Identification of extraocular extension in uveal melanoma by ophthalmological ultrasound.

BACKGROUND AND PURPOSE: Uveal melanoma is the most common primary malignant intraocular tumour in the adult population, with a survival rate of 50% despite advances in treatment and knowledge of this disease. The presence of extraocular extension (EE) worsens the prognosis of these patients, so its proper identification can ensure its management and early intervention. Ophthalmological ultrasound is the technique of choice for the diagnosis and follow-up of these patients, both of the anterior EE using ultrasonic biomicroscopy (UBM), and the posterior EE using A and B ultrasound. The aim of this study is to describe the ultrasound characteristics of the BMU and the A and B ultrasound. MATERIAL AND METHODS: A descriptive and retrospective study is carried out on patients diagnosed with uveal melanoma (UM) and EE from 2003 to 2019. The ultrasound characteristics of the local disease and the follow-up after treatment were recorded completely and at each visit. In the case of anterior EE, photographs of the anterior segment and UBM were taken, while those involving the posterior segment were explored under A and B mode ultrasound. All enucleated eyes were sent for anatomopathological study. RESULTS: Ten patients with an average age of 72.3 years were included. The largest proportion of them were medium-sized tumours, followed by large and small ones. The most frequent morphology of the primary tumour was cupuliform. All the EE presented lower internal reflectivity compared to the primary tumour. No trans-scleral connection bridges were found between the primary tumour and the EE in the ultrasound studies. 50% of patients underwent primary enucleation at the time of diagnosis of intraocular MU due to the presence of the EE, and the remaining 50% presented the EE after initial treatment of the primary tumour with I125 brachytherapy. Sixty percent of the patients presented with posterior EE, and were therefore diagnosed with ultrasound A and B. The most frequent histopathological pattern with 87.5% of patients was the epithelioid pattern. DISCUSSION: Ultrasound scanning in patients with MU is mandatory for diagnosis and follow-up of EE. BMU and A and B ultrasound are the test of choice for anterior and posterior EE, respectively. EE have particular ultrasound characteristics such as low internal reflectivity, regularity of their contour and their location usually adjacent to the base of the primary intraocular tumor.

Identificación de extensión extraocular en el melanoma uveal mediante ecografía oftalmológica / Identification of Extraocular Extension in Uveal Melanoma by Ophthalmological Ultrasound

Antecedentes y objetivoEl melanoma uveal es el tumor primario maligno intraocular más frecuente en la población adulta, con una tasa de supervivencia del 50% a pesar de los avances en el tratamiento y conocimiento de esta enfermedad. La presencia de extensión extraocular (EE) empeora el pronóstico de estos pacientes, por lo que su correcta identificación puede asegurar su manejo e intervención temprana. La ecografía oftalmológica es la técnica de elección para el diagnóstico y seguimiento de estos pacientes, tanto de la EE anterior mediante biomicroscopía ultrasónica (UBM), como de la EE posterior mediante ecografía A y B. El objetivo de este estudio es describir las características ecográficas de la UBM y de la ecografía A y B.Material y métodosSe realiza un estudio descriptivo y retrospectivo de los pacientes diagnosticados de melanoma uveal (UM) y EE desde 2003 hasta 2019. Las características ecográficas de la enfermedad local y el seguimiento luego del tratamiento se registraron de maneracompleta y en cada visita. En caso de EE anteriores se realizaron fotografías de segmento anterior y BMU, por el contrario las que involucran el segmento posterior se exploraron bajo ecografía modo A y B. Todos los ojos enucleados se enviaron para su estudio anatomopatológico.

Background and purposeUveal melanoma is the most common primary malignant intraocular tumour in the adult population, with a survival rate of 50% despite advances in treatment and knowledge of this disease. The presence of extraocular extension (EE) worsens the prognosis of these patients, so its proper identification can ensure its management and early intervention. Ophthalmological ultrasound is the technique of choice for the diagnosis and follow-up of these patients, both of the anterior EE using ultrasonic biomicroscopy (UBM), and the posterior EE using A and B ultrasound. The aim of this study is to describe the ultrasound characteristics of the BMU and the A and B ultrasound.Material and methodsA descriptive and retrospective study is carried out on patients diagnosed with uveal melanoma (UM) and EE from 2003 to 2019. The ultrasound characteristics of the local disease and the follow-up after treatment were recorded completely and at each visit. In the case of anterior EE, photographs of the anterior segment and UBM were taken, while those involving the posterior segment were explored under A and B mode ultrasound. All enucleated eyes were sent for anatomopathological study.

