Chronic Pregabalin Treatment and Oxycodone Requirement after Spinal Surgery Versus Short Course Perioperative Administration: A Prospective, Nonrandomized Study.

BACKGROUND: Although being controversial, pregabalin (PGB) is proposed during a short perioperative period  to improve pain relief.Comparisons between chronic and short-term users during lumbar spine surgery are lacking. OBJECTIVES: The purpose was to compare opioid requirements and postoperative pain among PGB chronic users and naive patients receiving a 48-hour perioperative administration. STUDY DESIGN: Prospective nonrandomized study. SETTING: Tertiary care hospital. METHODS: Chronic users (group PGB, n = 39) continued their treatment, naive patients (group C, n = 43) received a dose of 150 mg preoperatively and 75 mg/12 hours for 48 hours. Anesthesia and analgesia were standardized. The primary outcome was the cumulative oxycodone consumption at 24 hours, other outcomes included pain scores, DN4 (Douleur Neuropathique 4 Questions) scores, and side effects. RESULTS: Group PGB consumed less oxycodone at 24 hours (median [interquartile range] 10 mg [10-17.5] vs. 20 mg [10-20], P = 0.013], at 48 hours (15 mg [10-20] vs. 20 mg [12.5-30], P = 0.018), and required less intraoperative remifentanil (P = 0.004). Both groups showed similar pain scores during the 48-hour follow-up and at 3 months.Based on multivariate analysis, chronic users of PGB before surgery exhibited lower oxycodone requirements at 24 hours (odds ratio, 3.98; 95% confidence interval, 1.44-7.74; P = 0.008]. No differences were noted regarding side effects and DN4 scores. LIMITATIONS: Nonrandomized study. CONCLUSIONS: Patients chronically treated with PGB required less opioid when compared with a short perioperative administration before spinal surgery. Further prospective studies are required to confirm these results in spinal surgeries.

Impact of cleaning and disinfection procedures on microbial ecology and Salmonella antimicrobial resistance in a pig slaughterhouse.

To guarantee food safety, a better deciphering of ecology and adaptation strategies of bacterial pathogens such as Salmonella in food environments is crucial. The role of food processing conditions such as cleaning and disinfection procedures on antimicrobial resistance emergence should especially be investigated. In this work, the prevalence and antimicrobial resistance of Salmonella and the microbial ecology of associated surfaces communities were investigated in a pig slaughterhouse before and after cleaning and disinfection procedures. Salmonella were detected in 67% of samples and isolates characterization revealed the presence of 15 PFGE-patterns belonging to five serotypes: S.4,5,12:i:-, Rissen, Typhimurium, Infantis and Derby. Resistance to ampicillin, sulfamethoxazole, tetracycline and/or chloramphenicol was detected depending on serotypes. 16S rRNA-based bacterial diversity analyses showed that Salmonella surface associated communities were highly dominated by the Moraxellaceae family with a clear site-specific composition suggesting a persistent colonization of the pig slaughterhouse. Cleaning and disinfection procedures did not lead to a modification of Salmonella susceptibility to antimicrobials in this short-term study but they tended to significantly reduce bacterial diversity and favored some genera such as Rothia and Psychrobacter. Such data participate to the construction of a comprehensive view of Salmonella ecology and antimicrobial resistance emergence in food environments in relation with cleaning and disinfection procedures.

A survey of the administration of prednisolone versus ibuprofen analgesic protocols after ambulatory tonsillectomy.

