Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae?

Purpose To investigate the prevalence of infected herniated nucleus material in lumbar disc herniations and to determine if patients with an anaerobic infected disc are more likely to develop Modic change (MC) (bone oedema) in the adjacent vertebrae after the disc herniation. MCs (bone oedema) in vertebrae are observed in 6 % of the general population and in 35-40 % of people with low back pain. These changes are strongly associated with low back pain. There are probably a mechanical cause and an infective cause that causes MC. Several studies on nuclear tissue from herniated discs have demonstrated the presence of low virulent anaerobic microorganisms, predominantly Propionibacterium acnes, in 7-53 % of patients. At the time of a herniation these low virulent anaerobic bacteria may enter the disc and give rise to an insidious infection. Local inflammation in the adjacent bone may be a secondary effect due to cytokine and propionic acid production. Methods Patients undergoing primary surgery at a single spinal level for lumbar disc herniation with an MRI-confirmed lumbar disc herniation, where the annular fibres were penetrated by visible nuclear tissue, had the nucleus material removed. Stringent antiseptic sterile protocols were followed. Results Sixty-one patients were included, mean age 46.4 years (SD 9.7), 27 % female. All patients were immunocompetent. No patient had received a previous epidural steroid injection or undergone previous back surgery. In total, microbiological cultures were positive in 28 (46 %) patients. Anaerobic cultures were positive in 26 (43 %) patients, and of these 4 (7 %) had dual microbial infections, containing both one aerobic and one anaerobic culture. No tissue specimens had more than two types of bacteria identified. Two (3 %) cultures only had aerobic bacteria isolated. In the discs with a nucleus with anaerobic bacteria, 80 % developed new MC in the vertebrae adjacent to the previous disc herniation. In contrast, none of those with aerobic bacteria and only 44 % of patients with negative cultures developed new MC. The association between an anaerobic culture and new MCs is highly statistically significant (P = 0.0038), with an odds ratio of 5.60 (95 % CI 1.51-21.95). Conclusion These findings support the theory that the occurrence of MCs Type 1 in the vertebrae adjacent to a previously herniated disc may be due to oedema surrounding an infected disc. The discs infected with anaerobic bacteria were more likely (P<0.0038) to develop MCs in the adjacent vertebrae than those in which no bacteria were found or those in which aerobic bacteria were found. © Springer-Verlag Berlin Heidelberg 2013.

Should topical opioid analgesics be regarded as effective and safe when applied to chronic cutaneous lesions?

Objectives: The induction of analgesia for many chronic cutaneous lesions requires treatment with an opioid analgesic. In many patients suffering with these wounds such drugs are either contraindicated or shunned because of their association with death. There are now case reports involving over 100 patients with many different types of chronic superficial wounds, which suggest that the topical application of an opioid in a suitable gel leads to a significant reduction in the level of perceived pain. Key findings: Some work has been undertaken to elucidate the mechanisms by which such a reduction is achieved. To date there have been no proven deleterious effects of such an analgesic system upon wound healing. Although morphine is not absorbed through the intact epidermis, an open wound provides no such barrier and for large wounds drug absorption can be problematic. However, for most chronic cutaneous lesions, where data has been gathered, the blood levels of the drug applied ranges from undetectable to below that required for a systemic effect. Summary If proven, the use of opioids in this way would provide adequate analgesia for a collection of wounds, which are difficult to treat in patients who are often vulnerable. Proof of this concept is now urgently required. © 2011 Royal Pharmaceutical Society.

Pharmacology and the safe prescribing of drugs

Understanding the pharmacological principles and safe use of drugs is just as important in surgical practice as in any other medical specialty. With an ageing population with often multiple comorbidities and medications, as well as an expanding list of new pharmacological treatments, it is important that surgeons understand the implications of therapeutic drugs on their daily practice. The increasing emphasis on high quality and safe patient care demands that doctors are aware of preventable adverse drug reactions (ADRs) and interactions, try to minimize the potential for medication errors, and consider the benefits and harms of medicines in their patients. This chapter examines these aspects from the view of surgical practice and expands on the implications of some of the most common medical conditions and drug classes in the perioperative period. The therapeutic care of surgical patients is obvious in many circumstances – for example, antibacterial prophylaxis, thromboprophylaxis, and postoperative analgesia. However, the careful examination of other drug therapies is often critical not only to the sustained treatment of the associated medical conditions but to the perioperative outcomes of patients undergoing surgery. The benefit–harm balance of many therapies may be fundamentally altered by the stress of an operation in one direction or the other; this is not a decision that should wait until the anaesthetist arrives for a preoperative assessment or one that should be left to junior medical or nursing staff on the ward.