An extensive experimental survey of regression methods.

Regression is a very relevant problem in machine learning, with many different available approaches. The current work presents a comparison of a large collection composed by 77 popular regression models which belong to 19 families: linear and generalized linear models, generalized additive models, least squares, projection methods, LASSO and ridge regression, Bayesian models, Gaussian processes, quantile regression, nearest neighbors, regression trees and rules, random forests, bagging and boosting, neural networks, deep learning and support vector regression. These methods are evaluated using all the regression datasets of the UCI machine learning repository (83 datasets), with some exceptions due to technical reasons. The experimental work identifies several outstanding regression models: the M5 rule-based model with corrections based on nearest neighbors (cubist), the gradient boosted machine (gbm), the boosting ensemble of regression trees (bstTree) and the M5 regression tree. Cubist achieves the best squared correlation ( R2) in 15.7% of datasets being very near to it, with difference below 0.2 for 89.1% of datasets, and the median of these differences over the dataset collection is very low (0.0192), compared e.g. to the classical linear regression (0.150). However, cubist is slow and fails in several large datasets, while other similar regression models as M5 never fail and its difference to the best R2 is below 0.2 for 92.8% of datasets. Other well-performing regression models are the committee of neural networks (avNNet), extremely randomized regression trees (extraTrees, which achieves the best R2 in 33.7% of datasets), random forest (rf) and ε-support vector regression (svr), but they are slower and fail in several datasets. The fastest regression model is least angle regression lars, which is 70 and 2,115 times faster than M5 and cubist, respectively. The model which requires least memory is non-negative least squares (nnls), about 2 GB, similarly to cubist, while M5 requires about 8 GB. For 97.6% of datasets there is a regression model among the 10 bests which is very near (difference below 0.1) to the best R2, which increases to 100% allowing differences of 0.2. Therefore, provided that our dataset and model collection are representative enough, the main conclusion of this study is that, for a new regression problem, some model in our top-10 should achieve R2 near to the best attainable for that problem.

Tratamiento del dolor irruptivo / No disponible

La Sociedad Española de Oncología Médica (SEOM), la Sociedad Española de Cuidados Paliativos (SECPAL) y la Sociedad Española de Dolor (SED), establecieron un documento de consenso en el que asumieron el término "dolor irruptivo", para definir una exacerbación del dolor de forma súbita y transitoria, de gran intensidad (EVA > 7) y de corta duración (usualmente inferior a 20-30 minutos), que aparece sobre la base de un dolor persistente estable, cuando este se encuentra reducido a un nivel tolerable (EVA < 5) mediante el uso fundamental de opioides mayores. La clasificación del dolor irruptivo más utilizada es la que distingue entre dolor irruptivo incidental (predecible o impredecible), idiopático y relacionado con el final de dosis. El manejo adecuado del dolor irruptivo se basa en tres aspectos: prevención, anticipación y uso de la medicación adecuada. Existen formulaciones de opioides de inicio de acción rápida y duración de acción corta (ROOs) que se ajustan mucho mejor al perfil y al tratamiento de este tipo de dolor. Todas ellas contienen citrato de fentanilo y se administran a través de la mucosa oral (transmucosa oral, bucal o sublingual) o nasal. Todos tienen un inicio precoz del efecto, entre 5-15 minutos tras la administración y un tiempo de duración entre 2-4 h y una biodisponibilidad que puede variar según la presentación. Fentanilo sublingual, bucal e intranasal tienen un inicio de acción más rápido y una mayor biodisponibilidad que fentanilo transmucosa oral. Aunque la mayoría de los estudios controlados publicados al respecto, sobre la utilización de ROOs en el dolor irruptivo, recomiendan la necesidad de titulación de dosis (sobre todo los que incluyen CFOT y fentanilo bucal), la elección de una dosis eficaz sigue siendo dificultosa (AU)

