Transition from nerve stimulator to sonographically guided axillary brachial plexus anesthesia in hand surgery: block quality and patient satisfaction during the transition period

OBJECTIVES Sonographic guidance for peripheral nerve anesthesia has proven increasingly successful in clinical practice; however, fears that a change to sonographically guided regional anesthesia may impair the block quality and operating room work flow persist in certain units. In this retrospective cohort study, block quality and patient satisfaction during the transition period from nerve stimulator to sonographic guidance for axillary brachial plexus anesthesia in a tertiary referral center were investigated. METHODS Anesthesia records of all patients who had elective surgery of the wrist or hand during the transition time (September 1, 2006-August 25, 2007) were reviewed for block success, placement time, anesthesiologist training level, local anesthetic volume, and requirement of additional analgesics. Postoperative records were reviewed, and patient satisfaction was assessed by telephone interviews in matched subgroups. RESULTS Of 415 blocks, 341 were sonographically guided, and 74 were nerve stimulator guided. Sonographically guided blocks were mostly performed by novices, whereas nerve stimulator-guided blocks were performed by advanced users (72.3% versus 14%; P < .001). Block performance times and success rates were similar in both groups. In sonographically guided blocks, significantly less local anesthetics were applied compared to nerve stimulator-guided blocks (mean ± SD, 36.1 ± 7.1 versus 43.9 ± 6.1 mL; P< .001), and less opioids were required (fentanyl, 66.1 ± 30 versus 90 ± 62 μg; P< .001). Interviewed patients reported significantly less procedure-related discomfort, pain, and prolonged procedure time when block placement was sonographically guided (2% versus 20%; P = .002). CONCLUSIONS Transition from nerve stimulator to sonographic guidance for axillary brachial plexus blocks did not change block performance times or success rates. Patient satisfaction was improved even during the early institutional transition period.

Development of an ultrasound-guided technique for pudendal nerve block in cat cadavers.

The objective of this prospective experimental cadaveric study was to develop an ultrasound-guided technique to perform an anaesthetic pudendal nerve block in male cats. Fifteen fresh cadavers were used for this trial. A detailed anatomical dissection was performed on one cat in order to scrutinise the pudendal nerve and its ramifications. In a second step, the cadavers of six cats were used to test three different ultrasonographic approaches to the pudendal nerve: the deep dorso-lateral, the superficial dorso-lateral and the median transperineal. Although none of the approaches allowed direct ultrasonographical identification of the pudendal nerve branches, the deep dorso-lateral was found to be the most advantageous one in terms of practicability and ability to identify useful and reliable landmarks. Based on these findings, the deep dorso-lateral approach was selected as technique of choice for tracer injections (0.1 ml 1% methylene blue injected bilaterally) in six cat cadavers distinct from those used for the ultrasonographical study. Anatomical dissection revealed a homogeneous spread of the tracer around the pudendal nerve sensory branches in all six cadavers. Finally, computed tomography was performed in two additional cadavers after injection of 0.3 ml/kg (0.15 ml/kg per each injection sites, left and right) contrast medium through the deep dorso-lateral approach in order to obtain a model of volume distribution applicable to local anaesthetics. Our findings in cat cadavers indicate that ultrasound-guided pudendal nerve block is feasible and could be proposed to provide peri-operative analgesia in clinical patients undergoing perineal urethrostomy.

Electron density building block approach for metal organic frameworks

A general introduction to the state of the art in modeling metal organic materials using transferable atomic multipoles is provided. The method is based on the building block partitioning of the electron density, which is illustrated with some examples of potential applications and with detailed discussions of the advantages and pitfalls. The interactions taking place between building blocks are summarized and are used to discuss the properties that can be calculated.

