Inflammatory Choroidal Neovascular Membranes in Patients With Noninfectious Uveitis: The Place of Intravitreal Anti-VEGF Therapy.

Inflammatory choroidal neovascularization (iCNV) is an infrequent but an important cause of visual morbidity in patients with non-infectious uveitis and mostly occurs in intermediate or posterior uveitis. Punctate inner choroiditis, Vogt-Koyanagi-Harada disease and multifocal choroiditis are among the leading causes of uveitis entities resulting in iCNVs. The diagnosis and management of iCNVs still remain a challenge. Use of multimodal imaging techniques such as fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT) and OCT-angiography may be necessary for the diagnosis of iCNVs. The treatment algorithm is not straightforward for iCNV. While control of the active inflammation with steroids and/or immunosuppressive agents is a key to success, various adjunctive treatment modalities such as thermal laser photocoagulation, photodynamic therapy and surgical membrane removal were also co-administered previously. Nowadays, vascular endothelial growth factor (VEGF) inhibitors have become the most commonly administered adjunctive treatment option as they provide better anatomical and functional outcome and the recurrence rate of CNV is relatively low. We hereby reviewed important clinical studies and case series on anti-VEGF administration in iCNVs and briefly overviewed their results.

Vitreoretinal Interface Characteristics in Eyes with Idiopathic Macular Holes: Qualitative and Quantitative Analysis.

OBJECTIVES: To determine the qualitative and quantitative vitreoretinal interface characteristics with spectral domain optical coherence tomography (SD-OCT) in eyes with macular hole (MH) and investigate their relation with best corrected visual acuity (BCVA) and MH duration. MATERIALS AND METHODS: Sixty-one eyes of 46 consecutive patients diagnosed with idiopathic MH were included in the study. The mean age of the patients was 66.7±7.5 (51-79) years. Complete ophthalmologic examination and SD-OCT examination were performed in all eyes and MH stages were determined according to SD-OCT findings. Qualitative characteristics of the vitreoretinal interface were investigated, including vitreomacular traction, vitreopapillary traction, maculopapillary traction, vitreoschisis, intraretinal cyst, presence of epiretinal membrane, and the integrity of the photoreceptor inner segment-outer segment junction (IS/OS) and external limiting membrane (ELM). In addition, MH diameter, MH base diameter (MHBD), ELM defect diameter, IS/OS defect diameter, and MH height were quantitatively measured and the MH index was calculated. RESULTS: Out of 61 eyes, 9.8% were classified as stage 1a, 19.7% as stage 1b, 18% as stage 2, 23% as stage 3, and 29.5% as stage 4. Mean BCVA was 0.28±0.24 (1 mps-1.0) Snellen and MH duration was 10.08±18.6 (1-108) months. The most common interface characteristics associated with MH were determined as intraretinal cyst (91.8%), IS/OS defect (78.7%) and ELM defect (63.9%). Duration and stage of MH were inversely proportional to BCVA but directly proportional to the presence and diameter of IS/OS and ELM defects. BCVA was significantly lower in eyes with IS/OS and ELM defects (p<0.0001; p<0.0001 Mann-Whitney U test). CONCLUSION: We determined that the most important factors affecting BCVA in cases with idiopathic MH were MH stage, MH duration, MHBD, and the presence and diameter of IS/OS and ELM defects, which suggests that these parameters should be considered while making decisions about prognosis and treatment.

Intraarticular levobupivacaine or bupivacaine administration decreases pain scores and provides a better recovery after total knee arthroplasty.