Breakthrough pain is defined as an exacerbation of the pain of sudden and transient, high intensity (VAS > 7) and short duration (usually less than 20-30 minutes), which appears on the basis of a stable persistent pain, when this is reduced to a tolerable level (VAS < 5) by using strong opioids. The classification most used is the classification based on the following: Incident (predictable, unpredictable), idiopathic and end-of-dose. Proper management of breakthrough pain is based on three aspects: prevention, early and appropriate medication use. There are formulations of opioids rapid onset and short duration of action (ROOS) that better fit the profile and treatment of this type of pain. Everyone has an early onset of effect, between 5-15 minutes after dosing and a duration of 2-4 h and a bioavailability which may vary according to the filing. Fentanyl buccal tablets, sublingual fentanyl and intranasal nasal fentanyl have a faster onset of action and greater bioavailability of fentanyl transmucosal oral. Although most published controlled studies on this question, the use of de ROOs in the breakthrough pain, indicate the need for dose titration (especially fentanyl OTFC and oral), the choice of an effective dose is still difficult (AU)

[Angle-closure glaucoma secondary to topiramate use]. / Glaucoma de ángulo cerrado secundario a topiramato.

CASE REPORT: We describe a 42 year-old patient who developed acute myopia and closed-angle glaucoma one week after beginning treatment with topiramate. Ultrasound biomicroscopy revealed a bilateral angle closure and choroidal effusion. The clinical findings resolved with withdrawal of the topiramate. DISCUSSION: Topiramate may cause acute myopia and closure angle glaucoma in some patients due to a choroidal effusion. Ultrasound biomicroscopy seems to be a useful tool for monitoring the progression of the clinical lesions and their resolution when the drug is withdrawn.

Glaucoma de ángulo cerrado secundario a topiramato / Angle-closure glaucoma secondary to topiramate use

Caso clínico: Se presenta el caso de una mujer de 42 años que desarrolló un cuadro de miopía aguda y glaucoma de ángulo cerrado bilateral una semana después del inicio del tratamiento con topiramato. La biomicroscopía ultrasónica (BMU) reveló que la paciente presentaba un ángulo cerrado y una efusión coroidea bilateral. Con la retirada del fármaco se resolvió el cuadro. Discusión: El topiramato puede desencadenar miopía aguda y glaucoma de ángulo cerrado en algunos pacientes debido a una efusión coroidea. La realización de la BMU parece ser una herramienta útil para observar la evolución del cuadro y su resolución tras la suspensión del fármaco(AU)

Case report: We describe a 42 year-old patient who developed acute myopia and closed-angle glaucoma one week after beginning treatment with topiramate. Ultrasound biomicroscopy revealed a bilateral angle closure and choroidal effusion. The clinical findings resolved with withdrawal of the topiramate. Discussion: Topiramate may cause acute myopia and closure angle glaucoma in some patients due to a choroidal effusion. Ultrasound biomicroscopy seems to be a useful tool for monitoring the progression of the clinical lesions and their resolution when the drug is withdrawn(AU)

[Local and regional analgesia after pediatric surgery: study in 116 patients]. / Técnicas locorregionales para analgesia perioperatoria en anestesia pediátrica: estudio en 116 pacientes.

OBJECTIVES: Pain control is essential to patient comfort and reduced stress response, morbidity, and mortality after pediatric anesthesia. We assessed analgesic quality and the incidence of complications of regional blocks in combination with general anesthesia. MATERIAL AND METHODS: Prospective study of 116 patients under 3 years of age who underwent surgery in our hospital over a period of 2 years. The studied patients were classified in 3 groups according to whether they received general anesthesia only, a regional block by single injection, or a caudal nerve block via catheter. We recorded demographic and intraoperative variables, postoperative analgesic requirements, and the time the first postoperative analgesic dose was needed. RESULTS: Analgesia was significantly more effective in the patients who received either type of regional block. The patients who received general anesthesia alone needed supplemental analgesia earlier than the others (P < .001); patients with nerve blocks required fewer doses of rescue analgesics (P < .001). The incidence of complications was low and all were minor. No case of caudal catheter contamination occurred. CONCLUSIONS: Regional nerve blocks combined with general anesthesia in children are effective and safe. Advantages of providing nerve blocks include hemodynamic stability, prolonged postoperative analgesia, lower consumption of analgesics, and few complications.

