cells induced by combined exposure to black carbon and lead / 中国职业医学

Objective: To investigate the effects of combined exposure to black carbon and lead on the expression of cell adhesion molecules and their regulating microRNAs (miRNAs) in the rat choroid plexus epithelial Z310 cells. Methods: i) Z310 cells were randomly divided into control group, black carbon exposure group, lead exposure group and combined exposure group. The lead exposure group and black carbon exposure group were treated with 10 μmol/L lead acetate and 10 mg/L black carbon, respectively, and the combined exposure group was treated with both in the above doses. After 12.0 hours, the expressions of intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and mucosal vascular addressin cell adhesion molecule-1 (MAdCAM-1) in Z310 cells was detected by Western blotting. The expression of miR-326, miR-328-3p and miR-542-3p which regulated ICAM-1 was detected by real-time fluorescent quantitative polymerase chain reaction. ii) Z310 cells or Z310 cells transfected with miRNA-326 mimic were randomly divided into control group, miRNA-326 transfection control group, combined exposure group and miRNA-326 transfection combined exposure group. Cells in the two control groups were not treated. The two combined exposure groups were treated with 10 mg/L black carbon and 10 μmol/L lead acetate for 12.0 hours. The expression of ICAM-1 was detected by Western blotting. Results: i) The relative expression of ICAM-1, VCAM-1 and MAdCAM-1 in the cells of black carbon exposure group and ICAM-1 in the lead exposure group was higher than those in the control group (all P<0.05). The relative expression of ICAM-1 and MAdCAM-1 in the combined exposure group was higher than those in the other three groups (all P<0.05). The relative expression of VCAM-1 in cells of combined exposure group was higher than those in the control group and lead exposed group (all P<0.05). The relative expression of miR-326 in cells of the lead exposure group and black carbon exposure group was lower than those in the control group (all P<0.05). The relative expression of miR-326 in the combined exposure group was lower than that in the other three groups (all P<0.05). There was no significant difference between miR-328-3p and miR-542-3p in the four groups (all P>0.05). ii) The relative expression of ICAM-1 in cells of the miR-326 transfection control group cells was lower than that in the control group (P<0.05), while in the cells in the combined exposure and miRNA-326 transfection combined exposure group, it was higher than that in the control and miRNA-326 transfection control groups (all P<0.05), and lower in the miRNA-326 transfection combined exposure group than in the combined exposure group (P<0.05). Conclusion: Black carbon or lead exposure can upregulate the expression of ICAM-1, VCAM-1 and MAdCAM-1 in Z310 cells. Black carbon and lead combined exposure lead to a synergistic effect on upregulation of ICAM-1 and MAdCAM-1 expression, particularly ICAM-1. The combined exposure of black carbon and lead may upregulate the expression of ICAM-1 by downregulating the expression of miR-326.