Peribulbar anesthesia: one versus two injections

BACKGROUND AND OBJECTIVE: The authors describe their prospective, randomized study of a single peribulbar injection into the junction of the lateral third and medial two thirds of the lower lid compared with the standard two-injection peribulbar technique. PATIENTS AND METHODS: One hundred twenty patients undergoing elective intraocular surgery were randomly allocated to receive either one or two injections of a mixture of balanced salt solution, 2% lidocaine, 0.5% bupivacaine, and hyaluronidase. Preoperative akinesia was assessed following the injections. At the end of surgery, the patients were asked if they had experienced any pain or discomfort during surgery. RESULTS: There was no significant difference in pain or globe akinesia between the two groups. CONCLUSION: The single peribulbar injection was found to be as effective as the standard two-injection peribulbar technique.     

MR of the eye with retrobulbar anesthesia

MR imaging with retrobulbar anesthesia was performed in eight patients with uveal melanoma. Injection of 2 mL prilocain hydrochloride in 2% epinephrin into the eye muscle cone resulted in improved image quality in seven patients, without side effects. Ocular MR imaging can be indicated to clarify indeterminate sonographic findings in cases of extrascleral growth or to exclude optic nerve invasion in patients with tumors located at the posterior pole of the globe.     

Comparison of iontophoresis of lidocaine with a eutectic mixture of lidocaine and prilocaine (EMLA) for topically administered local anesthesia

BACKGROUND: Almost all dermatologic surgery is accomplished using local anesthesia. To make our patients more comfortable, there is a constant search for less painful methods of administering anesthetic agents. Topical EMLA as well as iontophoresis are both useful in this regard. OBJECTIVE: In this study we compared topical EMLA with lidocaine delivered by iontophoresis in a double-blind placebo-controlled trial. Our goal was to assess the degree of anesthesia obtained as well as the relative rapidity of onset. METHODS: A double-blind controlled study was performed on 10 healthy volunteers between 26 and 37 years of age. Three test sites were placed on each forearm. EMLA or a moisturizer control was placed on two of the three test sites on each arm. Each site was wiped free of cream and tested for sensitivity to pinprick 30 and 60 minutes after cream placement. One iontophoretic unit was placed on each forearm. Both units were saturated with anesthesia with the control unit being turned off. Sensitivity to pinprick was evaluated at the iontophoretic sites and one of the EMLA sites 30 minutes after site placement on the subject. The additional EMLA-treated site was tested in the same manner 60 minutes after placement. RESULTS: Both EMLA cream and the iontophoretic unit delivered topical anesthesia greater than the control. Significantly more anesthesia was acquired 1 hour after application of EMLA than was seen 30 minutes earlier. The iontophoretic patch-treated area provided greater anesthesia than the EMLA-treated sites evaluated 30 and 60 minutes after placement. Both modalities provided significant anesthesia when left in place for 60 minutes. CONCLUSION: Both iontophoresis of lidocaine and topical EMLA delivered significant, and sometimes complete, local anesthesia. A greater degree of anesthesia is delivered via iontophoresis after 30 minutes as compared with EMLA left on the skin for 30 or 60 minutes. Both modalities have important and unique advantages and disadvantages. Topical EMLA and iontophoretically delivered lidocaine are both valuable tools for the dermatologic surgeon.     

Postcataract ptosis. A randomized, double-masked comparison of peribulbar and retrobulbar anesthesia