Técnicas locorregionales para analgesia perioperatoria en anestesia pediátrica: estudio en 116 pacientes / Local and regional analgesia after pediatric surgery: study in 116 patients

OBJETIVOS: El tratamiento del dolor es imperativopara mejorar el confort del paciente y disminuir la respuestaal estrés y la morbi-mortalidad durante el periodopostoperatorio en anestesia pediátrica. En este estudioevaluamos la calidad analgésica y la incidencia decomplicaciones de los bloqueos regionales, asociados aanestesia general.MATERIAL Y MÉTODOS: Estudio prospectivo de 116pacientes menores de 3 años, intervenidos en nuestrohospital en un periodo de 2 años. Los pacientes se dividieronen 3 grupos: (A) sólo anestesia general, (B) bloqueoregional de punción única y (C) catéter caudal. Serecogieron las variables demográficas e intraoperatorias,la necesidad de analgésicos en el postoperatorio y elmomento en que se precisó la primera dosis analgésica.RESULTADOS: La eficacia analgésica fue significativamentemayor en los grupos B y C. Los pacientes del grupoA precisaron analgesia suplementaria más precozmenteque los de los grupos B y C (p < 0,001) y elnúmero de dosis de analgésicos de rescate fue significativamentemenor (p < 0,001). Se produjo una baja incidenciade complicaciones, todas ellas leves y ningunacontaminación de catéter caudal.CONCLUSIONES: Los bloqueos regionales asociados a laanestesia general en niños son efectivos y seguros puesproporcionan numerosas ventajas: estabilidad hemodinámica,analgesia postoperatoria prolongada, menorconsumo de analgésicos y escasas complicaciones(AU)

OBJETIVES: Pain control is essential to patient comfort and reduced stress response, morbidity, and mortality after pediatric anesthesia. We assessed analgesic quality and the incidence of complications of regional blocks in combination with general anesthesia. MATERIAL AND METHODS: Prospective study of 116 patients under 3 years of age who underwent surgery in our hospital over a period of 2 years. The studied patients were classified in 3 groups according to whether they received general anesthesia only, a regional block by single injection, or a caudal nerve block via catheter. We recorded demographic and intraoperative variables, postoperative analgesic requirements, and the time the first postoperative analgesic dose was needed. RESULTS: Analgesia was significantly more effective in the patients who received either type of regional block. The patients who received general anesthesia alone needed supplemental analgesia earlier than the others (P<.001); patients with nerve blocks required fewer doses of rescue analgesics (P<.001). The incidence of complications was low and all were minor. No case of caudal catheter contamination occurred. CONCLUSIONS: Regional nerve blocks combined with general anesthesia in children are effective and safe. Advantages of providing nerve blocks include hemodynamic stability, prolonged postoperative analgesia, lower consumption of analgesics, and few complications(AU)

Eficacia analgésica de la asociación duloxetina más pregabalina en el dolor neuropático: experiencia en 60 casos / Analgesic efficacy of the association of duloxetine plus pregabalin in neuropathic pain: experience in 60 patients