Understanding the Effect of Protein Tyrosine Phosphatase Receptor Type 0 on Mammalian Sensory Development: Behavioral Studies on PTPRO Knockout Mice

Nerve development, which includes axon outgrowth and guidance, is regulated by many protein families, including receptor protein tyrosine phosphatases (RPTP's).Protein tyrosine phosphatase receptor type 0 (PTPRO) is a type III RPTP that is important for axon growth and guidance, as observed in chicks and flies. In order to examine the effects ofPTPRO on mammalian development, standard behavioral tests were used to compare mice lacking the gene for PTPRO (ROKO mice) to wild-type (WT) mice. The ROKO mice showed a significant delay in reacting to a thermal noxious stimulus, hotplate analgesia, when compared to the WT mice suggesting deficient nociceptive function. In a rotarod test for proprioceptive function the ROKO mice exhibited a significant decrease in the amount of time spent on the rotating rod than did the WT mice. Additional proprioception tests were performed including the climb, step reflex, beam, and mesh walk tests. In the climb and step (place) test, the ROKO group had a significantly lower accuracy in performing the tests than did the WT mice. Thus, mice lacking the PTPRO gene showed behavioral deficiencies that reflect impairment in sensory function, specifically for nociception and proprioception.

Análisis mediante acelerometría del patrón locomotor, tras la administración de morfina con o sin acepromacina, en el caballo

Los opiáceos producen una serie de efectos farmacológicos en los caballos entre los cuales destaca la analgesia, ejercida principalmente sobre el sistema nervioso central. No obstante, también producen otros efectos no deseados como son sedación, excitación, depresión cardio-respiratoria, disminución de la motilidad gastrointestinal, aumento de la actividad motora, leve hipertermia y, en dosis crecientes, sueño profundo y coma. El representante principal de este grupo farmacológico es la morfina, la cual ejerce un efecto analgésico muy potente en esta especie animal, haciendo que su uso sea de gran interés en la clínica equina. Actualmente, uno de los usos clínicos más interesantes de la morfina es el tratamiento del dolor ortopédico severo en el caballo. Sin embargo, el principal inconveniente es que la morfina también da lugar a las reacciones adversas generales de los opiáceos destacando las producidas sobre la actividad motora (marcha compulsiva), por lo que su uso estaría contraindicado en animales con problemas músculo esqueléticos que requieran guardar reposo. Estos efectos adversos indeseados, así como la ausencia relativa de evidencia con respecto a la producción de analgesia en caballos con enfermedades que se producen de manera natural hacen que su utilización sea más limitada y exista controversia en lo que respecta a su eficacia y uso clínico. Para controlar o prevenir los efectos indeseados de los opiáceos, éstos se pueden administrar dentro de un protocolo de neuroleptoanalgesia, es decir, administrar de manera conjunta un neuroléptico (tranquilizante o sedante) y un analgésico opioide. Esta combinación farmacológica permite reducir la excitación que producen los opiáceos, por lo que supone una buena alternativa en aquellos pacientes que requieran un efecto analgésico potente y en los que queramos evitar el riesgo que suponen algunos efectos adversos de los opiáceos...

A prospective comparison of a noninvasive cardiac output monitor versus esophageal doppler monitor for goal-directed fluid therapy in colorectal surgery patients

Copyright © 2014 International Anesthesia Research Society.BACKGROUND: Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT. METHODS: One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient's stroke volume was optimized using 250- mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared. RESULTS: Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were -0.96 to +1.95 days (P = 0.5016). CONCLUSIONS: The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.

The impact of gestational age and fetal weight on the risk of failure of spinal anesthesia for cesarean delivery.

BACKGROUND: There are limited data about spinal dosing for cesarean delivery in preterm parturients. We investigated the hypothesis that preterm gestation is associated with an increased incidence of inadequate spinal anesthesia for cesarean delivery compared with term gestation. METHODS: We searched our perioperative database for women who underwent cesarean delivery under spinal or combined spinal-epidural anesthesia with hyperbaric bupivacaine ⩾10.5mg. The primary outcome was the incidence of inadequate surgical anesthesia needing conversion to general anesthesia or repetition or supplementation of the block. We divided patients into four categories: <28, 28 to <32, 32 to <37 and ⩾37weeks of gestation. The chi-square test was used to compare failure rates and a multivariable regression analysis was performed to investigate potential confounders of the relationship between gestational age and failure. RESULTS: A total of 5015 patients (3387 term and 1628 preterm) were included. There were 278 failures (5.5%). The incidence of failure was higher in preterm versus term patients (6.4% vs. 5.1%, P=0.02). Failure rates were 10.8%, 7.7%, 5.3% and 5% for <28, 28 to <32, 32 to <37 and ⩾37weeks of gestation, respectively. In the multivariable model, low birth weight (P<0.0001), gestational age (P=0.03), ethnicity (P=0.02) and use of combined spinal-epidural anesthesia (P<0.0001) were significantly associated with failure. CONCLUSIONS: At standard spinal doses of hyperbaric bupivacaine used in our practice (⩾10.5mg), there were higher odds of inadequate surgical anesthesia in preterm parturients. When adjusting for potential confounders, low birth weight was the main factor associated with failure.