PURPOSE: A randomized, double-masked study of 317 patients was conducted to determine if the incidence of postcataract ptosis is greater with retrobulbar or two-injection peribulbar injection anesthesia. METHODS: Surgery consisted of a planned extracapsular extraction with posterior chamber lens implantation, and no superior rectus bridle suture was used. Ptosis was quantitatively documented preoperatively and postoperatively at 1, 2, 5, and 90 days by the surgeon, photographically at 90 days by a masked observer, and subjectively by the patients. Postcataract ptosis was defined as a drop in the lid margin of 2 mm or greater after correcting for any change in the fellow eye. RESULTS: The incidence of ptosis at 90 days in patients given peribulbar anesthesia was 5.8% and in patients given retrobulbar anesthesia 5.5%, and this difference was not statistically significant (P = 0.90). Eighteen percent of patients in both groups reported a change in the appearance of their eyelids. There was a moderate, positive correlation among patients who reported a change in their lid position and objective measurements of ptosis. Preoperative clinical measurements of vertical lid fissure width and levator function, and the appearance of the lid crease or superior sulcus were not predictive for the development of postoperative ptosis at 90 days; the best predictor was the presence of ptosis in the immediate postoperative period. CONCLUSION: The incidence of postcataract ptosis is the same whether two injection peribulbar or retrobulbar anesthesia is used.     

Prospective evaluation of topical versus retrobulbar anesthesia: a converting surgeon''s experience

Kinetic experiments are of great importance in lipid research because they further the understanding of lipid metabolism in vivo and help to explain the physiopathology of lipid disorders in humans. At present, due to species specificity, no valid animal model can efficiently replace a study in humans to explore lipid metabolism, and the use of radioactive tracers is restricted in humans. Thus, stable-isotope tracer kinetic studies have become an important component of research programs to achieve in humans a quantitative understanding of the dynamics of metabolic processes in vivo. The aim of this review is to describe the practical aspects of compartmental model development in stable-isotope experiments. The recent development of computer hardware and modeling software has dramatically facilitated the task of the modeler in his or her calculations. In the current review, we show that the model may be considered an integral component of the experimental design and that model development must obey strict rules to provide a rigorous solution. The main difficulties of model development in tracer experiments, such as experiment design, model identifiability, data expression, comparison of models, or tracer recycling, are presented with extensive references. We have paid particular attention to kinetic modeling in stable-isotope experiments because they have shown the greatest development in recent years.     

Response of intraocular pressure to retrobulbar and peribulbar anesthesia

BACKGROUND AND OBJECTIVE: To evaluate the response of intraocular pressure (IOP) to retrobulbar and peribulbar anesthesia. PATIENTS AND METHODS: Patients were prospectively masked and randomized to receive either 4 cc of retrobulbar anesthesia (X = 29) or 6 cc of peribulbar anesthesia (X = 30), each consisting of a 50:50 mixture of 2% xylocaine and 0.75% bupivacaine with 150 units of hyaluronidase. IOPs were measured pre-anesthesia and 1, 2, and 5 minutes post-anesthesia in nonglaucoma patients undergoing cataract extraction and intraocular lens implantation. RESULTS: Mean IOPs in the retrobulbar group as determined with a tonometer were 18.24, 18.66, 19.14, and 17.86 mm Hg pre-anesthesia and 1, 2, and 5 minutes post-anesthesia, respectively. In the peribulbar group, the mean IOPs were 18.53, 21.20, 20.40, and 19.20 mm Hg, respectively. The 1-minute pressures in the two groups were statistically different (P = .023). Within the peribulbar group, the 1- and 2-minute pressures were statistically different from the pre-anesthesia IOP (P = .001 and P = .018, respectively). CONCLUSION: Peribulbar anesthesia, with its higher volume of anesthetic (6 vs 4 cc), results in a higher initial IOP. This difference was slight and short lived, and occurred in the absence of any external ocular compression. This study may have application in avoiding elevation of IOP in select patients undergoing a local procedure.     

Recovery from sevoflurane anesthesia: a comparison to isoflurane and propofol anesthesia

