Randomized comparison of popliteal-sciatic perineural catheter tip migration and dislocation in a cadaver model using two catheter designs.

BACKGROUND: New catheter-over-needle (CON) technology for continuous peripheral nerve blockade has emerged, but its effect on the risk of perineural catheter tip dislocation is unknown. Less flexible catheters may be more likely to migrate away from the nerve with simulated patient movement. In the present study, we evaluated catheter tip migration between CON catheters and traditional catheter-through-needle (CTN) catheters during ultrasound-guided short-axis in-plane (SAX-IP) insertion. METHODS: We evaluated the migration of popliteal-sciatic catheters in a prone, unembalmed male cadaver. Thirty catheter placement trials were divided randomly into two groups based on the catheter type: CON or CTN. A single anesthesiology resident placed the catheters by SAX-IP insertion, and the catheters were then examined by ultrasound before and after ipsilateral knee range of motion (ROM) exercises (0°-130° flexion). A blinded expert regional anesthesiologist performed caliper measurements on the ultrasound images before and after the ROM exercises. The primary outcome was the change in distance from the catheter tip to the center of the nerve (cm) between before and after the ROM exercises. RESULTS: The change in the tip-to-nerve distance (median [10th-90th percentile]) was 0.06 (-0.16 to 0.23) cm for the CTN catheter and 0.00 (-0.12 to 0.69) for the CON catheter (P = 0.663). However, there was a statistically significant increase in dislocation out of the nerve compartment for the CON catheter (4/15; 0/15 for CTN) (P = 0.043). CONCLUSIONS: Although the use of different catheter designs had no effect on the change in the measured migration distance of popliteal-sciatic catheters, 27% of the CON catheters were dislocated out of the nerve compartment. These results may influence the choice of catheter design when using SAX-IP perineural catheter insertion.

Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction: Is There a True Reduction in Postoperative Narcotic Use?

INTRODUCTION: The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period. METHODS: A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications. RESULTS: We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group. CONCLUSIONS: Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.

A comparison of strength for two continuous peripheral nerve block catheter dressings.

BACKGROUND: Despite the benefits of continuous peripheral nerve blocks, catheter dislodgment remains a major problem, especially in the ambulatory setting. However, catheter dressing techniques to prevent such dislodgment have not been studied rigorously. We designed this simulation study to test the strength of two commercially available catheter dressings. METHODS: Using a cadaver model, we randomly assigned 20 trials to one of two dressing techniques applied to the lateral thigh: 1) clear adhesive dressing alone, or 2) clear adhesive dressing with an anchoring device. Using a digital luggage scale attached to a loop secured by the dressing, the same investigator applied steadily increasing force with a downward trajectory towards the floor until the dressing was removed or otherwise disrupted. RESULTS: The weight, measured (median [10th-90th percentile]) at the time of dressing disruption or removal, was 1.5 kg (1.3-1.8 kg) with no anchoring device versus 4.9 kg (3.7-6.5 kg) when the dressing included an anchoring device (P < 0.001). CONCLUSIONS: Based on this simulation study, using an anchoring device may help prevent perineural catheter dislodgement and therefore premature disruption of continuous nerve block analgesia.

Comparative Effectiveness of Two Ultrasound-Guided Regional Block Techniques for Surgical Anesthesia in Open Unilateral Inguinal Hernia Repair.

Transversus abdominis plane (TAP) and ilioinguinal/iliohypogastric (II/IH) nerve blocks have been described as analgesic adjuncts for inguinal hernia repair, but the efficacy of these techniques in providing intraoperative anesthesia, either individually or together, is not known. We designed this retrospective cohort study to test the hypothesis that combining TAP and II/IH nerve blocks ("double TAP" technique) results in greater accordance between the preoperative anesthetic plan and actual anesthetic technique provided when compared to TAP alone. Based on this study, double TAP may be preferred for patients undergoing open inguinal hernia repair who wish to avoid general anesthesia.

A pilot in vitro evaluation of the "air test" for perineural catheter tip localization by a novice regional anesthesiologist.