Objetivo: Duloxetina y pregabalina han demostrado su eficacia por separado, y cuentan con la aprobación de la Food and Drug Administration para el tratamiento de determinados tipos de dolor neuropático. Nuestro objetivo fue valorar si la asociación de ambos puede mejorar su eficacia analgésica y el impacto de esta asociación en la calidad de vida del paciente. Material y métodos: Se estudiaron 60 pacientes con dolor neuropático severo (escala visual analógica [EVA] > 6) durante un período de 3 meses. Se distribuyeron aleatoriamente en 3 grupos (n = 20): grupo A (duloxetina 30 mg/24 h los primeros 3 días y luego 60 mg/24 h en medio del desayuno, con incrementos progresivos de 30 mg/3 días hasta alivio del dolor); grupo B (pregabalina 75 mg/noche los primeros 3 días, con incrementos de 75 mg/3 días hasta alivio del dolor; pautado/12 h), y grupo C (A + B). Las variables estudiadas fueron: edad; sexo; diagnóstico; EVA; componente lancinante, sordo y alodinia (EVA); dosis necesaria para alivio del dolor > 50%; impresión clínica de mejoría del paciente y del sueño (0-3; 0: nula, 1: leve, 2: moderada y 3: importante), y efectos indeseables. Los pacientes fueron evaluados semanalmente el primer mes, cada 15 días el segundo mes y luego mensualmente. Resultados: No se encontraron diferencias significativas en edad y diagnóstico según el grupo, siendo los diagnósticos más frecuentes: radiculopatía cervical y lumbar (68%), fibrosisposcirugía (17%), estenosis de canal (12%) y neuralgia postherpética (8%). Hubo un predominio del sexo femenino, excepto en el grupo A, con una distribución similar (50% F/M). La reducción del dolor > 50% se produjo con: 96,2 ± 24,1 mg de duloxetina en el 60% de los pacientes del grupo A; 532 ± 63 mg de pregabalina en el 68% de los pacientes del B, y 298,5± 56 mg de pregabalina + 65,2 ± 31,1 mg de duloxetina en el 73% de los pacientes del C (p< 0,05)...(AU)

Objective: The efficacy of duloxetine and pregabalin has been demonstrated separately and both drugs are approved by the Food and Drug Administration for the treatment of specific types of neuropathic pain. Our objective was to determine whether the association of both drugs improves their analgesic effectiveness and the effect of this association on patients’ quality of life. Material and methods: We studied 60 patients with severe neuropathic pain (visual analog scale [VAS] > 6) over a 3-month period. The patients were randomized to three groups (n = 20): group A (duloxetine 30 mg/24 h the first 3 days followed by 60 mg/24 hat breakfast, with progressive increases of 30 mg every 3 days until pain relief was achieved). Group B (pregabalin 75 mg/night for the first 3 days, with increases of 75 mg every 3 days until pain relief was achieved. Group C (A+B). The variables studied were age, sex, diagnosis, VAS; stabbing pain, dull pain and allodynia (VAS); the dose required for pain relief > 50%, and subjective feeling of overall symptom improvement in patients and their sleep quality (0-3: 0 = none; 1 = mild; 2 = moderate; 3 = excellent). Patients were evaluated weekly in the first month, every 15 days in the second month and then once a month. Results: No significant differences were found in age or diagnosis among the three groups. The most common diagnoses were cervical and lumbar radiculopathy (68%), fibrosis after lumbar disc surgery (17%), lumbar canal stenosis (12%) and postherpetic neuralgia (8%).There were more women, except in group A, with equal distribution of men and women (50% F/M). Pain relief > 50% was achieved with 96.2 ± 24.1 mg of duloxetine in 60% of patients in group A, 532 ± 63mg of pregabalin in 68% of patients in group B, and 298.5 ±56 mg of pregabalin plus 65.2 ± 31.1 mg of duloxetine in 73% of patients in group C (p >0.05)...(AU)

Helicopter emergency medical system in a region lacking trauma coordination (experience from Tehran).

BACKGROUND: The helicopter emergency medical service (HEMS) has been working in Iran since 2000. The present study is the first prospective research to determine the epidemiological characteristics of injured patients transported by helicopter in Tehran. METHODS: All injured patients brought to three hospitals from the injury scene by HEMS were reviewed in a 4-month period. RESULTS: The mean transport time was 54 minutes. The most common mechanism of trauma was road traffic accidents (96.2%). The mean injury severity score was 8.6 (SD 8.6) and 9.6% of patients were sent to the intensive care unit; 10.2% of patients died. CONCLUSION: This study shows that overtriage in HEMS (transportation of patients without severe injuries) and the long transportation time is mainly a result of not having a trauma system. The study has shown HEMS to be an effective and feasible option in countries with heavy traffic and no trauma system.

