Combined thoracic erector spinae plane and inter-transverse plane blocks for awake breast surgery.

Worldwide, breast cancer is the most commonly diagnosed cancer in women. Surgical procedures are typically performed using general anaesthesia, often complemented by regional anaesthesia to manage postoperative pain. However, avoidance of general anaesthesia for breast surgery may be desirable for clinical reasons or patient choice. It is theorised that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes, and there is some evidence to support this. While many patients successfully undergo awake breast surgery, a limited number of anaesthetists possess direct experience of this approach, despite familiarity with regional anaesthesia techniques. Undertaking regional anaesthesia for awake breast surgery requires patient cooperation and excellent staff teamwork. Here, we present a case of a patient who underwent awake bilateral mastectomy with reconstruction. This was carried out under two 'paravertebral-by-proxy' blocks: the thoracic erector spinae plane and inter-transverse plane blocks, with intravenous sedation.

Unilateral sacral erector spinae plane block for hip fracture surgery.

The provision of anaesthesia for hip fracture surgery in elderly and frail patients can be challenging, with potentially significant risks associated with both general and neuraxial techniques. Here, we report the use of a sacral erector spinae plane block as an alternative to conventional anaesthetic approaches for a frail 89-year-old woman with significant cardiovascular and respiratory comorbidity who underwent intramedullary nailing for a proximal femoral fracture. A unilateral injection of local anaesthetic at the intermediate crest of the second sacral vertebra resulted in bilateral sensory block of the T12 to S2 dermatomes. The technique did not result in hypotension or motor block of the limbs, and the surgery was completed uneventfully. Sacral erector spinae plane block warrants further investigation as an alternative to spinal and general anaesthesia for hip and lower limb surgery.

Eficacia analgésica del bloqueo del grupo de nervios pericapsulares (PENG) en comparación con el bloqueo de la fascia ilíaca (FIB) en pacientes mayores con fractura de fémur proximal en la unidad de urgencias. Ensayo controlado aleatorizado / Analgesic efficacy of Pericapsular Nerve Group (PENG) block compared with Fascia Iliaca Block (FIB) in the elderly patient with fracture of the proximal femur in the emergency room. A randomised controlled trial

Introducción y objetivos: Son escasos los datos relativos a la eficacia del bloqueo PENG (grupo de nervios pericapsulares) para el dolor por traumatismo de cadera. Formulamos la hipótesis de que el bloqueo PENG era más efectivo que el bloqueo FIB (fascia ilíaca) ecoguiado (infrainguinal) para controlar el dolor en los pacientes de 65 o más, con fractura de fémur proximal traumática en la unidad de urgencias hospitalarias (UUH). Materiales y métodos Realizamos un ensayo controlado aleatorizado exploratorio y doble ciego, siendo diferentes el anestesiólogo que realizó el bloqueo y el que evaluó los resultados. Se asignó aleatoriamente a los pacientes al grupo PENG con 20ml de ropivacaína al 0,375% o al grupo FIB (infrainguinal) con 40ml de ropivacaína al 0,2%. Se realizaron las pruebas de hipótesis estándar (prueba t o prueba χ2) para analizar las características basales y los parámetros del resultado. El objetivo primario del estudio fue el éxito analgésico de PENG evaluado como «puntuación NRS de dolor incidental≤4» 30min tras la colocación del bloqueo en comparación con FIB, también a los 30min del bloqueo. Los objetivos secundarios fueron el dolor en reposo («puntuación NRS de dolor en reposo≤4» 30min tras la colocación de los bloqueos), la duración de los bloqueos (tiempo transcurrido antes de la primera solicitud de analgesia del paciente), incidencia de administración de medicación de rescate en caso de fracaso del bloqueo, complicaciones relativas a la colocación del bloqueo. Resultados Tras la obtención de la aprobación del comité ético y el consentimiento informado escrito, se incluyó a 60 pacientes. Considerando el resultado primario, se logró el objetivo en el grupo PENG en 16 de entre 30 pacientes (53,3%), y en 15 de entre 28 casos en el grupo FIB (53,6%). La comparación entre ambos grupos no demostró la superioridad del bloqueo PENG frente a FIB (valor p=0,98). Conclusiones El bloqueo PENG no es superior ... . (AU)