Ultrasound-guided block of sciatic and femoral nerves: an anatomical study

The sheep is a popular animal model for human biomechanical research involving invasive surgery on the hind limb. These painful procedures can only be ethically justified with the application of adequate analgesia protocols. Regional anaesthesia as an adjunct to general anaesthesia may markedly improve well-being of these experimental animals during the postoperative period due to a higher analgesic efficacy when compared with systemic drugs, and may therefore reduce stress and consequently the severity of such studies. As a first step 14 sheep cadavers were used to establish a new technique for the peripheral blockade of the sciatic and the femoral nerves under sonographic guidance and to evaluate the success rate by determination of the colorization of both nerves after an injection of 0.5 mL of a 0.1% methylene blue solution. First, both nerves were visualized sonographically. Then, methylene blue solution was injected and subsequently the length of colorization was measured by gross anatomical dissection of the target nerves. Twenty-four sciatic nerves were identified sonographically in 12 out of 13 cadavers. In one animal, the nerve could not be ascertained unequivocally and, consequently, nerve colorization failed. Twenty femoral nerves were located by ultrasound in 10 out of 13 cadavers. In three cadavers, signs of autolysis impeded the scan. This study provides a detailed anatomical description of the localization of the sciatic and the femoral nerves and presents an effective and safe yet simple and rapid technique for performing peripheral nerve blocks with a high success rate.

Liberale Romandie, radikale Deutschschweiz? Kantonale Demokratien zwischen Repräsentation und Partizipation

Der vorliegende Beitrag untersucht die weit verbreitete These, dass Deutschschweizer Kantone vor allem radikaldemokratische Merkmale aufweisen, während die lateinischen Kantone stärker liberal-repräsentative Demokratieformen besitzen. Die empirische und mehrdimensionale Messung der Demokratiequalität in den Kantonen zeigt, dass die pauschale These der direktdemokratisch-partizipatorischen Deutschschweizer Kantone auf der einen Seite und der repräsentativdemokratischen Stände der lateinischen Schweiz auf der anderen Seite der Komplexität der kantonalen Demokratien nicht gerecht wird. Als erklärungskräftige Alternative für die Positionen der Kantone auf den Achsen liberaler und radikaler Demokratien an der Schwelle des 21. Jahrhunderts erweist sich vielmehr die Stärke der liberalen und demokratischen Verfassungsbewegungen in den Kantonen Mitte des 19. Jahrhunderts.

Internetbasierte geleitete Selbsthilfe bei verschiedenen Angststörungen: Eine randomisiert kontrollierte Studie zum Vergleich eines individualisierten vs. standardisierten Ansatzes

Hintergrund und Ziel: Internetbasierte psychotherapeutische Interventionen wurden in den letzten Jahren intensiv erforscht. Als besonders vielversprechend haben sich therapeutengeleitete Selbsthilfeprogramme bei verschiedenen Angststörungen erwiesen. Eine neue Entwicklung sind transdiagnostische und individualisierte Ansätze, in welchen auch komorbide Probleme und Störungen, und breitere Patientengruppen angesprochen werden. Beim individualisierten Ansatz werden dem Selbsthilfeprogramm in Abhängigkeit der Probleme der Patienten unterschiedliche Inhalte zugeschaltet. Das Ziel dieser Studie ist die Evaluation einer internetbasierten, individualisierten, geleiteten Selbsthilfeintervention für verschiedene Angststörungen. Methode: In einer kontrolliert-randomisierten Studie wurde der individualisierte Ansatz mit einer standardisierten Intervention, die sich nur auf die primäre Störung der Klienten bezieht, verglichen. 132 StudienteilnehmerInnen, diagnostiziert mit einer Sozialen Angststörung, Panikstörung mit oder ohne Agoraphobie, und/ oder einer Generalisierten Angststörung wurden randomisiert einer der beiden Behandlungsbedingungen oder einer Warteliste zugeteilt. Die Selbsthilfebehandlung dauerte 8 Wochen und wurde von Therapeuten via Email unterstützt. Erhebungszeitpunkte waren Prä, Post und 6 Monate nach Ende der Behandlung. Primäre Ergebnismasse sind störungsübergreifende Masse wie das Beck Angstinventar (BAI) und Daten aus einem diagnostischen Interview. Sekundäre Ergebnismasse sind störungsspezifische Fragebogen. Ergebnisse: Beide Behandlungsgruppen zeigten gegenüber der Warteliste-Kontrollgruppe signifikante Veränderungen auf allen Ergebnismassen. Auf der Basis der Intent-to-treat-Stichprobe betrugen die über die verschiedenen Ergebnismasse gemittelten Effektstärken im Vergleich zur Warteliste-Kontrollgruppe d=.80 für die individualisierte und d=.82 für die standardisierte Behandlungsbedingung. Die Symptomreduktion wurde bis zum 6-Monats-Follow-Up aufrechterhalten. Zwischen den beiden aktiven Behandlungsbedingungen wurden keine Unterschiede gefunden. Diskussion: Die Ergebnisse zeigen, dass sowohl individualisierte wie auch standardisierte internetbasierte Ansätze zur Behandlung verschiedener Angststörungen vielversprechend sind