Comparison between local anaesthetic agents, lidocaine and bupivacaine, in patients undergoing third molar extraction in terms of patient satisfaction.

AIMS: (1) To determine if anaesthetic agent bupivacaine, has a prolonged effect on the period of acute postoperative pain when compared to lidocaine, a shorter acting agent. (2) To determine patient’s post-operative satisfaction and preference with regard to anaesthetic choice. METHODS: This double blind, randomised, interventional clinical trial included 85 patients. All patients had bilateral impacted lower third molars of removed under general anaesthetic. All patients received 0.5% plain bupivacaine on one randomly allocated side, with 2% lidocaine (with adrenaline) administered on the opposite side. Pain was measured using visual analogue scales at 0, 30, 60 minutes and 3, 4, 6 and 8 hours post-surgery. Pain was analysed for 1 week following surgery. Psychological evaluations and patient reported outcomes, including patient satisfaction were evaluated. RESULTS: A significant difference in pain (P=0.001) was seen during the 3-8 hour post-operative period. The upper limit of the 95% confidence interval was 10.0 or above at 3hours and 4 hours post-surgery. Two-thirds of patients preferred bupivacaine. CONCLUSION: Longer lasting anaesthetics such as bupivacaine offer a longer period of analgesia, and improve overall patient satisfaction.

Postoperative analgesic effect, of preoperatively administered dexamethasone, after operative fixation of fractured neck of femur: randomised, double blinded controlled study.

Background: Fractured neck of femur is a common cause of hospital admission in the elderly and usually requires operative fixation. In a variety of clinical settings, preoperative glucocorticoid administration has improved analgesia and decreased opioid consumption. Our objective was to define the postoperative analgesic efficacy of single dose of dexamethasone administered preoperatively in patients undergoing operative fixation of fractured neck of femur. Methods: Institutional ethical approval was granted and written informed consent was obtained from each patient. Patients awaiting for surgery at Cork University Hospital were recruited between July 2009 and August 2012. Participating patients, scheduled for surgery were randomly allocated to one of two groups (Dexamethasone or Placebo). Patients in the dexamethasone group received a single dose of intravenous dexamethasone 0.1 mg kg -1 immediately preoperatively. Patients in the placebo group received the same volume of normal saline. Patients underwent operative fixation of fractured neck of femur using standardised spinal anaesthesia and surgical techniques. The primary outcome was pain scores at rest 6 h after the surgery. Results: Thirty seven patients were recruited and data from thirty patients were analysed. The groups were similar in terms of patient characteristics. Pain scores at rest 6 h after the surgery (the principal outcome) were lesser in the dexamethasone group compared with the placebo group [0.8(1.3) vs. 3.9(2.9), mean(SD) p = 0.0004]. Cumulative morphine consumption 24 h after the surgery was also lesser in the dexamethasone group [7.7(8.3) vs. 15.1(9.4), mean(SD) mg, p = 0.04]. Conclusions: A single dose of intravenous dexamethasone 0.1 mg kg -1 administered before operative fixation of fractured neck of femur improve significantly the early postoperative analgesia. Trial registration: ClinicalTrials.gov identifier: NCT01550146, date of registration: 07/03/2012

Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

AIMS AND OBJECTIVES: To explore hospice, acute care and nursing home nurses' experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

BACKGROUND: Pain management in end-stage dementia is a fundamental aspect of end of life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

DESIGN: A qualitative study using semi-structured interviews and thematic analysis to examine data.

METHODS: 24 registered nurses caring for people dying with advanced dementia were recruited from ten nursing homes, three hospices, and two acute hospitals across a region of the United Kingdom. Interviews were conducted between June 2014 and September 2015.

RESULTS: Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development. Patient-related challenges to pain management were universal across care settings; nurse- and organisation-related barriers differed between settings. A need for interactive learning and practice development, particularly in pharmacology, was identified.

CONCLUSIONS: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

RELEVANCE TO CLINICAL PRACTICE: Nurses considered pain management fundamental to end of life care provision; however, nurses working in acute care and nursing home settings may be under-supported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology. This article is protected by copyright. All rights reserved.

Implementing change in practice: Part 2- the change process

Pain management in premature and sick babies has long been recognisedas a vital component of neonatal care; however practices pertaining to painassessment and administration of analgesia remain variable in Neonatal Units(NNU). Sucrose has been identified as an effective agent in reducing pain during minorpainful procedures in premature babies but the uptake has been modest.This article (part 2) follows on from an earlier article on evidence to support theimplementation of sucrose administration as a measure for pain relief for minorprocedures (part 1) and will centre on practice-based change in the NNU and reflecton the strategies used as well as the effectiveness of the proposed change. A theoreticalchange model will be used as a framework to help unpack the influencesinherent within the change process.