Trombosis de seno cavernosopostraumática / Posttraumatic cavernous sinus thrombosis

No disponible

Fentanilo transdérmico en analgesia postoperatoria / A Transdermal fentanyl in postoperative analgesia

Objetivos: Valorar la efectividad del uso de fentanilo transdérmico en la prevención del dolor postoperatorio, en pacientes intervenidos de artroplastia de cadera o rodilla. Material y métodos: Se han incluido 60 pacientes que iban a ser intervenidos de artroplastia de cadera o rodilla. La noche antes de la intervención, se colocaba a las 12 horas, un parche de fentanilo. El anestesiólogo en la consulta preanestésica, prescribía el tratamiento, en función del peso y estado físico del paciente. Durante el postoperatorio se permitía como medicación de rescate para el dolor paracetamol o metamizol. Se valoraron: control analgésico (escala nominal: ausencia de dolor, dolor leve, moderado, severo o insoportable), uso de medicación de rescate y efectos secundarios. Resultados: De los 60 pacientes incluidos, 28 fueron tratados con fentanilo-TTS 25 µg . h- 1 y 32 con fentanilo-TTS 50 µg . h- 1.No presentaron dolor un total de 41 pacientes, presentaron dolor leve 15 pacientes y tres pacientes experimentaron dolor moderado. De los pacientes que fueron tratados con fentanilo-TTS 25 µg . g- 1, 18 no tuvieron dolor, 6 tuvieron dolor leve y 3 dolor moderado. De los pacientes tratados con fentanilo-TTS 50, ninguno presentó dolor moderado, 9 presentaron dolor leve y 23 no experimentaron dolor. En cuanto a la medicación de rescate, 32 pacientes no necesitaron ninguna y sólo 5 de ellos necesitaron la cantidad pautada o más (3 pacientes del grupo fentanilo-TTS 25 µg . h- 1 y 2 del grupo fentanilo-TTS 50 µg . h- 1). Se presentaron efectos secundarios en 15 pacientes: náuseas y vómitos en 12 pacientes y en tres sedación ligera. Conclusiones: El uso de fentanilo-TTS en la prevención del dolor postoperatorio de pacientes intervenidos de artroplastia de cadera o rodilla, puede ser un tratamiento efectivo y seguro (AU)

Mujer de 77 años con estreñimiento y un hematoma en el tórax / 77-year old woman with constipation and chest hematoma

No disponible

Eficacia analgésica de la asociación ketamina+morfina epidural: experiencia en 75 casos / Analgesic effectiveness of combined epidural ketamine+morphine: experience in 75 cases

Objetivo: El objetivo de este estudio fue comprobar la eficacia analgésica de la combinación de morfina y ketamina por vía epidural, y determinar la dosis óptima de ketamina que incrementa la capacidad analgésica de los opiáceos peridurales, en pacientes sometidos a artroplastia total de cadera y rodilla. Material y métodos: Se realizó un estudio prospectivo, de 75 pacientes, a lo largo de un año. La técnica locorregional anestésica realizada fue combinada intradural-epidural, con colocación de catéter epidural para analgesia. Todos los pacientes recibieron 30 mg de ketamina epidural 30 min antes de la intervención. La anestesia intradural se realizó con bupivacaína 0,5 por ciento hiperbara, 2-3 cc, según el paciente tuviera una estatura <170 cm o 170 cm, respectivamente .Los pacientes fueron divididos e 5 grupos: Grupo A: recibieron analgesia i.v. con metamizol (2 g i.v. . 6 h- 1) y tramado l (100 mg i.v./6 h). Grupo B: 10 mg de ketamina epidural, diluidos en 10 ml de suero salino fisiológico (SSF), al llegar al despertar y 12 h después. Grupo C: 2 mg de morfina epidural, diluidos en 10 ml de SSF, a la llegada al despertar y 12 h después. Grupo D: 10 mg de ketamina + 0,5 mg de cloruro mófico epidural, diluidos en 10 ml de SSF, a la llegada al despertar y 12 h después.Grupo E: 5 mg de Ketamina + 0,5 mg de morfina epidural, diluidos en 10 ml de SSF, a la llegada al despertar y 12 h después. Se valoraron la eficacia analgésica (utilizando la Escala Analógica Visual: EVA), la necesidad de analgesia suplementaria y los efectos indeseables (despertar, salida, 12, 24, 48 y 72 h postcirugía).Resultados: Se observó una eficacia analgésica significativamente superior en los grupos C, D y E, respecto a los grupos A y B (p<0,05). La analgesia obtenida en los grupos en los que se administró la asociación ketamina+cloruro mórfico (D,E), fue superior a la del grupo en que se administró sólo cloruro mórfico, pero sin diferencias significativas. El consumo de analgésicos fue significativamente superior (p<0,02) para los grupos A y B, con respecto al resto. Los efectos secundarios fueron significativamente superiores (p<0,03) en el grupo C. Discusión: La administración epidural de ketamina, no se comportó como analgésico eficaz, sin embargo la asociación ketamina+morfina permitió una analgesia eficaz y prolongada, con bajas dosis de ambos fármacos, reduciéndose de forma significativa los efectos secundarios. Ambas dosis de ketamina fueron consideradas como eficaces para la analgesia preventiva (AU)

