Regional nerve blockade prior to direct injection to achieve anaesthesia of the nasal ala.

BACKGROUND: Dermatological surgical procedures involving the nasal alae are commonplace in clinical practice. Direct infiltration of local anaesthetic into the nasal ala is extremely uncomfortable. OBJECTIVES: In this prospective clinical study, we investigate the effectiveness of alar anaesthesia provided by an infraorbital nerve block (IOB). METHODS: We recruited 100 consecutive patients requiring dermatological surgical procedures involving the nasal ala (or other sites necessitating an IOB). Following topical mucosal anaesthesia, an IOB was administered via the intraoral route. Effectiveness of anaesthesia was assessed after 10 min by testing the perception of a sharp stimulus at five standardized reference points on the nasal ala. If the ala was not completely anaesthetized, blockade of the external nasal branch of the anterior ethmoidal nerve (external nerve block, ENB) was performed. Sensation of the nasal ala was re-assessed after 10 min using the above method. RESULTS: Complete anaesthesia of the nasal ala was achieved with an IOB in 66 of 100 (66%) patients. Of the remaining 34 patients, the addition of an ENB achieved complete anaesthesia in 15 (44%). CONCLUSIONS: An IOB provides effective alar anaesthesia in the majority of patients. In those where it is ineffective for complete anaesthesia, an ENB is a useful adjunct. We recommend using an IOB (and ENB if required) prior to direct infiltration of local anaesthetic into the nasal ala to reduce patient discomfort.

Toxic epidermal necrolysis: current evidence, practical management and future directions.

Toxic epidermal necrolysis (TEN) is a rare disorder characterized by extensive epidermal death. Almost all cases appear to be caused by an idiosyncratic drug reaction. Proposed pathogenic mechanisms are conflicting, and the evidence for the benefits of individual treatments is inadequate, and in some cases contradictory. The mortality rate remains high. We review the literature pertaining to the pathogenesis of TEN and drug reactions in general. The rationale for therapeutic interventions, together with reported evidence of efficacy, are considered. We present a composite model of TEN, based on previous work and suggested pathogeneses of TEN, mechanisms of drug reactions and reported cytotoxic lymphocyte (CTL) cytolytic pathways. In this system, TEN, like some other cutaneous drug eruptions, is an HLA class I-restricted, specific drug sensitivity, resulting in clonal expansion of CD8+ CTLs. Cytotoxicity is mediated by CTL granzyme and possibly death receptor (DR) ligand (DR-L), probably Fas ligand (FasL). Particular to TEN, there is then an amplification sequence involving further DR-L expression. FasL is likely to be particularly important but tumour necrosis factor (TNF) may well contribute, via the TNF receptor 1 (TNF-R1) death pathway. Alternatively, we suggest the possibility of upregulation of an antiapoptotic TNF-R1-nuclear factor kappaB pathway, which would proscribe treatments which downregulate this pathway. None of the published data on individual treatment efficacies is sufficiently strong to suggest a definitive single treatment. Currently a multifaceted regimen appears indicated, targeting various likely intermediary mechanisms, including elimination of residual drug, immunosuppression, inhibition of DR pathways, general antiapoptotic strategies, and aggressive supportive care. Particular attention has been directed at avoiding potential conflicts between different treatments and avoiding agents that theoretically might have a net proapoptotic rather than antiapoptotic effect. Nursing on a specialized unit is of paramount importance.

A community study of lower urinary tract symptoms in older men in Sydney, Australia.

BACKGROUND: The aim of the present paper was to determine the prevalence, bother attributable to and self-reported management of uncomplicated lower urinary tract symptoms (LUTS) in men aged 40-80 years in Sydney, Australia. METHODS: A total of 340 randomly selected men aged 40-80 years (65% response rate) participated in a community-based study (computer-assisted telephone survey). RESULTS: Lower urinary tract symptoms are common: 54% of men needed to wake up at least once at night to urinate; 47% indicated they had terminal dribbling 'sometimes' or 'frequently'; 30% experienced urgency although few (4%) had urge incontinence; 21% experienced hesitancy; and 19% could retain urine in their bladder during the day for no more than 2 hours. Urinary symptoms correlated poorly with self-rated bother and there was no increase in age-specific prevalence of bothersome symptoms with increasing age. Only 37 (26%) men inconvenienced by urinary symptoms had seen a general practitioner (GP) about these symptoms in the last 5 years: of these, two-thirds had been referred to a urologist and half of these received surgical treatment. Independent predictors of attending a GP were increasing age (adjusted odds ratio (AOR) = 12.3; P = 0.0015); place of birth outside Australia (AOR = 3.8; P = 0.0036) and anxiety about prostate cancer (AOR = 2.6; P = 0.0318), but not the degree of worry due to urinary symptoms. CONCLUSION: Lower urinary tract symptoms are common in men, but their experiences of bother correlate weakly with symptoms and do not appear to influence referral and treatment. Public and professional campaigns might increase wider understanding of the benefits of surgery for bothersome symptoms, not symptoms per se.