INTRODUCTION: Postoperative pain, nausea and vomiting are frequent symptoms after tonsillectomy. There have been controversies concerning the advantages and drawbacks of different analgesics in this setting, especially non-steroidal anti-inflammatory drugs, because of potential side effects. We have evaluated the effectiveness and safety of a shift from prednisolone to ibuprofen for postoperative analgesia after tonsillectomy. PATIENTS AND METHODS: Data from 1231 children scheduled for tonsillectomy over a period of 30 months were analysed. During the first period, children received a combination of paracetamol-prednisolone with codeine as a rescue therapy; in the second period, they received paracetamol and ibuprofen, with tramadol as a rescue therapy. All children received IV dexamethasone at 0.1mg/kg for antiemetic prophylaxis. The primary end-point was the incidence of severe pain defined as an Objective Pain Scale (OPS) score≥6 at the seventh postoperative day (POD7). Other end-points were postoperative nausea or emesis (PONV), sleep disturbance, oral intake and postoperative haemorrhage and reoperation. RESULTS: Six hundred and seventy-two and 559 children were included in the prednisolone and ibuprofen groups respectively. OPS scores≥6 were observed in 3.1% of cases (95% confidence interval, 2.3-4.2%) on POD7 for the entire study population. Ibuprofen reduced the incidence of OPS scores≥6 on POD7 (relative risk 0.37, 95% CI: 0.18-0.78; P=0.009), OPS scores in the ambulatory unit (P<0.001) and POD1 (P<0.001), nalbuphine requirements (RR 0.42, 95% CI, 0.34-0.5, P<0.0001), and PONV (P=0.01) compared with prednisolone. Ibuprofen enhanced sleep quality on POD0 (P<0.0001) and POD7 (P=0.02), and oral intake on POD1 (P<0.0001). The incidence of bleeding requiring reoperation was comparable between the two groups (RR 0.8 [95% CI, 0.13-4.78], p=0.8). Predictive factors for an OPS score≥6 at POD7 were OPS score>4 on the morning and the evening of POD1 (OR 1.24, 95% CI 1.02-1.49, P=0.03 and OR 1.30, 95% CI 1.12-1.55, P=0.008, respectively) and prednisolone use (OR 2.37, 95% CI 1.06-5.31, P=0.04). CONCLUSION: The administration of ibuprofen compared to prednisolone improves postoperative comfort in children undergoing ambulatory tonsillectomy without increasing the incidence of side effects.

Pain and recovery after total knee arthroplasty: a 12-month follow-up after a prospective randomized study evaluating Nefopam and Ketamine for early rehabilitation.

OBJECTIVES: Ketamine and nefopam has been documented to decrease pain intensity and improve rehabilitation after total knee arthroplasty (TKA). We conducted a follow-up study of a previously randomized clinical trial to determine the prevalence and risk factors of chronic pain 1 year after TKA and to assess the role of perioperative administration of ketamine and nefopam. MATERIALS AND METHODS: The original randomized, double-blind trial evaluated postoperative pain in 75 patients scheduled for TKA who received either a 48-hour infusion of ketamine or nefopam compared with placebo. The current study has evaluated patients at 6 and 12 months for the presence of chronic pain defined as a visual analogue scale ≥40 mm during a stair-climbing test. Other outcomes were incidence of neuropathic pain evaluated (DN4 score), active flexion of the knee, and functional outcome (KOOS-PS score). RESULTS: A total of 69 patients completed the trial. The prevalence of chronic pain at 12 months was 17.4% (95% confidence interval [CI], 10.2%-27.9%) without difference between the ketamine (12.5%), nefopam (13.7%), and placebo groups (26.1%). Prevalence of neuropathic pain was 10.2% (95% CI, 3%-17.3%). Ketamine reduced DN4 scores (P=0.02), increased knee flexion (P=0.0007), and KOOS-PS scores (P<0.0001) compared with placebo. A visual analogue scale score ≥60 mm in the postoperative period was the only risk factor associated with the occurrence of chronic pain (odds ratio 4.54; 95% CI, 1.17-17.67). DISCUSSION: After TKA, the intensity of postoperative pain is a risk factor of chronic pain on movement. Intraoperative ketamine seems to improve long-term results of rehabilitation in this setting.

Perineural ultrasound-guided catheter bacterial colonization: a prospective evaluation in 747 cases.

BACKGROUND AND OBJECTIVES: Ultrasound guidance is increasingly used for catheter insertion and could make it more complicated to guarantee aseptic insertion of catheters. The current study evaluated the incidence of colonization of ultrasound-guided perineural catheter (US-PNC) placed for postoperative analgesia. METHODS: We evaluated prospectively for 14 months 760 ultrasound-guided catheters in a single center placed under sterile conditions. Quantitative culture of all the catheters was performed after withdrawal. Colonization was defined as ≥10(3) colony-forming units/mL. Infection was defined as the isolation of the same microorganism from the colonized catheter and from blood culture and/or culture of an abscess. Univariate and multivariate logistic regression analyses were performed to determine the independent risk factors of US-PNC colonization. RESULTS: Incidences of colonization and infections were 10.4% (95% confidence interval [95% CI], 8.2%-14.4%) and 0.13% (95% CI, 0%-3.8%), respectively, in a total of 747 catheters. Coagulase-negative staphylococci colonization was documented in 69% of the colonized catheters. Local inflammation was more frequently noted when catheters were colonized (26.9% [95% CI, 15.2%-38.7%] versus 8.1% [95% CI, 4.2%-11.9%], P = 0.005). Independent factors for ultrasound-guided catheter colonization were duration of catheter placement more than 48 hours (odds ratio [OR], 4.9; 95% CI, 1.1-12.7; P = 0.003), diabetes (OR, 2.3; 95% CI, 1.4-9.6; P = 0.004), and antibiotic administration during the month preceding surgery (OR, 1.8; 95% CI, 1.5-7.8; P = 0.01). CONCLUSIONS: Although infection rate is low, there is a risk of ultrasound-guided catheter colonization that deserves careful monitoring of the insertion site in the postoperative period.