Introduction and objectives: Data on the efficacy of PENG (Pericapsular Nerve Group) block in hip trauma pain are scarce. We hypothesized that PENG block was more effective than infra-inguinal ultrasound-guided FIB (Fascia Iliaca block) for pain control in patients aged 65 years or older presenting in the emergency room (ER) with traumatic proximal femoral fracture. Materials and methods We conducted an exploratory, double-blind, randomized controlled trial. One anaesthesiologist performed the block and another assessed outcomes. Patients were randomly allocated to the PENG group (20ml ropivacaine 0.375%) or the infrainguinal FIB group (40ml ropivacaine 0.2%). Standard hypothesis tests (t test or χ2 test) were performed to analyse baseline characteristics and outcome parameters. The primary end-point of the study was analgesic success, defined as «NRS pain score≤4» 30min after blockade, with PENG vs to FIB. Secondary outcomes were pain at rest («pain at rest NRS score≤4» 30min after blockade), duration of analgesia (time to first request for analgesia), need for rescue medication in case of block failure, and complications during blockade. Results After obtaining ethical committee approval and written informed consent, 60 patients were included.The primary endpoint was achieved in 16 out of 30 patients (53.3%) in the PENG group and in 15 out of 28 patients (53.6%) in the FIB group. Comparison between groups did not show superiority of the PENG vs FIB (p=0.98). Conclusions PENG block does not provide better pain than FIB in proximal femoral fracture in elderly patients treated in the ER. (AU)

Analgesic efficacy of Pericapsular Nerve Group (PENG) block compared with Fascia Iliaca Block (FIB) in the elderly patient with fracture of the proximal femur in the emergency room. A randomised controlled trial.

INTRODUCTION AND OBJECTIVES: Data on the efficacy of PENG (Pericapsular Nerve Group) block in hip trauma pain are scarce. We hypothesized that PENG block was more effective than infra-inguinal ultrasound-guided FIB (Fascia Iliaca block) for pain control in patients aged 65 years or older presenting in the emergency room (ER) with traumatic proximal femoral fracture. MATERIALS AND METHODS: We conducted an exploratory, double-blind, randomized controlled trial. One anaesthesiologist performed the block and another assessed outcomes. Patients were randomly allocated to the PENG group (20 ml ropivacaine 0.375%) or the infrainguinal FIB group (40 ml ropivacaine 0.2%). Standard hypothesis tests (t test or χ2 test) were performed to analyse baseline characteristics and outcome parameters. The primary end-point of the study was analgesic success, defined as "NRS pain score ≤ 4" 30 min after blockade, with PENG vs to FIB. Secondary outcomes were pain at rest ("pain at rest NRS score ≤ 4" 30 min after blockade), duration of analgesia (time to first request for analgesia), need for rescue medication in case of block failure, and complications during blockade. RESULTS: After obtaining ethical committee approval and written informed consent, 60 patients were included. The primary endpoint was achieved in 16 out of 30 patients (53.3%) in the PENG group and in 15 out of 28 patients (53.6%) in the FIB group. Comparison between groups did not show superiority of the PENG vs FIB (P-value .98). CONCLUSIONS: PENG block does not provide better pain than FIB in proximal femoral fracture in elderly patients treated in the ER.

An exhaustive phylogeny of the combtooth blenny genus Salaria (Pisces, Blenniidae) shows introgressive hybridization and lack of reciprocal mtDNA monophyly between the marine species Salaria basilisca and Salaria pavo.

