External oblique intercostal (EOI) block for enhanced recovery after liver surgery: a case series.

We report our clinical experience with the external oblique intercostal block in three consecutive adult patients who underwent liver surgery for resection of metastases. Enhanced recovery guidelines for liver surgery recommend intrathecal opioids and peripheral regional anaesthetic techniques in the context of multimodal analgesia to achieve adequate postoperative analgesia and early functional recovery. However, both laparoscopic and open approaches to liver surgery involve incisions in the upper abdomen, an anatomical area not well covered by previously described peripheral regional anaesthetic techniques. The external oblique intercostal block is a novel motor- and opioid-sparing technique which blocks both the anterior and lateral cutaneous branches of the thoracoabdominal nerves which innervate the upper abdominal quadrant. In all cases in this series, we performed the blocks in a short period of time and without complications. All patients remained pain- and opioid-free in the postoperative period and achieved enhanced recovery outcomes early. We found the external oblique intercostal block to be a simple, convenient, effective and opioid-sparing regional anaesthetic technique for postoperative analgesia after liver surgery. By minimising opioid use and by obviating the need for central neuraxial anaesthesia techniques in the postoperative period, this block could be incorporated into enhanced recovery protocols for hepatobiliary surgery.

Cartilage tympanoplasty: a reliable technique for smokers.

The aim of this study was to report our experience with cartilage tympanoplasty (CT) in smokers and compare it with that of non-smokers using a retrospective chart review at a tertiary referral center. Between September 2008 and September 2010, cartilage tympanoplasty was performed in 52 patients. Among them, 27 were active smokers and 25 former or non-smokers. The entire tympanic membrane was replaced with conchal cartilage, shaped either as a shield for cases with intact canal wall mastoidectomies, or crashed for cases with canal wall down procedures. The mean post-operative follow-up was 12 months (range 6-18 months). A complete pre- and post-operative audiologic evaluation was obtained in all patients. Graft take was successful in all patients. The overall average pre-operative and post-operative pure tone average air-bone gaps (PTA-ABG) was 52.2 dB ± 17.7 dB and 35.4 dB ± 17.9 dB, respectively, with an overall improvement of 16.8 dB (p < 0.001). A post-operative PTA-ABG of 25 dB or less was achieved in 39 (75 %) patients (p < 0.001). In smokers, the hearing improvement was 17.6 dB (p < 0.001) with a PTA-ABG of 25 dB or less in 19 (70 %). In non-smokers, the average hearing improvement was 16.8 dB (p < 0.0005) with a post-operative PTA-ABG of 25 dB or less in 19 (76 %), (p < 0.001). The results showed that the CT technique is a very effective procedure for smokers. Excellent graft take and satisfactory hearing results can be accomplished regardless of smoking habits.

Prognosis of patients with idiopathic sudden hearing loss: role of vestibular assessment.

OBJECTIVE: To evaluate the correlation between caloric and vestibular evoked myogenic potential test results, initial audiogram data, and early hearing recovery, in patients with idiopathic sudden hearing loss. MATERIALS AND METHODS: One hundred and four patients with unilateral idiopathic sudden hearing loss underwent complete neurotological evaluation. Results for vestibular evoked myogenic potential and caloric testing were compared with patients' initial and final audiograms. RESULTS: Overall, abnormal vestibular evoked myogenic potential responses occurred in 28.8 per cent of patients, whereas abnormal caloric test results occurred in 50 per cent. A statistically significant relationship was found between the type of inner ear lesion and the incidence of profound hearing loss. Moreover, a negative correlation was found between the extent of the inner ear lesion and the likelihood of early recovery. CONCLUSION: In patients with idiopathic sudden hearing loss, the extent of the inner ear lesion tends to correlate with the severity of cochlear damage. Vestibular assessment may be valuable in predicting the final outcome.

Semicircular canal versus otolithic involvement in idiopathic sudden hearing loss.

OBJECTIVE: To evaluate the results of vestibular evoked myogenic potential testing in patients with idiopathic sudden hearing loss, and to correlate these results with the findings of caloric testing, the clinical appearance of vertigo and the influence of age. MATERIALS AND METHODS: Eighty-six patients with unilateral idiopathic sudden hearing loss and 35 healthy controls underwent a standard protocol of neurotological evaluation. Vestibular evoked myogenic potential responses were measured and compared with caloric responses. RESULTS: On the affected side, 30.2 per cent of patients showed abnormal vestibular evoked myogenic potential responses, while 52.3 per cent had abnormal caloric responses. A statistically significant relationship was found between the results of these two tests. A statistically significant relationship was also found between the type of vestibular lesion and the occurrence of vertigo. Advancing age correlated statistically with more extensive labyrinthic lesions. CONCLUSIONS: A combination of vestibular evoked myogenic potential and electronystagmography testing indicated the existence of vestibular involvement in many patients with idiopathic sudden hearing loss. Both tests are necessary in order to obtain a more thorough and in-depth knowledge of the pathophysiology of idiopathic sudden hearing loss.

The evolution of lower limb amputation through the ages. Historical note.

The aim of this study was to highlight the important stages of the evolution of limb amputation through the ages through the search of the relevant international literature. Limb amputation is one of the most serious surgical operations, which is associated with high mortality and morbidity. Evidence regarding the execution of limb amputation can be found back in Neolithic times. The most important steps in the evolution of the technique of limb amputation were made in the 16th, 17th, and 18th centuries when A. Pare' introduced the vessel ligation and the French barber surgeon Morell introduced the use of a tourniquet to reduce the bleeding. During the same period, from the ''one-stage circular cut'' the technique evolved to either ''three-stage circular cut'' or to ''flap amputation'', single or double. Limb amputation represents one of the oldest and most serious surgical operations. Its evolution parallels the maturation process of surgery, with the major developments in the technique to have been made from the 16th to the 18th century. In the beginning of the 21st century, limb amputation appears to be a safe operation ending up with a functional stump.