BACKGROUND: Sevoflurane has a lower blood:gas partition coefficient than isoflurane, which may cause a more rapid recovery from anesthesia; it also might cause faster emergence times than for propofol-based anesthesia. We evaluated a database that included recovery endpoints from controlled, randomized, prospective studies sponsored by Abbott Laboratories that compared sevoflurane to isoflurane or propofol when extubation was planned immediately after completion of elective surgery in adult patients. METHODS: Sevoflurane was compared to isoflurane in eight studies (N=2,008) and to propofol in three studies (N=436). Analysis of variance was applied using least squares method mean values to calculate the pooled mean difference in recovery endpoints between primary anesthetics. The effects of patient age and case duration also were determined. RESULTS: Sevoflurane resulted in statistically significant shorter times to emergence (-3.3 min), response to command (-3.1 min), orientation (-4.0 min) and first analgesic (-8.9 min) but not time to eligibility for discharge (-1.7 min) compared to isoflurane (mean difference). Times to recovery endpoints increased with increasing case duration with isoflurane but not with sevoflurane (patients receiving isoflurane took 4-5 min more to emerge and respond to commands and 8.6 min more to achieve orientation during cases longer than 3 hr in duration than those receiving sevoflurane). Patients older than 65 yr had longer times to orientation, but within any age group, orientation was always faster after sevoflurane. There were no differences in recovery times between sevoflurane and propofol. CONCLUSIONS: Recovery from sevoflurane was 3-4 min faster than with isoflurane in all age groups, and the difference was magnified in longer-duration surgical cases (> 3 hr).     

Dynamic cerebral autoregulation during sevoflurane anesthesia: a comparison with isoflurane

OBJECTIVE: To study the incidence and pattern of epilepsy in patients with periventricular leukomalacia (PVLM) in two specialty clinic settings. BACKGROUND: Motor and cognitive deficit as well as epilepsy are common in patients with PVLM. With modern imaging techniques, PVLM is now easily recognized. METHODS: Epileptic seizures and syndromes as well as motor and cognitive deficits were correlated with MRI findings. Two patient populations were studied: Group A-children with cerebral palsy and PVLM presenting to a center for children with motor disability (n = 19); and Group B-epileptic patients with PVLM presenting to a tertiary epilepsy center (n = 12). A single patient with PVLM and epilepsy who underwent extensive investigations, including intracranial EEG telemetry, is reported. RESULTS: In Group A, 47% of patients had epilepsy (9/19). PVLM was found in 1.27% of patients investigated for epilepsy at a tertiary epilepsy center (12/942). The majority of patients in both groups had multiple seizure types, with complex partial seizures being most common. Of patients with seizures (Groups A and B), 85.7% had intractable epilepsy (18/21). Intracranial EEG in the illustrative case demonstrated a multifocal epileptic process with occipitotemporal predominance. CONCLUSIONS: PVLM was an uncommon underlying cause in patients presenting with epilepsy (Group A); however, patients presenting with motor disability and PVLM (Group B) had a high incidence of seizures. PVLM in epileptic patients is associated with multiple seizure types and medically refractory disease.     

Peribulbar anesthesia. A prospective statistical analysis of the efficacy and predictability of bupivacaine and a lignocaine/bupivacaine mixture

Involvement of endogenous nitric oxide (NO) on glutamate receptor-mediated response was investigated in neuronal cells cultured from embryonic rat hippocampus. L-NG-Nitroarginine (NOARG), a NO synthase inhibitor, augmented NMDA- and kainate-induced increase in intracellular Ca2+ concentration ([Ca2+]i) measured by fura-2 fluorometry. However, quisqualate-induced response was not affected. The potentiating effect of NOARG was blocked by L-arginine, a substrate for NO synthase. NOARG was also effective when added after glutamate-induced response had reached a steady-state. Hemoglobin itself increased the basal level of [Ca2+]i at concentrations higher than 10 mM, and treatment of the cells with 1.0 mM hemoglobin had no effect on NMDA response. 8-Bromo-cyclic GMP was not effective on NMDA response. These results suggest that endogenous NO inhibits NMDA- and kainate-induced increase in [Ca2+]i as a negative feedback system independent of guanylate cyclase activation.     