Electrophysiological effects of guanosine and MK-801 in a quinolinic acid-induced seizure model

TORRES, F ; FILHO, M.S. ; ANTUNES, C. ; KALININE, E. ; ANTONIOLLI, E. ; PORTELA, Luis Valmor ; SOUZA, Diogo Onofre ; TORT, A. B. L. . Electrophysiological effects of guanosine and MK-801 in a quinolinic acid-induced seizure model. Experimental Neurology , v. 221, p. 296-306, 2010

A terapia da realidade virtual e a pessoa queimada: redução da dor nos cuidados à ferida -Uma revisão integrativa da literatura

Introdução: Terapias farmacológicas não têm conseguido um controle efetivo da dor na pessoa queimada nas três dimensões da dor aquando os cuidados à ferida. Assim, a Terapia da Realidade Virtual (TRV) baseia-se numa abordagem tecnológica que isola a pessoa do mundo real, visualizando apenas um ambiente virtual. Objetivo: Nesta Revisão Integrativa da Literatura pretende-se: identificar se a aplicação da TRV reduz a dor nas três dimensões aquando os cuidados à ferida; verificar em que medida a aplicação da TRV reduz a dor em cada uma das três dimensões de dor; verificar se a aplicação da TRV permite a redução de administração da analgesia opioide. Método: Efetuou-se pesquisa em motores de busca online, num período temporal de dez anos por meio de descritores e critérios de inclusão predefinidos. Definiu-se como questão de investigação "Qual é a eficácia da aplicação da Terapia da Realidade Virtual na redução da dor nos cuidados à ferida à pessoa numa unidade de queimados?". Na consecução deste trabalho, teve-se como método os Sete Passos do Cochrane Handbook, sendo incluídos seis artigos. Resultados: Pela análise dos resultados, evidencia-se a redução da dor nas três dimensões, na maioria dos estudos, quando associada a TRV a terapias farmacológicas. Conclusões: Propõem-se mais estudos randomizados controlados para definir os benefícios da TRV, comparativamente com terapias não farmacológicas menos dispendiosas.

Eficacia de la ropivacaína 0,1% intraperitoneal en el control del dolor postoperatorio en cirugía ginecológica laparoscópica

Introducción: Determinar la eficacia de la administración preincisional de ropivacaína al 0,1 % intraperitoneal en el control del dolor abdominal y/o de hombro, durante la primera semana de la cirugía laparoscópica ginecológica benigna. Diseño: Ensayo clínico aleatorizado y doble ciego. Material y métodos: Se realizó un ensayo clínico aleatorizado y doble ciego donde participaron 64 pacientes ASA I-III sometidas a cirugía laparoscópica ginecológica por patología benigna. Tras la realización del neumoperitoneo, se administraron 100 ml de ropivacaína 0,1 % o suero fisiológico intraperitoneal, dependiendo del grupo al que pertenecieran. Las pacientes recibieron, además, AINE junto con una bomba de PCA con opción de morfina de rescate como analgesia multimodal asociada. Se evaluó el dolor abdominal y/o de hombro al despertar, en reposo y en movimiento, a los 5, 30, 60 y 120 minutos, así como a las 24 horas. Se registró el consumo de morfina en las primeras 24 horas y la incidencia de náuseas y/o vómitos postoperatorios. A la semana, mediante encuesta telefónica, se registró la presencia de dolor de hombro a partir de las 24 horas, así como de dolor abdominal persistente al 7º día. Resultados: No se observaron diferencias significativas en el ENV durante las primeras 24 horas. Tampoco se observaron diferencias en el consumo de morfina, en la incidencia de náuseas y/o vómitos o en el dolor de hombro. Se evidenciaron diferencias estadísticamente significativas en la incidencia de dolor abdominal persistente al 7º día (18,52 % en grupo tratamiento vs. 57,58 % en grupo control con p = 0,04). Conclusiones: La administración intraperitoneal preincisional de 100 ml de ropivacaína 0,1 % en comparación con la administración de suero fisiológico, en el contexto de una técnica anestésica y analgésica multimodal, no ha demostrado reducir el dolor postoperatorio, el consumo de opioides ni la incidencia de náuseas y vómitos postoperatorios en las primeras 24 horas. Tampoco ha demostrado reducción del dolor de hombro a partir del primer día tras cirugía laparoscópica ginecológica. El uso de ropivacaína al 0,1 % intraperitoneal preincisional presenta una disminución estadísticamente significativa en la incidencia de dolor abdominal persistente al séptimo día de postoperatorio.