Pencil-point needle bevel direction influences ED50 of isobaric ropivacaine with fentanyl in spinal anesthesia for cesarean delivery: a prospective, double-blind sequential allocation study.

BACKGROUND: There is little evidence on the influence of bevel direction of a pencil-point needle on the median effective dose (ED50) of isobaric ropivacaine and fentanyl in spinal anesthesia for cesarean delivery. METHODS: In this prospective, double-blind, sequential allocation study, 82 parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia were included. We sought to determine the median effective dose of intrathecal 0.75% isobaric ropivacaine plus fentanyl 15µg with two different bevel directions of a 26-gauge Whitacre needle using up-down sequential allocation. Parturients were randomly allocated to either Group Ce (needle aperture oriented in a cephalad direction) or Group Ca (aperture directed caudally). The initial dose was 0.75% ropivacaine 11.25mg plus fentanyl 15µg in both groups. Each dose was classified as effective if, after 15min and during the next 60min, there was inability to appreciate pin-prick as sharp at T4, a visual analogue pain score <2 and no requirement for an epidural rescue bolus. RESULTS: Eighty patients were included in the analysis. The ED50 in group Ca was significantly higher (13.09mg, 95% CI 12.19-14.00) than in group Ce (10.10mg, 95% CI 9.54-10.65, P <0.001). CONCLUSION: The orientation of the distal aperture of a 26-gauge Whitacre needle during induction of spinal anesthesia for cesarean delivery influences the ED50 of 0.75% ropivacaine.

The distance from the skin to the epidural and subarachnoid spaces in parturients scheduled for caesarean section.

BACKGROUND: The purpose of this study was to measure the skin to epidural space distance (SED), the skin to subarachnoid space distance (SSD) and the epidural to subarachnoid space distance (ESD) at the L3-4 interspace in parturients scheduled for caesarean section (CS) and to investigate whether any correlations exist between these distances and various physical and anthropometric parameters. METHODS: This study consisted of 332 parturients scheduled for CS. The epidural space was identified by noting the loss of resistance to air at the L3-4 intervertebral space with a Tuohy needle, thus permitting measurement of the SED. The spinal needle was introduced through the Tuohy needle and, after identification of the subarachnoid space, was locked in the epidural needle. The distance between the tip of the Tuohy needle and tip of spinal needle (ESD) was recorded. This number was added to the SED to obtain the SSD value. RESULTS: Mean values ± standard deviations for SED, SSD and ESD were 5.6 ± 1.6 cm, 6.5 ± 1.2 cm and 0.9 ± 0.5 cm, respectively. Statistically significant correlations were observed between SED, SSD and ESD with body mass index and body weight of the parturients, as well as between the SED and the parturient's height. Furthermore, a significant negative correlation was observed between the ESD and gestational age. Finally, a significant correlation existed between the SSD and ESD. CONCLUSION: Measurements of SED, SSD and ESD in parturients and the correlations between these distances to various physical and anthropometric parameters may be of potential value for combined spinal-epidural anesthesia (CSEA) in parturients scheduled for CS.

Cathepsin D may help in discriminating node-negative breast cancer patients at risk for local-regional recurrence.

OBJECTIVE: The objective of this retrospective study was to define the prognostic value of cathepsin D (CD) in the node-negative (N-) and node-positive (N+) subsets of breast cancer (BC) patients. PATIENTS AND METHODS: In primary tumor cytosols of 348, stage I-III, BC patients, with a complete standard histological examination and a 56 months mean follow-up, the ER, PR and CD concentrations were measured by standardized assays. CD values were then compared to the classical prognostic factors, the type of treatment and the outcome, in terms of Disease-Free-Survival (DFS) and type of Relapse, after stratification according to the nodal status. Statistical methods used were Cox regression and logistic regression. RESULTS: Using univariate analysis, CD > 60 pmol/mg prot in N- patients was significantly associated with shorter DFS as well as local-regional recurrence (LRR) while in multivariate analysis the same CD levels, together with T status, are the best predictors of short DFS. However, CD > 60 is the only potent predictor of LRR in N- patients. No prognostic value of CD was identified in N+ patients. The cutoff value of CD should be 60 pmol/mgprot. The combination of tumor size, ER status and CD concentration may yield reliable prediction of primary BC outcome in N- patients. CONCLUSION: CD is a marker of invasiveness, particularly loco-regional in node-negative breast cancer. The integration of this marker, in the routine of initial prognostic evaluation of this subset of patients is proposed.