Rapid assay of plasma acetate by gas chromatography: evaluation and comparison with two other methods

Human plasma acetate is derived from colonic fermentation of fiber and endogenous metabolism of dextrose and fatty acids. Acetate may have regulatory functions in hepatic carbohydrate metabolism. Intake of dietary fiber is associated with several beneficial effects on carbohydrates and lipids metabolisms. To study theses effects a valid and automated method for routine analysis of acetate in plasma is necessary. After oral administration of lactulose to healthy human volunteers, the concentration of plasma acetate was measured by head space gas chromatography (HS-GC), vacuum distillation gas chromatography (VD-GC) and enzymatic spectrometric method (ES). The method HS-GC was linear to 0.5 mmol.l-1 (n = 5, r = 0.998), the detection limit is 0.005 mmol.l-1. Within-day variation (CV) was 3.60% and day-to-day variation was 4.5% (0.1 mmol.l-1). The coefficients of correlation between CG-ET/CG-DsV and CG-ET/E-M are 0.903 (p = 0.0001) and 0.54 (p = 0.006) respectively, the mean square errors are respectively 0.118 and 0.138 mmol.l-1. The variation curves of plasma acetate measured by GC versus time show peak concentration of 0.323 to 0.380 mmol.l-1 at 120 min.     

Cutaneous loop versus Roux-en-Y ureterostomy: a comparison of two methods for diversion of urine

Loop and Roux-en-Y ureterostomies are compared. Both methods have a place if diversion is necessary in cases of severe hydronephrosis and decompensated ureters. Although the loop ureterostomy has advantages, it can lead to problems, i.e., the nonfunctioning and the contracted bladder. This serious complication is not seen after Roux-en-Y ureterostomy, because the bladder continues to function. The localization of the new pyeloureteral junction is discussed as the formation of kinks in this region must be avoided.     

Incidence of transient neurologic symptoms after hyperbaric subarachnoid anesthesia with 5% lidocaine and 5% prilocaine

Laparoscopy causes an increase in intraabdominal pressure and may lead to an increase in gastroesophageal reflux (GER). We designed this study to assess and compare the frequency of GER and tracheal contamination in patients undergoing laparoscopic cholecystectomy (LC) and gynecological laparoscopy (LG). We studied 20 LC and 17 LG patients. The pH was measured using monocrystalline antimony pH electrodes positioned in the middle to upper esophagus and on the posterior wall of the trachea distal to the tip of the endotracheal tube. Acid reflux was defined as a decrease in esophageal pH to 4.0 or less. Alkaline reflux was defined as an abrupt increase in esophageal pH of more than 1.0, not associated with previous acid reflux. More than 80% of all patients at baseline had a gastric pH < or = 2. Overall, acid GER alone occurred in 47% patients in the LG group and in 15% patients in the LC group. During recovery, a larger proportion of patients had acid reflux in the LG group (47%) than in the LC group (10%). In contrast, alkaline reflux occurred in 75% of LC patients and 11.7% of LG patients. After cholecystectomy, there is an acute increase in the incidence of alkaline reflux. This alkaline reflux may be due to duodenogastric reflux resulting in an alkaline gastric shift. IMPLICATIONS: We studied the incidence of reflux of stomach contents in patients undergoing laparoscopic (keyhole) surgery for cholecystectomy or gynecology, using pH probes in the esophagus (gullet) and the trachea (windpipe). Acid reflux was very common but did not pass into the trachea. After gallbladder removal, the refluxed material became alkaline.     

Effectiveness and hazard of endomyocardial biopsy in dogs: comparison of two methods

Two different methods of endomyocardial biopsy were evaluated. Compared to the Konno bioptome, a technique using a biopsy forceps originally designed for fiberoptic bronchoscopy and bronchial biopsy, passed through a No. 9 Fr. end-hole catheter, was easier to perform. The biopsy device is smaller than the Konno bioptome, has sharper teeth, and is easier to clean. The two techniques did not differ in arrhythmogenicity, hemorrhagic changes in the myocardium, or distortion of the specimens. Ventricular tachycardia as defined by three beats in a row was observed in 34 per cent. Epicardial hemorrhage was seen in nine of 14 animals, and the specimen distortion rate was 43 per cent. In one animal, perforation of the right ventricle and hemopericardium occurred.     