Ropivacaine 0.2% and lidocaine 0.5% for intravenous regional anesthesia in outpatient surgery.

BACKGROUND: A longer-acting local anesthetic agent, such as ropivacaine, may offer advantages over lidocaine for intravenous regional anesthesia. The objectives of this study were to evaluate whether the findings of volunteer investigations with intravenous regional anesthesia with ropivacaine (which have shown prolonged analgesia after release of the tourniquet) translates into improved pain control after surgery. METHODS: With Human Investigation Committee approval and a double-blind study design, 20 healthy patients with American Society of Anesthesiologists physical status I or II classification who were scheduled to undergo forearm and hand surgery were randomly assigned to administration of 40 ml of either 0.2% ropivacaine or 0.5% lidocaine for intravenous regional anesthesia. Evidence of central nervous system side effects, such as lightheadedness, tinnitus, and metallic taste, as well as cardiac arrhythmias, were evaluated and treated (if necessary) after local anesthetic administration, before and during surgery, and after release of the tourniquet until discharge from the postanesthesia care unit. Regression of sensory anesthesia in the nerve distributions of the forearm and hand was recorded. Verbal numerical pain scores were monitored and quantified until the patients were discharged to home from the postanesthesia care unit. Patient pain scores, side effect profiles, time to first oral intake, and total amount of oral analgesics were recorded 24 h postoperatively. RESULTS: Intravenous regional anesthesia with 0.2% ropivacaine and 0.5% lidocaine provided equivalent levels of surgical anesthesia. After release of the tourniquet, the first evidence for return of sensation in the distribution of the five peripheral nerves occurred later in the ropivacaine group (median, 20 min; range, 15-40 min) than in the lidocaine group (median, 1 min; range, 1-25 min). Verbal numerical pain scores were significantly lower at the time of admission, whereas during the remainder of the postanesthesia care unit stay and later at home, the difference in verbal numerical pain scores between the two groups was no longer statistically significant. CONCLUSIONS: Ropivacaine 0.2% may be an alternative to 0.5% lidocaine for intravenous regional anesthesia in the outpatient surgical setting. Longer-lasting analgesia in the immediate postoperative period may be due to a more profound and prolonged tissue binding effect of ropivacaine.

Bronchiolitis obliterans with organizing pneumonia associated with acute Coxiella burnetii infection.

We report the case of a 62-year-old man who developed bronchiolitis obliterans with organizing pneumonia (BOOP) associated with acute Coxiella burnetii infection. The diagnosis of BOOP was made by fiber-optic transbronchial biopsy. Treatment with corticosteroids resulted in rapid clinical improvement and complete resolution of airspace opacities. To the best of our knowledge, this is the first well-documented case of BOOP associated with C. burnetii infection. This case suggests that this infection might trigger the development of BOOP.