A 40-year-old woman with cauda equina syndrome caused by rectothecal fistula arising from an anterior sacral meningocele.

BACKGROUND AND IMPORTANCE: We present a rare case of a rectothecal fistula arising from an anterior sacral meningocele in a patient with Currarino syndrome. CLINICAL PRESENTATION: The patient was a 40-year-old woman presenting with cauda equina syndrome and ascending meningitis. The meningocele was removed using an anterior abdominal approach. A sigmoid resection was performed with rectal on-table antegrade lavage followed by closure of the rectal fistula, closure of the rectal stump, and proximal colostomy. Closure of the sacral deficit was carried out by suturing a strip of well-vascularized omentum and fibrin glue. CONCLUSION: We discuss the characteristics, management, and evolution of this unusual case. Prompt surgical management using an anterior approach, resection of the sac, closure of the sacral deficit, and fecal diversion resulted in a satisfactory outcome.

Postoperative efficacies of femoral nerve catheters sited using ultrasound combined with neurostimulation compared with neurostimulation alone for total knee arthroplasty.

BACKGROUND AND OBJECTIVE: Neurostimulation is commonly used to perform femoral nerve block. Ultrasound can be used to identify nerve structures and guide needle placement. The aim of this study was to compare postoperative analgesic efficiency when femoral nerve catheters were sited using ultrasound (in-plane approach) combined with neurostimulation or neurostimulation alone, for total knee arthroplasty. METHOD: Ninety-three patients were enrolled in this prospective, randomized, blind study to receive a continuous femoral nerve block performed using conventional neurostimulation or ultrasound guidance combined with neurostimulation. The primary endpoint was the postoperative 48 h total local anaesthetic consumption. Other outcomes included visual analogue scale scores at rest, after 12, 24 and 48 h; total oral opioid dose; onset time of femoral block; procedural time; knee flexion and complications. Results are expressed with medians (25-75th percentiles), mean ± SD and n (%), as appropriate. RESULTS: The onset time of sensory and motor block was faster in the ultrasound group [11 (6-17) min] than in the conventional group [16 (11-23) min, P = 0.009]. Total local anaesthetic dose was reduced [299 ± 45 vs. 333 ± 48 ml, (difference = 34.0 ml, 95% confidence interval 15.6-52.5 ml), P = 0.0003] and the time to the first analgesic request was lengthened [11 (7-13) vs. 7 (4-12) h, P = 0.034] in the ultrasound group. Visual analogue scale scores at 12, 24 and 48 h were lower in the ultrasound group as well as visual analogue scale scores during knee flexion at 48 h [14.5 (11.0-23.0) vs. 28.5 (21.0-43.5) mm, P < 0.0001]. Total oral morphine doses were 20 (0-40) vs. 40 (20-60) mg (P = 0.0065). Durations of hospital stay were comparable in both groups. CONCLUSION: Continuous perineural femoral catheter placement using ultrasound combined with neurostimulation and an in-plane approach reduces total doses of local anaesthetic, morphine consumption and improves postoperative pain management by comparison with neurostimulation alone.

Physiological and psychological effects of escape from a sunken submarine on shore and at sea.