The "air test" is used clinically to infer perineural catheter location and has been recently evaluated for use by experts. However, its utility for practitioners with less experience is unknown. We tested the hypothesis that the air test, when performed by a novice regional anesthesiologist, will improve assessment of perineural catheter tip position in a validated porcine-bovine model and determined the test's positive and negative predictive values, sensitivity, and specificity for a novice. In contrast to the results of the expert study, the air test did not improve the novice's assessment of perineural catheter tip location over chance.

A pilot study of 2 brief forms of dialectical behavior therapy skills training for emotion dysregulation in college students.

OBJECTIVE: To examine the feasibility and initial efficacy of 2 abbreviated dialectical behavior therapy (DBT) skills training groups: emotion regulation skills only and emotion regulation with mindfulness skills. PARTICIPANTS: Participants were 24 undergraduates (aged 18-29) with significant emotion dysregulation who participated between February and May of 2010, 2011, and 2012. METHODS: Participants participated in 2-hour weekly group sessions for 8 weeks and completed outcome measures at baseline, midtreatment, posttreatment, and 4-week follow-up. RESULTS: Participants in both conditions made significant gains, with large effect sizes, across measures of emotion regulation, affect, skills use, and functioning. There were no differences between the 2 groups, suggesting no additive benefit of mindfulness skills. CONCLUSIONS: This pilot study provides support for the acceptability and efficacy of abbreviated DBT skills training in colleges, given significant improvements, positive feedback, and low attrition. Impediments to feasibility included recruitment difficulties, particularly due to scheduling constraints.

Prediction of late disease recurrence and extended adjuvant letrozole benefit by the HOXB13/IL17BR biomarker.

BACKGROUND: Biomarkers to optimize extended adjuvant endocrine therapy for women with estrogen receptor (ER)-positive breast cancer are limited. The HOXB13/IL17BR (H/I) biomarker predicts recurrence risk in ER-positive, lymph node-negative breast cancer patients. H/I was evaluated in MA.17 trial for prognostic performance for late recurrence and treatment benefit from extended adjuvant letrozole. METHODS: A prospective-retrospective, nested case-control design of 83 recurrences matched to 166 nonrecurrences from letrozole- and placebo-treated patients within MA.17 was conducted. Expression of H/I within primary tumors was determined by reverse-transcription polymerase chain reaction with a prespecified cutpoint. The predictive ability of H/I for ascertaining benefit from letrozole was determined using multivariable conditional logistic regression including standard clinicopathological factors as covariates. All statistical tests were two-sided. RESULTS: High H/I was statistically significantly associated with a decrease in late recurrence in patients receiving extended letrozole therapy (odds ratio [OR] = 0.35; 95% confidence interval [CI] = 0.16 to 0.75; P = .007). In an adjusted model with standard clinicopathological factors, high H/I remained statistically significantly associated with patient benefit from letrozole (OR = 0.33; 95% CI = 0.15 to 0.73; P = .006). Reduction in the absolute risk of recurrence at 5 years was 16.5% for patients with high H/I (P = .007). The interaction between H/I and letrozole treatment was statistically significant (P = .03). CONCLUSIONS: In the absence of extended letrozole therapy, high H/I identifies a subgroup of ER-positive patients disease-free after 5 years of tamoxifen who are at risk for late recurrence. When extended endocrine therapy with letrozole is prescribed, high H/I predicts benefit from therapy and a decreased probability of late disease recurrence.

Treatment utilization by gender in patients with borderline personality disorder.

Minimal data exist on treatment utilization by gender in borderline personality disorder (BPD). This study used an online questionnaire to investigate initial and lifetime patterns of utilization of multiple treatment modalities by patients with BPD, and parental satisfaction with treatment. Respondents were parents of probands diagnosed with BPD who completed a 100-question anonymous Internet survey. Of the 495 surveys that were analyzed, 409 pertained to female subjects with BPD and 86 to male subjects with BPD. Results for probands with BPD across gender were notable for similar high lifetime levels of use of care, including hospitalization, day programs, and halfway houses, but not similar levels of use of drug/alcohol rehabilitation services, which was greater among the male subjects with BPD. The male subjects with BPD received significantly less lifetime psychotherapy and pharmacotherapy than the female subjects with BPD, although the duration of medication and psychotherapy treatment did not differ by gender. These results highlight the need for more research to better understand what might account for these gender differences in treatment and improve strategies to provide appropriate care for male patients with BPD.