Tratamiento del dolor neuropático: estudio preliminar de amitriptilina frente a nefazodona / Management of neuropathic pain: preliminary study of amitriptiline versus nefazodone

Objetivo: Valorar la eficacia analgésica y la tolerancia de la amitriptilina frente a la nefazodona en el tratamiento del dolor neuropático.Material y Métodos: Se realizó un estudio prospectivo en 120 pacientes durante un periodo de 18 meses. Todos los pacientes presentaban dolor neuropático de 1 a 6 meses de evolución. La calidad del dolor fue quemante y cortante en el 62,3 por ciento de los casos, lancinante en el 40 por ciento, y punzante en el 25 por ciento. Se dividieron en dos grupos: a) recibieron amitriptilina a dosis de 25 mg.día- 1 con incrementos semanales de 25 mg, hasta un máximo de 150 mg; b) recibieron nefazodona a dosis de 50 mg.día- 1 con incrementos semanales de 50 mg hasta un máximo de 300 mg. En 48 pacientes se inició tratamiento simultáneo con anticonvulsivantes debido a que presentaban un componente de dolor paroxístico lancinante, estos pacientes fueron valorados aisladamente. Se valoraron el dolor así como los efectos indeseables en la tercera semana de tratamiento, al mes y a los tres meses, mediante la escala analógica visual (EAV ) .Resultados: Los síndromes dolorosos más frecuentes fueron: dolor neuropático por cáncer y neuralgia post-herpética (n = 16), polineuropatía diabética, dolor lumbar y neuralgia del trigémino (n = 14), miembro fantasma doloroso, síndrome de dolor regional complejo tipo I ,y neuralgia post-cirugía (n = 10), fibromialgia y neuralgia de Arnold (n = 6), dolor talámico (n = 4). Las dosis medias de amitriptilina y nefazodona fueron respectivamente: 75 ñ 52 mg y 220 ñ 64 mg.La intensidad global del dolor, medida por EVA fue para el grupo de la amitriptilina de 8,7 ñ 1,2 y para el grupo de la nefazodona 8,5 ñ 0,9. A los tres meses de tratamiento el grupo de la amitriptilina presentaba una intensidad de dolor de 2 ñ 0,9 y el de la nefazodona 3 ñ 1,1. El alivio del dolor fue superior al 75 por ciento (excelente) en 42 pacientes tratados con amitriptilina y en 36 pacientes tratados con nefazodona, entre 50-75 por ciento (bueno) en 18 pacientes tratados con amitriptilina y 12 con nefazodona, y menor del 50 por ciento (malo) en 3 pacientes tratados con amitriptilina y 3 con nefazodona. Los efectos secundarios fueron superiores en la amitriptilina respecto a la nefazodona (p<0,05) excepto para las náuseas y vómitos, que fueron más fre c u e ntes en el grupo de la nefazodona: hipotensión ortostática (10/4), sequedad de boca (20/5), náuseas y vómitos (3/15). Las dosis medias a las que comenzaron a apare c e r los efectos secundarios fueron: 80 ñ 15 mg de amitriptilina y 245 ñ 25 de nefazodona.Conclusiones: Ambos fármacos fueron eficaces en el tratamiento del dolor neuropático. El grupo tratado con nefazodona presentó una menor incidencia de efectos secundarios, excepto en lo re f e rente a las náuseas y vómitos (AU)

[Subarachnoid anesthesia: 100 years of an established technique]. / Anestesia subaracnoidea: 100 años de una técnica establecida.

Over the 100 years since the introduction of spinal anesthesia into clinical practice, this technique, like most others, has enjoyed varying degrees of popularity. The attraction of spinal anesthesia is easy to identify: a relatively simple technique is used to inject a very small amount of drug into a readily identifiable body compartment to provide deep anesthesia. However, the apparent simplicity of spinal anesthesia is as much as weakness as a strength, given that the technique can be put to use with relatively little understanding of its problems, which are what underlie the shifts in popularity that spinal anesthesia has suffered over the years. In addition to reviewing the history of spinal anesthesia and the local anesthetics and adjuvant drugs administered by this route, we discuss single-dose and continuous spinal injection, combined spinal-epidural technique, and spinal anesthesia for outpatient settings. The problems typical of dural puncture and placement of local anesthetics and adjuvant drugs into the intrathecal space are also reviewed.