Das radikale Milieu in Russland vor 1917 als "imperiale Gegenelite"

Im Russischen Reich bildete sich ab den 1860er Jahren im Untergrund eine radikale Gegenelite heraus, welche die bisher geltenden Autoritäten, Konventionen und Werte in Frage stellte und durch etwas Besseres ersetzen wollte. In diesen Netzwerken fanden vor allem junge Menschen aus dem europäischen Teil des Russischen Reiches zusammen. Nationale Identitäten schienen sekundär. Russisch diente als Verständigungssprache. Entscheidend für die Aufnahme in diese Gegengesellschaft war einerseits die „persönliche Qualifikation“, andererseits eine gewisse schulische Bildung. Die verschiedensten radikalen Netzwerke können als Gesamtheit mit dem Begriff radikales Milieu gefasst werden. Dabei lehne ich mich an den Milieubegriff des Soziologen M. Rainer Lepsius an. Dieser definierte Milieus als „soziale Einheiten, die durch eine Koinzidenz mehrerer Strukturdimensionen […] gebildet werden.“ (Demokratie in Deutschland, 1993, 38). Die Strukturdimensionen des radikalen Milieus in Russland von den 1860er Jahren bis 1917 waren: a) Intellektuelle, meist „privilegierte“, städtische Mitglieder, b) Organisation in Zirkeln, c) eine Identität als Gegengesellschaft mit Gegenwerten, die eine Gegenrealität aufbaute sowie d) die Zugehörigkeit durch Kooptation. Obwohl sie den autokratischen Staat ablehnten, organisierten sich die Radikalen aber im imperialen Raum; ihre soziale Zusammensetzung spiegelte mit bestimmten Einschränkungen die ethnische und soziale Pluralität des Gesamtreiches wieder. In ihren autobiographischen Texten deuteten sich die Radikalen als „imperiale Gegenelite“. Dabei lässt sich auch ein Gefälle zwischen Zentrum und Peripherie feststellen: Die führenden Zirkel befanden sich meist in den grossen Städten des Reiches wie St. Petersburg, Moskau und Kiew oder im Exil und waren von dort aus gegenüber den Sympathisanten in den Provinzstädten oder gegenüber den Verbannten in Sibirien bei der Setzung interner Diskurse wegweisend.

Hillel und Schamai, oder die conservative Reform und der stabile Conservatismus : eine Friedensstimme an die Gemeinden Israels und ihre Führer

verf. und hrsg. von L. Adler

Transvenous demand Pacemaker Treatment for intermittent complete Heart Block in a Cat

A 13-year-old male neutered domestic shorthaired cat had repeated syncopal episodes over a 6 month period, which had variable duration and continued to increase in frequency. Intermittent ventricular asystole, due to complete heart block, and hyperthyroidism were documented. As the syncopal episodes did not respond to a 4-week medical treatment and symptoms became severe, a transvenous ventricular demand pacemaker system (VVIM) was implanted via the external jugular vein. The unipolar lead was tunneled subcutaneously and connected with the generator in a preformed ventral abdominal muscle pocket. During follow up of 18-months there were no recurrences of the syncopal episodes.