PURPOSE: The aim of this prospective randomized blinded controlled study was to compare the efficacy of the two local anesthetics, intraarticular bupivacaine and levobupivacaine administration, versus control for postoperative pain control and functional recovery. Length of hospital stay, opioid consumption, and the side effects of opioids were also evaluated. METHODS: Sixty patients of American Society of Anesthesiologists class I-III undergoing elective knee arthroplasty under spinal anesthesia were randomized into three groups. Groups B (n = 20) and L (n = 20) both received 150 ml solution intraarticularly, containing 200 mg bupivacaine or 200 mg levobupivacaine combined with 0.5 mg epinephrine, respectively, at the end of the surgery. Group C (n = 20) received 150 ml saline intraarticularly. Postoperatively, all groups received injections through the intraarticular catheters in quantities of 120 mg (levobupivacaine for group L, bupivacaine for group B) and 0.5 mg epinephrine whereas group C received a saline bolus at 10 and 22 h. Patients were given tramadol by intravenous patient-controlled analgesia (PCA), and sodium diclofenac 75 mg intramuscularly was used for rescue analgesic medication. Visual analogue score (VAS) for pain at rest and during mobilization (which was defined as flexion exercise supported by physiotherapist in postoperative first 8 h and afterward a 3-m walk with walker), consumption of tramadol, side effects, and patient satisfaction were recorded until the 48th hour postoperatively. RESULTS: Area under the curve values for VAS were lower in groups B and L compared to the control, both at rest and during mobilization (first 48 h) (P = 0.032 and P = 0.029, respectively). Tramadol consumption was lower (P < 0.05), patient satisfaction as evaluated with a five-point Likert score (completely comfortable; quite comfortable; slight discomfort; painful; very painful) was higher (P = 0.03), and length of hospital stay was shorter (P = 0.03) in groups B and L compared to group C. CONCLUSION: Intraarticular bupivacaine and levobupivacaine provided better postoperative analgesia both at rest and during mobilization in total knee replacement surgery compared to control. Tramadol consumption and hospital stay were also decreased in the study groups.

Premedication with oral midazolam with or without parental presence.

BACKGROUND AND OBJECTIVE: In this study, we aimed to investigate whether the combination of low-dose (0.25 mg kg(-1)) midazolam premedication with parental presence can effectively reduce anxiety at induction as well as provide a smoother emergence. METHODS: Institutional ethics committee approval and informed consent from one of the parents were obtained prior to the study. Sixty ASA grade I or II children undergoing surgery were enrolled in the study. Children were randomized to receive either 0.5 mg kg(-1) midazolam orally (group M) or 0.25 mg kg(-1) midazolam orally with parental presence (group MP) or parental presence alone (group P). The child's anxiety and sedation scores were evaluated as 1-4 points on the Anxiety Scale and as 0-4 points on the University of Michigan Sedation Scale (UMSS), respectively, at the entrance to the operating room and for tolerance to the face mask. Heart rate, the mean arterial blood pressure and O2 saturation (%) were assessed at repeated intervals before and after induction. At the end of surgery, the child's Anxiety Scale score, UMSS score, Observer's Pain Scale (OPS) score and FLACC score were also assessed. RESULTS: There were no differences between groups in demographic variables and duration of surgery or anaesthesia. Mean blood pressure changes were similar between groups at measured intervals, but the heart rate was higher in group M before and after induction of anaesthesia (P<0.05). UMSS score was greater in both midazolam groups (groups M and MP) in the preoperative period (P<0.05). Anxiety Scale scores for anxiolysis were higher in groups M and MP than in group P (less anxious and more sedated) at 20 min after premedication, at the entrance to the operating room and at mask tolerance time points (P<0.05). During recovery there was no significant difference in sedation, recovery scores or behavioural anxiety assessment between groups, Anxiety Scale score, UMSS score, FLACC score, Visual Analog Scale (VAS) score and Observer's Pain Scale score in groups MP, M and P. CONCLUSION: Preoperative administration of midazolam 0.5 mg kg(-1) for premedication alone, without parental presence at induction, and that of low-dose midazolam 0.25 mg kg(-1) for premedication with parental presence at induction are both equally effective in reducing separation anxiety and providing a smooth emergence. However, parental presence alone, without midazolam for premedication, is not an adequate approach for this outcome. If the environment for parental presence is convenient, the dose of midazolam may be reduced and induction and emergence conditions may still be of high quality.

The impact of two arterial catheters, different in diameter and length, on postcannulation radial artery diameter, blood flow, and occlusion in atherosclerotic patients.

