Regional anaesthesia is associated with less patient satisfaction compared to general anaesthesia following distal upper extremity surgery: a prospective double centred observational study.

BACKGROUND: Patient satisfaction is a well-established indicator to evaluate the quality of medical care and there is an increasing support for the use of patient-reported experience measures (PREMs) to evaluate satisfaction. To anesthetize the upper limb for surgery, both general and regional plexus anaesthesia are appropriate techniques. However, the best technique in the anaesthesiologist's perspective might not necessarily result in the highest patient satisfaction. The aim of this study is to investigate patient satisfaction following general and regional anaesthesia, and to identify areas where anaesthesiologists can focus on improving patient care. METHODS: Patients scheduled for elective distal upper extremity surgery under either general or regional plexus anaesthesia were prospectively included. On the first postoperative day, patient satisfaction and main reason for dissatisfaction with the anaesthesia technique were investigated during a telephone interview. RESULTS: Of the 243 patients included in the current study, 79.8% report being "fully satisfied" with their anaesthesia technique. 32.1% of the patients who received regional anaesthesia reported not feeling "fully satisfied". This figure is 5.5% following general anaesthesia. Main reason for dissatisfaction following regional anaesthesia are reported as "insufficient anaesthesia prior to surgery", and "the discomfort of having a long-lasting insensate extremity postoperatively". CONCLUSIONS: Following regional plexus anaesthesia, a third of the patients are not "fully satisfied". To optimize patient satisfaction following regional anaesthesia techniques, we advocate stronger focus on patient counselling preoperatively, addressing the issues of block failure and prolonged postoperative sensory and motor block.

Individual duration of axillary brachial plexus block is unpredictable: a prospective double centered observational study.

BACKGROUND: The duration of effect for axillary plexus block using ropivacaine is highly variable. The available literature does not offer any plausible means of predicting time of block offset for individual patients, making it difficult to give accurate information and plan postoperative analgesics. This study was designed to identify factors influencing axillary plexus block offset time. METHODS: A total of 92 patients participated in this prospective double centred observational study. All patients were scheduled for axillary plexus block with ropivacaine 0.75% and subsequent block duration was recorded. RESULTS: Mean time of axillary plexus block offset was 13.5 hours, with a range of 4.8 to 25.4 hours. No statistical significant differences in offset time was seen with regard to gender, age, body weight, BMI and ASA-classification. A trend for increasing duration of blocks associated with increasing age was observed. No statistically significant difference was identified in block duration between blocks performed with nerve stimulator guidance versus ultrasound guidance. Similarly, neither dose nor volume of ropivacaine 0.75% was identified as a factor influencing block duration. CONCLUSIONS: This prospective study demonstrates a large inter individual variation in time of axillary plexus block offset using ropivacaine 0.75%. The lack of association between offset time and both demographic and block performance factors, makes predictability of individual duration of axillary plexus blocks in clinical practice extremely difficult. We suggest that all patients should be made aware of such variability in duration prior to block placement.

Induction and recovery of estrogenic effects after short-term 17ß-estradiol exposure in juvenile rainbow trout (Oncorhynchus mykiss).

Estrogenic compounds found in the aquatic environment include natural and synthetic estrogen hormones as well as other less potent estrogenic xenobiotics. In this study, a comprehensive approach was used to examine effects on fish endocrine system endpoints during a short-term xenoestrogen exposure as well as after post-exposure recovery. Rainbow trout (Oncorhynchus mykiss) were exposed to an aqueous 17ß-estradiol (E2) concentration of 0.473 µg l(-1) for 2 and 7 days (d) followed by a 14-d recovery period. At d2 and d7, plasma E2 concentrations in treated fish were 458- and 205-fold higher than in control fish and 23- and 16-fold higher than the exposure water concentration. E2 treatment resulted in significant increases in hepatosomatic index (HSI), plasma vitellogenin (VTG) protein concentrations, and liver VTG and estrogen receptor alpha mRNA levels. All of these parameters, with the exception of plasma VTG protein, returned to baseline values during the recovery period. Plasma cortisol concentrations were unaffected by treatment. This research shows varied time frames of the estrogen-responsive molecular-, biochemical-, and tissue-level alterations, as well as their persistence, in juvenile rainbow trout treated with aqueous E2. These results have implications for feral rainbow trout exposed to xenoestrogens and indicate the importance of evaluating a comprehensive suite of endpoints in assessing the impact of this type of environmental contaminant.

Concentration-response relationships and temporal patterns in hepatic gene expression of Chinook salmon (Oncorhynchus tshawytscha) exposed to sewage.