Third degree atrioventricular block and accelerated idioventricular rhythm associated with a heart base chemodectoma in a syncopal Rottweiler.

A 7-year-old male intact Rottweiler was presented with a 1-week history of lethargy, anorexia, vomiting and multiple syncopal events. The results of the clinical examination and electrocardiography were consistent with a third degree atrioventricular block and an intermittent accelerated idioventricular rhythm. Haematology, serum biochemistry, serology for Borrelia burgdorferi, blood culture, total T4, thoracic radiography and echocardiography did not reveal the cause of the arrhythmia. Response to medical treatment with isoproterenol was poor. Pacemaker placement was declined by the owners and the dog was euthanized at their request. Histopathological examination of the heart revealed a chemodectoma at the base of the heart. There was no neoplastic infiltration of the conduction tissue. Potential mechanisms explaining the association of the arrhythmias and the tumour, such as vagal stimulation and neuroendocrine factors are discussed.

Nerve stimulator-guided sciatic-femoral nerve block in raptors undergoing surgical treatment of pododermatitis.

OBJECTIVE To describe the nerve stimulator-guided sciatic-femoral nerve block in raptors undergoing surgical treatment of pododermatitis. STUDY DESIGN Prospective clinical trial. ANIMALS Five captive raptors (Falco peregrinus) aged 6.7 ± 1.3 years. METHODS Anaesthesia was induced and maintained with isoflurane in oxygen. The sciatic-femoral nerve block was performed with 2% lidocaine (0.05 mL kg(-1) per nerve) as the sole intra-operative analgesic treatment. Intraoperative physiological variables were recorded every 10 minutes from endotracheal intubation until the end of anaesthesia. Assessment of intraoperative nociception was based on changes in physiological variables above baseline values, while evaluation of postoperative pain relied on species-specific behavioural indicators. RESULTS The sciatic-femoral nerve block was feasible in raptors and the motor responses following electrical stimulation of both nerves were consistent with those reported in mammalian species. During surgery no rescue analgesia was required. The anaesthesia plane was stable and cardiorespiratory variables did not increase significantly in response to surgical stimulation. Iatrogenic complications, namely nerve damage and local anaesthetic toxicity, did not occur. Recovery was smooth and uneventful. The duration (mean ± SD) of the analgesic effect provided by the nerve block was 130 ± 20 minutes. CONCLUSION AND CLINICAL RELEVANCE The sciatic-femoral nerve block as described in dogs and rabbits can be performed in raptors as well. Further clinical trials with a control groups are required to better investigate the analgesic efficacy and the safety of this technique in raptors.

Nerve Stimulator–Guided Sciatic-Femoral Block in Pet Rabbits (Oryctolagus cuniculus) Undergoing Hind Limb Surgery: A Case Series

This article describes the clinical applicability of a nerve stimulator–guided technique, previously described in dogs, to block the sciatic and the femoral nerves in 4 pet rabbits (Oryctolagus cuniculus) undergoing hind limb surgeries. Preanesthetic intramuscular doses of medetomidine (0.08 mg/kg), ketamine (15 mg/kg), and buprenorphine (0.03 mg/kg) were administered to the rabbit patients. The rabbits were intubated and general anesthesia was maintained using isoflurane in oxygen. The sciatic-femoral nerve block was performed with 2% lidocaine at a volume of 0.05 mL/kg/nerve. Sciatic-femoral block was feasible in rabbits, and the motoric responses following electrical stimulation of both nerves were consistent with those reported in dogs after successful nerve location. Iatrogenic complications, namely nerve damage and local anesthetic toxicity, did not occur. Based on these results, the authors conclude that the sciatic-femoral nerve block described in dogs can be safely performed in rabbits. Clinical trials are required to assess the analgesic efficacy of the combined sciatic-femoral nerve block in rabbits as a part of multimodal pain management.