PURPOSE: Arterial cannulation is a common intervention in anesthesia practice. However, the success rates and complications of radial arterial cannulation with 20-G or smaller catheters in patients with atherosclerosis have been underevaluated. The aim of this prospective randomized study was to compare the efficacy of and complications with 20- and 22-G catheters for radial arterial cannulation in atherosclerotic patients. METHODS: Thirty patients with atherosclerosis, American Society of Anesthesiologists (ASA) III-IV, undergoing general anesthesia were enrolled in the study. Radial artery cannulation was performed in group 20G (n = 15) with a 20-gauge (20 x 1.1 x 33 mm; flow, 61 ml.min(-1)) catheter and in group 22G (n = 15) with a 22-gauge (22 x 0.9 x 25 mm; flow, 36 ml.min(-1)) catheter. Radial artery systolic blood flow (SBF) and radial artery diameter (RAD) were assessed by a Doppler ultrasound probe before cannulation and 24 h after decannulation for vascular complications. The number of puncture attempts, arterial blood gas samples, and manual flushes; total heparinized solution consumption; duration of cannulation; decannulated radial arterial systolic blood flow; postcannulation RAD; and vascular complications such as occlusion, hematoma, pseudoaneurysm, bleeding, and thrombosis were noted. The Mann Whitney U-test, chi(2) test, and one-sample t-test were used. Values are expressed as medians and quartiles and P < 0.05 was considered as significant. RESULTS: The number of puncture attempts was greater in group 20G (range, 1 to 4) than in group 22G (range, 1 to 2; P = 0.02). In group 20G patients, postoperative RAD was larger than preoperative RAD (P = 0.02) and postoperative SBF was lower than preoperative SBF (P = 0.03). In group 22G patients postoperative SBF was higher than preoperative SBF (P = 0.03), while there was no significant difference between preoperative and postoperative RAD. The occlusion rate of atherosclerotic radial arteries was 6% with the 22-gauge catheter and 26% with the 20-gauge catheter (P = 0.02). CONCLUSION: A 22-gauge catheter for radial arterial cannulation in patients with atherosclerosis provides unchanged postcannulated radial artery diameter, decreases postcannulation complications, and improves the first-attempt success rate.

Evaluation of the longus colli muscle in relation to stellate ganglion block.

BACKGROUND AND OBJECTIVES: The longus colli (LC) muscle is an important structure of the anterior cervical spine and has a critical role in stellate ganglion block. This technique involves withdrawing the needle to locate its port for injection above the anterior surface of the LC muscle; however, its exact thickness at the C5, C6, and C7 levels has not been measured. The aim of this anatomic and magnetic resonance-supported study was to evaluate the thickness of the LC muscle at these levels from the anterior tubercle of each vertebra toward the vertebral body at 5-, 10-, and 15-mm distances to provide precise anatomic data for stellate ganglion block. METHODS: Ten cadavers, 60 vertebral body specimens, and cervical magnetic resonance imaging (MRI) scans of 40 adult patients were used for measurements. RESULTS: The main findings of this study are that the thickness of the LC muscle varies between 5.0 and 10.0 mm at C6 and C7 in cadavers and between 8.0 and 10.0 mm in MRI scans. Sex has an important role; MRI scans revealed that male patients have a considerably thicker LC muscle at each vertebral level. CONCLUSION: We found a highly variable thickness of the LC muscle in anatomic and imaging studies, which may lead to negative block results.

Ultrasound-guided obturator nerve block: a sonoanatomic study of a new methodologic approach.