Changes in liver gene expression were examined in juvenile Chinook salmon (Oncorhynchus tshawytscha) exposed in vivo for 8d to seawater (control) or one of 5 concentrations of sewage (environmentally-relevant dilutions of 0.05%, 0.1%, and 0.7%; 2%, 5% or 10%) and subsequently transferred to clean seawater for an 8-d recovery period. Livers were sampled on days 1, 4, 8 (sewage-exposed) and 16 (8d of sewage exposure plus 8d of recovery). A custom cDNA microarray using a universal DNA reference design was used to examine trends of altered gene expression across sewage concentrations, across timepoints, and at the end of the recovery period. Alterations in gene expression followed four distinct concentration-dependent patterns: (1) concentration response (e.g. estrogen receptor alpha), (2) inverse-concentration response (e.g. insulin receptor beta), U-shaped (e.g. mineralocorticoid receptor), (3) inverse U-shaped (e.g. benzodiazepine receptor), and (4) concentration-independent responses (e.g. ubiquitin). Temporal trends included: (1) peak gene expression at one of the sewage exposure timepoints with recovery to baseline levels after the depuration phase (e.g. vitelline envelope protein beta), (2) gene expression alterations that did not recover (e.g. glucose transporter 3), and (3) delayed gene expression alterations initiated only at the recovery timepoint (e.g. insulin-like growth factor 2). In summary, patterns in gene expression changes were found across sewage concentrations and exposure timepoints. This study is the first to show gene expression trends of this nature.

Toxicity of silver nanoparticles to rainbow trout: a toxicogenomic approach.

Silver (Ag) nanoparticles are used as antimicrobial adjuvant in various products such as clothes and medical devices where the release of nano-Ag could contaminate the environment and harm wildlife. The purpose of this study was to examine the sublethal effects of nano-Ag and dissolved Ag on Oncorhynchus mykiss rainbow trout. Hepatic Ag contents and changes in gene expression were monitored to provide insights on bioavailability and mode of action of both forms of silver. Fish were exposed to increasing concentrations (0.06, 0.6 and 6 µg L(-1)) of nano-Ag (20 nm) and silver nitrate (AgNO(3)) for 96 h at 15°C. A gene expression analysis was performed in the liver using a DNA microarray of 207 stress-related genes followed by a quantitative polymerase chain reaction on a selection of genes for validation. The biochemical markers consisted of the determination of labile zinc, metallothioneins, DNA strand breaks, lipid peroxidation (LPO) and vitellogenin-like proteins. The analysis of total Ag in the aquarium water revealed that nano-Ag was mostly aggregated, with 1% of the total Ag being dissolved. Nevertheless, hepatic Ag content was significantly increased in exposed fish. Indeed, dissolved Ag was significantly more bioavailable than nano-Ag only at the highest concentration with 38 ± 10 and 11 ± 3 ng Ag mg(-1) proteins for dissolved and nano-Ag respectively. Exposure to both forms of Ag led to significant changes in gene expression for 13% of tested gene targets. About 12% of genes responded specifically to nano-Ag, while 10% of total gene targets responded specifically to dissolved Ag. The levels of vitellogenin-like proteins and DNA strand breaks were significantly reduced by both forms of Ag, but DNA break levels were lower with nano-Ag and could not be explained by the presence of ionic Ag. Labile zinc and the oxidized fraction of metallothioneins were increased by both forms of Ag, but LPO was significantly induced by nano-Ag only. A discriminant function analysis revealed that the responses obtained by biochemical markers and a selection of ten target genes were able to discriminate completely (100%) the effects of both forms of Ag. Exposure to nano-Ag involved genes in inflammation and dissolved Ag involved oxidative stress and protein stability. Hence, the toxicity of Ag will differ depending on the presence of Ag nanoparticles and aggregates.

Immunocompetence and alterations in hepatic gene expression in rainbow trout exposed to CdS/CdTe quantum dots.

Cadmium (Cd) tellurium quantum dots (QDs) are long-lived fluorescent nanocrystals that have the ability to produce potentially toxic reactive oxygen species at the surface of the nanoparticle and release toxic cadmium ions. The purpose of this study was to examine the sublethal effects of CdS/CdTe QDs and dissolved Cd on the immune system of rainbow trout. Changes in hepatic gene expression were also monitored to provide insight on the mode of action of both forms of cadmium. Oncorhynchus mykiss fish were exposed to increasing concentrations of CdS/CdTe or dissolved Cd (CdSO(4)) for 48 h at 15 degrees C. The anterior head kidney was analyzed for leukocyte count, viability and phagocytic activity. The livers were harvested and prepared for gene expression analysis using a DNA microarray comprised of 207 stress-related genes. An analysis of total Cd in the aquarium water revealed that the nominal concentrations corresponded well to the actual concentrations and that a small proportion (0.4%) of Cd in the QDs was found in the dissolved fraction. Exposure to QDs led to significant reductions in leukocyte counts, viability and both resting and active phagocytic activity. On a mass concentration basis, QDs were more potent than dissolved Cd in suppressing immunocompetence in rainbow trout. The analysis revealed that both forms of Cd were strong inducers of metallothionein and CP2K1 gene expressions, which are respectively involved in metal detoxification processes and xenobiotic transformation/inflammation conditions. The analysis revealed different modes of action for each form of Cd. For QDs, 25 genes specific to QDs and related to the immune endpoints were found. The genes were involved in inflammation, xenobiotic biotransformation and endocrine system (including the induction of vitellogenin and its receptor). The effect for dissolved Cd was narrower than for QDs, with 9 genes specific to dissolved Cd being strongly correlated with the observed effects on immunocompetence. The involved genes were binding and transport of various solutes (urea, sodium, potassium) and the complement system. The present study revealed that each form of Cd produced a different pattern of gene expression and lowered fish immunocompetence.