Patterns of Cryptosporidium oocyst shedding in calves and a comparison of two diagnostic methods

Cryptosporidium spp. oocyst shedding was observed in calves from approximately 1 to 30 days of age. Oocysts were detected by either the Kinyoun acid-fast staining technique (microscopic examination--ME) or a commercially produced enzyme immunoassay EIA). Test concordance between the two detection methods was determined. The mean (+/- SD) number of days to detection of cryptosporidial oocysts was 9.52 +/- 1.92 for the ME and 9.83 +/- 3.19 for the EIA. No significant difference between the means was found (P = 0.17). The period prevalence of cryptosporidiosis was 100% in calves from 1 to 30 days of age. The overall agreement between the ME and EIA was 72%, with a kappa value of 0.42 (SE +/- 0.05). McNemar's test indicated that the proportion of tests determined positive by the two methods was not equal (P < 0.01). The findings or this study indicate moderate agreement between the two diagnostic methods, with the EIA being the more sensitive of the two. However, in most cases the herd-level determination of cryptosporidiosis requires minimal sample sizes and is more economically and easily accomplished by the ME method of detection.     

Early identification of learning disabilities: A comparison of two methods.

Computed discrepancy scores (multiple regression equations using IQs from the Slosson Intelligence Test, SES, sex, and age of child to predict reading and math achievement raw scores) and an unadjusted low-achievement criterion (discrepancy between achievement and potential) for 218 1st graders from normal classrooms in 6 rural elementary schools. In addition to determining the predictor variables already mentioned, the authors also administered the Behavior Problem Checklist, the Bender Visual Motor Gestalt Test for Children, the Visual Matching subtest of the Metropolitan Readiness Test, Level I—Form P, the Wepman Auditory Discrimination Test, and measures of audio-visual integration, handedness, finger localization, finger tapping, lateral dominance, letter and number recognition, motor coordination, name writing, and quantitative concepts. A rating of academic performance was obtained from each teacher. Data show that unadjusted low-achievement criteria misidentified as learning disabled (LD) a significant number of Ss who were achieving at levels commensurate with overall abilities, while failing to identify a significant number of truly LD children. Many of the variables that significantly discriminated low achievers from high achievers did not significantly discriminate LD from non-LD children. (68 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of two methods for indexing and retrieval from a full-text medical database

The purpose of this study is to investigate the effects of endotoxin on human in vitro fertilization and embryo transfers (IVF-ET) and to evaluate a quality control system for a culture medium using endotoxin assays. Before the final water purification (in an ultra-pure water system with a depyrogen filter) of the medium, the sources of water were pre-purified as follows; (I) distillation-->deionization x 2, (II) distillation-->ultra-pure water system or (III) reverse osmosis system. The limulus amebocyte lysate gelation tests (sensitivities of 0.03 and 0.25EU/ml) were used to detect endotoxin in the medium and in pre-purified water (pre-water). No pregnancies occurred in the endotoxin-positive medium (endotoxin > or = 0.03EU/ml). The endotoxin-negative medium resulted in a 33.3% pregnancy rate and 13.4% implantation rate. No statistical differences in the implantation rate were found among these methods of pre-purification (I: 12.5%, II: 13.4% and III: 20.0%). Endotoxin was detected in all the pre-water between 0.25 and 4.0EU/ml. The clinical pregnancy rate (36.6%) and the implantation rate (16.9%) in pre-water of endotoxin < 0.25EU/ml were significantly higher than those (10.5% and 5.5%) in pre-water of endotoxin > or = 0.25EU/ml (p < 0.05). We confirmed that a very low concentration of endotoxin disturbed a human embryo implantation. Endotoxin assays, not only in the media, but also in pre-water before final purification are useful as a quality control for the IVF-ET program.     