BACKGROUND: Obturator nerve block is one of the most technically challenging regional anesthesia techniques. Recently, the characteristics of the nerve have been described using ultrasound. However, clinical application of proximal ultrasound-guided obturator nerve block on patients has not been reported. In this study, we used ultrasound to describe the anatomical localization of the obturator nerve and its two branches in cadavers, volunteers, and also patients. METHODS: A hyperechoic triangular shape formed by the superior pubic ramus, posterior margin of the pectineus muscle and anterior aspect of the external obturator muscle containing the obturator vessels and nerve was defined by ultrasound imaging in cadavers. In eight volunteers, bilateral obturator nerve images were obtained and the distances to specific landmarks (femoral artery, femoral vein, and pubic tubercle) were recorded. Ultrasound-guided obturator nerve block was further performed in 15 patients by using the previously defined approach. The final distance of the needle tip to the femoral artery, distances between the needle insertion point to the pubic tubercle and the depth of needle insertion were recorded. RESULTS: The rates of common obturator nerve, anterior and branching obturator nerve pattern visibility with ultrasound were determined in 12/16, 13/16, and 7/16 sites in volunteers, respectively. Mean (SD) values of critical landmarks obtained from volunteers were obturator nerve-femoral vein 12.9 +/- 2.9 mm and obturator nerve-pubic tubercle 19.9 +/- 2.6 mm. Mean measurements obtained from patients were: femoral artery- needle tip 18.5 +/- 2.4 mm, needle depth 48.3 +/- 10.4 mm, pubic tubercle- needle insertion point (horizontal) 18.8 +/- 2.0 mm, and pubic tubercle- needle insertion point (vertical) 21.1 +/- 2.9 mm. Visual analog scale scores obtained from patients at 1 and 24 h were lower compared to baseline values (P < 0.001). Ninety-three percent (14 of 15) of the patients reported satisfaction from the block. CONCLUSIONS: Landmarks defined in this clinical trial can be used in patients for obturator nerve block with ultrasound guidance.

Botulinum toxin for the treatment of headaches: a review of current practices and evidence based-data.

Botulinum toxin type A has been used clinically for the prophylaxis and treatment of various types of primary headache disorders for over 15 years. Several studies have been performed to demonstrate its mechanism of its effect. There is adequate data to support the idea that; beside its well-known effect on acetylcholine release, an additional antinociceptive effect related to a possible block in one or more pain transmitters exists. Earlier open-labeled studies investigating the clinical outcome of botulinum toxin in primary headache disorders have come out with positive results on the topic however recent evidence based evaluation of data do not seem to support the widespread clinical use of this agent. In this manuscript use of botulinum toxin is reviewed with special emphasize on its mechanism of effect, injection techniques and recent evidence-based data.

Is there an ideal approach for rapid-sequence induction in hypertensive patients?

STUDY OBJECTIVE: To compare 4 different anesthesia induction protocols, in a simulated model of rapid-sequence induction, in controlled hypertensive patients. DESIGN: Prospective, randomized, double-blind, clinical investigation. SETTING: Large metropolitan university hospital. PATIENTS: 120 ASA II-III adult hypertensive patients. INTERVENTIONS: Patients were allocated to 4 groups at random. After preoxygenation for 3 minutes, induction and tracheal intubation was performed in a 30 degrees head-up position. Thiopental (5-7 mg/kg) was the induction agent. Study groups were as follows: group LS (n = 30), lidocaine (1.5 mg/kg) and succinylcholine (1 mg/kg); group LR (n = 30), lidocaine (1.5 mg/kg) and rocuronium (1 mg/kg); group RS (n = 30), remifentanil (1 microg/kg) and succinylcholine (1 mg/kg); group RR (n = 30), remifentanil (1 microg/kg) and rocuronium (1 mg/kg). Patients were intubated 60 seconds after administration of muscle relaxant. MEASUREMENTS: Hemodynamic data were obtained before induction (baseline), after induction, at intubation, and at 1, 3, 5, and 10 minutes after intubation. More than 20% change in blood pressure and heart rate was considered significant. MAIN RESULTS: Systolic and mean arterial blood pressures at intubation and 1 and 3 minutes after intubation were higher in group LS compared with groups RS and RR (P < 0.01). Mean arterial blood pressure decreased after induction in groups LS, LR, and RR, but increased at intubation and 1 minute after intubation in groups LS and LR (P < 0.01). Mean arterial blood pressure was similar at all measurement intervals in group RS. The median area under the systolic, mean, and diastolic blood pressure time curves was higher in groups LS and LR compared with groups RS and RR (P < 0.05 and P < 0.01). CONCLUSIONS: Remifentanil is a better adjunct for attenuation of the response to laryngoscopy and intubation compared with lidocaine, whereas remifentanil-succinylcholine combination appears to be more beneficial in terms of hemodynamic stability in hypertensive patients.