Malpractice issues in modern anaesthesiology.

Medical malpractice has been raised as an important problem in daily practice, while the media and public remain unforgiving to those perceived to have harmed the patients' life. This article highlights important legal issues related to medical malpractice and summarizes the sources and the nature of potential errors in anaesthesiology practice.

Laparoscopic cholecystectomy under spinal anesthesia: a pilot study.

BACKGROUND: Regional anesthesia has not been used as the sole anesthetic procedure other than in the scenario of a patient at high risk to undergo laparoscopic cholecystectomy with CO2 pneumoperitoneum under general anesthesia. METHODS: Fifteen ASA grade I or II patients underwent laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under spinal anesthesia. Intraoperative parameters, postoperative pain and recovery in general, as well as patient satisfaction at follow-up were prospectively recorded in a pilot study to assess the feasibility and safety of the procedure. RESULTS: All operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score 4 h postoperatively was 1.5 (range, 0-5), at 8 h it was 1 (range, 0-6), and at 24 h it was 1 (range, 0-4). All patients were discharged after 24 h. Follow-up 2 weeks postoperatively showed all but one patient to be satisfied and strongly recommending the anesthetic procedure. CONCLUSION: Laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and at least an equally good recovery as with general anesthesia.

Evidence that termination of the estradiol-induced luteinizing hormone surge in women is regulated by ovarian factors.

BACKGROUND: The endogenous LH surge is the result of the estrogen-positive feedback effect. However, the factors that are responsible for the termination of LH surge are not known. OBJECTIVE: The objective of the study was to investigate the mechanism that terminates the LH surge in women. SUBJECTS AND METHODS: Eight normally cycling women (aged 42-48 yr) were investigated in two cycles, i.e. cycle 1 (control) and cycle 2. In cycle 2 total abdominal hysterectomy plus bilateral salpingooophorectomy was performed on d 3. In both cycles, estradiol was administered transdermally at the dose of 100 microg on d 3 and 150 microg on d 4 and 5. Blood samples were obtained every 12 h from d 3 to 5 and every 6 h thereafter until d 9. RESULTS: In both cycles, after suppression of gonadotropins, the women displayed an endogenous LH surge. The time intervals between the commencement of estradiol treatment and the LH surge onset (73.5 +/- 1.5 vs. 76.5 +/- 2.5 h) and peak LH values (11.4 +/- 1.9 vs. 12.4 +/- 3.1 IU/liter) were comparable in the two cycles (mean +/- sem). After peaking, LH values decreased gradually in cycle 1, whereas in cycle 2 they remained stable and were higher than the corresponding values in cycle 1 (P < 0.05). Before the LH surge onset, estradiol values showed in both cycles a preovulatory pattern of changes, but starting 24 h after the onset of the LH surge, they were lower in cycle 2 (P < 0.05). Progesterone levels were similar in both cycles until the day of the LH surge onset, but in cycle 2 they declined thereafter and were lower than in cycle 1 (P < 0.05). CONCLUSIONS: It is suggested that ovarian factors rather than exhaustion of pituitary reserves are important for termination of the endogenous LH surge during the normal menstrual cycle.

Qualitative and quantitative alterations of cell surface carbohydrate residues during epidermal morphogenesis.

The purpose of this study was to investigate the carbohydrate residue composition of cell surface in the developing epidermis and to define the chronological sequence of its alterations in human fetuses from the 10th to the 20th weeks of gestation and at the 23rd week of gestation, using a panel of six biotinylated lectins: Concanavalin A, Ulex europaeus agglutinin-I, Ricinus communis agglutinin-I, Peanut agglutinin, Wheat germ agglutinin, and Dolichos biflorus agglutinin. Distinct qualitative and quantitative alterations in the expression of cell surface carbohydrate residues were found during epidermal morphogenesis prior to keratinization (10th to 20th weeks). At the 23rd week of gestation, the already keratinized fetal human epidermis revealed a pattern of cell surface glycosylation very similar to that of the adult human epidermis. Further studies are now warranted to answer the question regarding whether the glycosylation pattern in the developing human epidermis is disturbed in fetuses with genodermatoses and whether these disturbances might be important for prenatally diagnosing the latter.

Novel 3-(2-adamantyl)pyrrolidines with potent activity against influenza A virus-identification of aminoadamantane derivatives bearing two pharmacophoric amine groups.

The 3-(2-adamantyl)pyrrolidines 8a-g, 14 were synthesized and evaluated for activity against influenza A virus. The parent N-H compound 14 was several times more active than amantadine against H(2)N(2) and H(3)N(2) influenza A virus. The combined use of NMR spectroscopy and computational chemistry showed that the conformation around the pyrrolidine-adamantyl carbon-carbon bond is trans and the pyrrolidine heterocycle has an envelope conformation with C-2 out of the plane of the other ring atoms. N-Dialkylaminoethyl substitution of compound 14 resulted in the potent diamine analogues 8e,f,g. Interestingly, their lactam amine precursors were also active. Compounds 8e,f,g are the first adamantane derivatives, bearing two amine groups, reported to be active against influenza A virus.