Perioperative physiological and cognitive functions following oral premedication with 3.75 mg midazolam in operations with retrobulbar anesthesia

The number of surgical procedures performed as day surgery has significantly increased in recent years. Therefore, a safe and short postoperative recovery period has become increasingly important. The aim of the present study was to investigate perioperative cognitive and physiological function after oral premedication with low-dose midazolam (3.75 mg), especially during the postoperative period. METHODS: Forty-seven men (age > 69 years, weight 50-90 kg) scheduled for elective cataract surgery under retrobulbar anaesthesia (RBA) were included in the study. The patients were randomly assigned to either group 1 (n = 28), receiving 3.75 mg midazolam p.o. (Dormicum), or group 2 (n = 19), receiving a placebo orally 30 min before RBA. We measured the following parameters: sedation (modified Glasgow coma scale); anxiety (visual analogue scale); numerical and verbal memory (digit span and reproduction of previously presented words); concentration (Revisions test of Stender/Marschner). To identify depression of ventilation, pulse oximetry and nasal end-tidal PCO2 were monitored intraoperatively. RESULTS: After premedication with 3.75 mg midazolam, patients were significantly more sedated (P < 0.01) and systolic blood pressures were significantly reduced (P < 0.05); 30 min after midazolam premedication only concentration was significantly (P < 0.05) decreased. The results of the other cognitive functions did not differ. No differences in cognitive and physiological functions between and groups could be found 2 h after the operation (293 +/- min after premedication). Intraoperatively, there were no significant differences in end-tidal PCO2 and oxygenation between the groups. In both groups anxiety and blood pressure were significantly higher pre- than postoperatively. CONCLUSION: Oral administration of low-dose midazolam (0.049 +/- mg/kg) seems to be appropriate for premedication before ambulatory surgical procedures in elderly patients. In the interest of patient safety, standardised oral premedication with 3.75 mg midazolam may not be sufficient for some of the patients.     

Ergonomics in rehabilitation: a comparison of two methods of moving an empty manual wheelchair short distances

Phthalimidomethyl derivatives 1, encompassing a wide range of leaving group abilities, are rapidly hydrolysed to the corresponding phthalamic acid via rate-determining attack at the phthalimide carbonyl group.     

Magnesium isotopic abundance measurement in humans: comparison of two mass spectrometric methods

OBJECTIVE: A population of children having bilateral moderate to profound hearing impairment was investigated to find out the number who passed (false negatives) and who failed (true positives) a screening test based on the auditory brain stem response (ABR). DESIGN: This study of the ABR is a parallel report to Lutman, Davis, Fortnum, and Wood (1997), where the transient evoked otoacoustic emission was examined on a similar but not identical population of at-risk neonates. Hearing screening was undertaken in at-risk neonates (targeted screening) at seven hospitals in the UK using the Nottingham ABR Screener. During the period from January 1988 to December 1993, a total of 6983 neonates had been tested. Assessment of audiological records from the participating centers ascertained that 201 children born between January 1988 and December 1993 had hearing threshold levels in both ears of 50 dB or more, averaged over the speech frequencies 0.5, 1, 2, and 4 kHz. Of these, 51 had completed the ABR screening test. Examination of the ABR records, which included both machine and visual scoring, indicated whether they had passed or failed the screening test. RESULTS: Forty-six of the 51 hearing impaired babies failed the neonatal ABR screen either on one or both ears (five false negatives), and 42 failed the test on both ears (nine false negatives). This resulted in field sensitivities of 90% and 82%, respectively. Two cases of suspected progressive hearing loss have been included in the numbers of false negative results. The percentage of babies passing the screen on both ears and subsequently having normal hearing (specificity) is typically 93%. CONCLUSIONS: Neonatal hearing screening in an at-risk population using a highly automated ABR test is a viable and effective tool for identification of hearing impairment. Although the field sensitivity of the test is high, it is unable to identify all babies with a criterion level of hearing loss. There are a number of possible explanations as to the origin of false negative results: configuration of the pure-tone audiogram, a progressive hearing loss, acquired sensorineural or conductive loss, retrocochlear deafness, or an incorrect interpretation of the screening test. Passing a neonatal screening test, therefore, does not exclude the possibility of subsequent hearing impairment and highlights the need for further surveillance.