Comparison of low-dose intrathecal and epidural morphine and bupivacaine infiltration for postoperative pain control after surgery for lumbar disc disease.

This prospective, blinded, placebo-controlled study was performed to compare the postoperative analgesic efficacy of low-dose intrathecal and epidural morphine with paraspinal muscle infiltration of bupivacaine in lumbar discectomy cases. Eighty ASA I-III adult patients undergoing elective surgery for lumbar disc disease were enrolled in the study. Patients were randomized to four groups by envelopes. Study groups were as follows: group 1 (n = 20), intrathecal morphine 0.1 mg; group 2 (n = 20), epidural morphine 2 mg; group 3 (n = 20), 30 mL of bupivacaine 0.25% paraspinal muscle infiltration; group 4 (n = 20), 30 mL of saline paraspinal muscle infiltration before wound closure. Recorded parameters were time to response to painful and verbal stimuli and postoperative pain assessed at 30 minutes and 2, 4, 6, 8, 12, and 24 hours by Visual Analog Scale (VAS) and Numeric Pain Scale (NPS). Hemodynamic data, sedation scores, and side effects were also recorded. Meperidine and naproxen sodium were used for postoperative analgesia. Follow-up was performed by a blinded investigator. Mean VAS scores were lower in groups 1 and 2 at 30 minutes (P < 0.05). Mean VAS score of group 2 was lower than that of group 4 at 4 hours postoperatively (P < 0.05). Mean NPS scores were lower in groups 1 and 2 at 2, 4, and 6 hours (P < 0.05) and in group 2 at 8 hours compared with the other groups. The number of patients requiring meperidine at early postoperative phase (0-6 hours) was less in groups 1 and 2 compared with groups 3 and 4 (P < 0.05). There were no statistically significant differences in the late postoperative analgesic requirements, after correction for multiple testing. In conclusion, low-dose intrathecal and epidural morphine provide lower postoperative pain scores and a reduction in early postoperative analgesic requirement with insignificant side effects compared with paraspinal bupivacaine or saline infiltration.

Cervicogenic headache: pathophysiology, diagnostic criteria and treatment.

Cervicogenic headache is a relatively common and still controversial form of headache arising from structures in the neck. Cervicogenic headache is a unilateral fixed headache characterised by pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines and nitric oxide. A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group or the International Headache Society's most recent International Classification of Headache Disorders (2004). Various therapies have been used in the management of cervicogenic headache. These range from lowly invasive, drug-based therapies to highly invasive, surgical-based therapies. Unfortunately, the paucity of experimental models for cervicogenic headache and the relative lack of biomolecular markers for the condition mean much is still unclear about cervicogenic headache and the disorder remains inadequately treated.

Should we reevaluate the variables for predicting the difficult airway in anesthesiology?

UNLABELLED: Anesthesiologists have often been confronted with the difficult question of determining which patient will present an increased difficulty for endotracheal intubation. The limits of the previously reported morphometric airway measurements for predicting difficult intubation have inadequately addressed the normal patient population variables. We designed this prospective study to investigate the age and sex-related changes in the morphometric measurements of the airway in a large group of patients without anatomic abnormality and a group of cadavers. Hyomental, thyromental, sternomental distances, neck extension, and Mallampati scores were evaluated in 12 cadavers and in 334 patients. Patients were allocated to three groups based on age: Group 1 (20-30 yr), Group 2 (31-49 yr), and Group 3 (50-70 yr). Male and female sex differences were also evaluated. Hyomental distance was the only variable not affected by age. In addition, the mean population values were less than the threshold values suggested as criteria for difficult endotracheal intubation. All the other criteria were age-dependent and inversely affected by the increase in age. Male sex was also a distinction for increased measurements of all the morphometric distances. The mean degree of neck extension was similar in both sex groups. This study provides a more comprehensible approach to the morphometric measurements of the human airway. Adequate data of normal values may help the clinician to identify patients that are outside the range and therefore may be challenging. IMPLICATIONS: This study was performed to establish data on the average values of airway morphology in the adult population of different age groups and sex. Hyomental, thyromental, sternomental distances and neck extension values were measured on 12 cadavers and 334 patients.