A comprehensive phylogeny of the genus Salaria based on mitochondrial and nuclear markers grouped the extant species of the genus in well-characterised marine and freshwater clades, thus rejecting the hypothesis of a polytypic origin of the freshwater Salaria populations and supporting the occurrence of a single invasion event of the inland waters by the genus. Based on both mitochondrial and nuclear DNA datasets, the Salaria species of the freshwater clade proved to be vicariant taxa originating from a common ancestor which could possibly spread throughout the circum-Mediterranean inland waters during the late Miocene Messinian salinity crisis, then experiencing a process of allopatric differentiation after the re-flooding of the Mediterranean basin. Within the marine clade, although the nuDNA datasets showed the existence of well-supported subclades in accordance to the morphological identification of the studied specimens, one of the two subclades obtained in the phylogenetic tree based on the mtDNA dataset included both S. basilisca and S. pavo specimens, thus failing to find the two species as reciprocally monophyletic. Such a mito-nuclear discordance is here ascribed to multiple mtDNA unidirectional introgression events from S. basilisca to S. pavo, and the molecular diversity pattern of the marine Salaria species is here ascribed to a Pleistocene speciation event nowadays partly concealed by the occurrence of introgressive hybridization phenomena between the two taxa. Our results urge for prudence when implementing DNA barcoding approaches since, in the presence of mito-nuclear discordance phenomena, single-marker mtDNA-only analyses might lead to significant misidentifications.

Hepatitis B immunity in teenagers vaccinated as infants: an Italian 17-year follow-up study.

We assessed the persistence of hepatitis B surface antigen antibody (anti-HBs) and immune memory in a cohort of 571 teenagers vaccinated against hepatitis B as infants, 17 years earlier. Vaccinees were followed-up in 2003 and in 2010 (i.e. 10 years and 17 years after primary vaccination, respectively). When tested in 2003, 199 vaccinees (group A) had anti-HBs <10 mIU/mL and were boosted, 372 (group B) were not boosted because they had anti-HBs ≥10 mIU/mL (n = 344) or refused booster (n = 28) despite anti-HBs <10 mIU/mL. In 2010, 72.9% (416/571) of participants had anti-HBs ≥10 mIU/mL (67.3% in group A vs. 75.8% in group B; p 0.03). The geometric mean concentrations (GMCs) were similar in both groups. Between 2003 and 2010, anti-HBs concentrations in previously boosted individuals markedly declined with GMC dropping from 486 to 27.7 mIU/mL (p <0.001). Fifteen vaccinees showed a marked increase of antibody, possibly due to natural booster. In 2010, 96 individuals (37 of group A and 59 of group B) with anti-HBs <10 mIU/mL were boosted; all vaccinees of the former group and all but two of the latter had an anamnestic response. Post-booster GMC was higher in group B (895.6 vs. 492.2 mIU/mL; p 0.039). This finding shows that the immune memory for HBsAg persists beyond the time at which anti-HBs disappears, conferring long-term protection.

In vitro evaluation of the antimicrobial activity of meropenem in combination with polymyxin B and gatifloxacin against Pseudomonas aeruginosa and Acinetobacter baumannii.

The antimicrobial activity of meropenem combined with either polymyxin B or gatifloxacin was evaluated by the checkerboard method against Pseudomonas aeruginosa (10 strains) and Acinetobacter baumannii (10 strains). In addition, the triple combination of polymyxin B, gatifloxacin, and meropenem was also studied as well as the polymyxin B and gatifloxacin combination. A partial synergism interaction between meropenem and polymyxin B was observed for 80% of the A. baumannii strains. In contrast, this combination showed an indifferent effect for 80% of the P. aeruginosa strains tested. The combination of meropenem and gatifloxacin showed synergism only for two strains of A. baumannii, and partial synergism and additive effect for seven strains and indifference for four strains of both species. For the strains of P. aeruginosa, the double combination of polymyxin B and gatifloxacin and the triple combination of meropenem, polymyxin B and gatifloxacin were indifferent for the majority of the strains tested, that is, 90 and 80% respectively.