INTRODUCTION: The stress effects induced by diverse military scenarios are usually studied under tightly controlled conditions, while only limited research has addressed realistic scenarios. This study was designed to compare the effects of two levels of realism in stressful training for escape from a sunken submarine. METHODS: Thirteen qualified submariners served as subjects. All had previously participated in underwater escape training using a simulated submarine in a land-based tank submerged at a depth of 6 m; for this study, they repeated the simulator escape, following which six of them executed escape from an actual submarine lying at a depth of 30 m on the sea floor. The men were studied before the exercises, immediately after surfacing, and 2 h later. Measured variables included sympathovagal balance, salivary cortisol, perceived mood, and sleep, as well as short-term and declarative memory. RESULTS: Compared to the simulator exercise in the tank, the escape at sea showed the following significant differences: 1) higher salivary cortisol values (6.33 +/- 3.9 nmol x L(-1) on shore and 13.38 +/- 7.5 nmol x L(-1) at sea); 2) greater adverse changes in mood, including vigor, tension, and ability to fall asleep; and 3) impairment in declarative memory. Responses were found to differ further for the five submariners who had prior experience of accident or injury while at sea. CONCLUSION: The psychophysiological and cognitive effects of military exercises may be influenced by the realism of conditions and by prior exposure to life-threatening situations.

Perceived head-trunk angle during microgravity produced by parabolic flight.

INTRODUCTION: Neck proprioceptors are essential for orienting the head relative to the trunk. However, it has been shown that the available information about the relationship of gravity to different body parts would augment the clues about their relative orientation. In weightlessness, the absence of relevant body position signals from the otoliths and other inertial graviceptors requires the substitution of other sensory information. The aim of the present study was to investigate the ability of humans to accurately locate the head relative to the trunk in microgravity. METHODS: Experiments were conducted during two separate sessions: on Earth and during parabolic flights. Volunteers were asked to adjust a visual rod until it looked parallel to their head or trunk axis in two different segmental configurations: head and trunk aligned or head tilted. RESULTS: There was no effect of microgravity when the head and trunk were aligned. However, when the head was tilted with respect to the trunk, the orientation of the visual rod relative to the head or the trunk (visual egocentric coordinates) was deviated toward the head tilt, although the orientation between the body parts themselves (head-trunk angle) was correctly estimated. DISCUSSION: These results suggested that, in microgravity, the proprioceptive signals from neck muscles seem sufficient to provide accurate head on trunk information. However, the representation of orientation in visual space was modified. This experiment provides evidence for the role of gravity on the visual perception of head- and trunk-based egocentric coordinates.

Effect of Achilles tendon vibration on postural orientation.

Vibration applied to the Achilles tendon is well known to induce in freely standing subjects a backward body displacement and in restrained subjects an illusory forward body tilt. The purpose of the present experiment was to evaluate the effect of Achilles tendon vibration (90Hz) on postural orientation in subjects free of equilibrium constraints. Subjects (n=12) were strapped on a backboard that could be rotated in the antero-posterior direction with the axis of rotation at the level of the ankles. They stood on a rigid horizontal floor with the soles of their feet parallel to the ground. They were initially positioned 7 degrees backward or forward or vertical and were required to adjust their body (the backboard) to the vertical orientation via a joystick. Firstly, results showed that in response to Achilles tendon vibration, subjects adjusted their body backward compared to the condition without vibration. This backward body adjustment likely cancel the appearance of an illusory forward body tilt. It was also observed that the vibratory stimulus applied to the Achilles tendon elicited in restrained standing subjects an increased EMG activity in both the gastrocnemius lateralis and the soleus muscles. Secondly, this vibration effect was more pronounced when passive displacement during the adjustment phase was congruent with the simulated elongation of calf muscles. These results indicated that the perception of body orientation is coherent with the postural response classically observed in freely standing subjects although the relationship between these two responses remains to be elucidated.

Effects of neck muscles vibration on the perception of the head and trunk midline position.

The present study focused on the influence of neck vibration on the perception of the head and trunk midline position (orientation and localization). The orientation of the head and trunk was investigated by the rolling adjustment of a rod on their midline while their localization was investigated by the adjustment of the position of a visual dot as being straight-ahead the eyes or the sternum. The first experiment investigated whether a head-trunk dissociation was induced by the unilateral vibration of neck muscles in upright and restrained subjects. Results showed that the subjective orientation and localization of whole-body midline were shifted toward the vibrated side. The second experiment determined the effect of the neck muscles vibration when the subjects were lying on their side. The effect of vibration disappeared when the side of vibration was opposed to the side of postural inclination and it was stronger than in the upright position when the side of vibration and the side of postural inclination were congruent. Whereas, results suggested that the input from neck muscle proprioceptors participates directly to the elaboration of the egocentric space, the question may be raised as to how the sensory cues interacted in their contribution to the neural generation of an egocentric, body centred coordinate system.