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Transmuscular quadratus lumborum (TQL) block for laparoscopic colorectal surgery: study protocol for a double-blind, prospective randomized placebo-controlled trial
No full textBACKGROUND: Thoracic epidural anesthesia is no longer considered the gold standard for perioperative analgesia in laparoscopic colorectal procedures. In the search for alternatives, the efficacy of the transverse abdominal plane (TAP) block and other abdominal wall blocks such as the transmuscular quadratus lumborum (TQL) block continues to be investigated for postoperative pain management. Most of the initial studies on TAP blocks reported positive effects; however, the amount of studies with negative outcomes is increasing, most probably due to the fact that the majority of abdominal wall blocks fail to mitigate visceral pain. The TQL block could prove attractive in the search for better postoperative pain relief after laparoscopic colorectal surgery. In several cadaveric studies of the TQL, a spread of dye into the thoracic paravertebral space, the intercostal spaces, and even the thoracic sympathetic trunk was reported. Given the advantage of possibly reaching the thoracic paravertebral space, the potential to reach nerves transmitting visceral pain, and the possible coverage of dermatomes T4-L1, we hypothesize that the TQL provides superior postoperative analgesia for laparoscopic colorectal surgery as compared to patient-controlled intravenous analgesia with morphine alone. METHODS AND DESIGN: In this prospective, randomized, double-blind controlled clinical trial, 150 patients undergoing laparoscopic colorectal surgery will be included. Patients will be randomly allocated to two different analgesic strategies: a bilateral TQL with 30 ml ropivacaine 0.375% each on both sides, administered before induction of anesthesia, plus postoperative patient-controlled intravenous analgesia with morphine (TQL group, n = 75), or a bilateral TQL block with 30 ml saline each on both sides plus postoperative patient-controlled intravenous analgesia with morphine (placebo group, n = 75). Our primary outcome parameter will be the morphine consumption during the first 24 h postsurgery. Secondary endpoints include pain intensity as assessed with the numerical rating scale (NRS) for pain, time to return of intestinal function (defined as the time to first flatus and the time to the first postoperative intake of solid food), time to first mobilization, the incidence of postoperative nausea and vomiting during the first 24 h, length of stay on the post anesthesia care unit (PACU) and in the hospital, the extent of sensory block at two time points (admission to and discharge from the PACU), the doses of morphine IV as requested by the patient from the PCA pump, the total dosage of morphine administered IV, the need for and dose of rescue analgesics (ketamine, clonidine), free plasma ropivacaine levels after induction and at discharge from the PACU, and the incidence of adverse events during treatment (in particular, signs of local anesthetic systemic toxicity (LAST)). Epidural analgesia is no longer the standard of care for postoperative analgesia in laparoscopic colorectal surgery. Until now, the most effective analgesic strategy in these patients especially in an enhanced recovery program is still unknown. Several abdominal wall blocks (TAP, fascia transversalis plane block) are known to have an analgesic effect only on somatic pain. Recognizing the importance of procedure-specific pain management, we aim to investigate whether a transmuscular quadratus lumborum block delivers superior pain control in comparison to patient-controlled intravenous analgesia with morphine alone. TRIAL REGISTRATION: EudraCT identifier 2019-002304-40. Registered on 17 September 2019.sponsorship: The study is funded by institutional departmental sources (Anesthesiology at the University Hospital Leuven) and additionally funded by the BARA (Belgian Association of Regional Anesthesia) board GRANT awarded at BARA 2019Sponsors details:UZ Leuven, Herestraat 49, 3000 Leuven, Belgium. Phone: 0032 (0) 16 33 22 11BARA vzw, BARA office UZ Leuven Department Anesthesia, Herestraat 49, 3000 Leuven. Phone 0032 (0) 16 34 86 52 (Anesthesiology at the University Hospital Leuven, BARA (Belgian Association of Regional Anesthesia) board GRANT, UZ Leuven, Herestraat, Leuven, Belgium, BARA vzw, BARA office UZ Leuven Department Anesthesia, Herestraat, Leuven)status: Publishe
De continue zoektocht voor de verbetering van de postoperatieve outcome
No full textFor further improvements of postoperative outcome, prevention of postoperative nausea and vomiting and adequate pain control are crucial, as these two entities remain the most frequent postoperative complications and hence also most important complaints of patients after surgery. The reduction of PONV and postoperative pain will thus have a large impact on patient well-being and satisfaction.
The overall incidence of PONV after general anesthesia is still 20-30% (when no adequate prophylaxis has been administered), and can reach up to 80% in high risk patients. Occasionally, PONV can lead to aspiration pneumonia, wound dehiscence, surgical bleeding and esophageal rupture and dehydration. The real burden of PONV is the impairment of patients’ comfort. Moreover, PONV can lead to prolonged post anesthesia care unit (PACU) stay, necessitates an increase in nursing care and results in unanticipated hospital admissions following ambulatory surgery. As a result, PONV and its associated complications do increase costs.
80% of the patients experience acute postoperative pain after surgery, of which less than 50% receive adequate pain relief. Insufficient pain management might lead to clinical and psychological sequelae that can drastically reduce quality of life and impair recovery. Traditionally, opioids are still considered the gold standard for postoperative analgesia, but their use can cause clinically relevant, dose-limiting side effects including respiratory depression, sedation, constipation, itching, ileus, urinary retention and PONV. In an attempt to reduce opioid-related side effects, the concept of multi-modal analgesia for postoperative pain has been introduced.
The overall aim of this thesis was to investigate and develop new therapeutic approaches with which the incidence of the above-mentioned two major postoperative complications (i.e., PONV and pain) could be reduced and postoperative outcome be improved. We evaluated the efficacy of two established drugs (alizapride and lidocaine) and of a relatively new peripheral nerve block (quadratus lumborum block) for the prevention of PONV and treatment of postoperative pain.
We studied in a randomized placebo-controlled clinical trial whether 100 mg alizapride is non-inferior to 4 mg ondansetron for the prevention of PONV in patients undergoing laparoscopic gynecological surgery. Primary endpoint was the incidence of nausea and the incidence of vomiting on the PACU. Non-inferiority was tested separately for both outcomes. With respect to the incidence of nausea and to the incidence of vomiting during PACU-stay alizapride failed to show non-inferiority in comparison to ondansetron. Also regarding the incidence of PONV in the PACU and the overall incidence of PONV during 24 hours alizapride failed to demonstrate non-inferiority. Ondansetron-treated patients required significantly less rescue medication than placebo-treated patients. From this study, we concluded that there is no evidence that 100 mg alizapride is non-inferior in comparison to 4 mg ondansetron for the prophylaxis of PONV.
Unfortunately, the low adherence to and the limited knowledge of clinical guidelines is a well-known medical problem.
We studied the incidence of PONV and the compliance to the departmental guidelines for the prevention of PONV in our institution in an uncontrolled before-and-after study using a quasi-experimental design. In a first audit, we investigated the compliance with the departmental algorithm for PONV prevention. The results of this audit revealed that the adherence to our institutional guidelines for PONV-prevention was very low. The results of this audit prompted us to simplify our institutional algorithm for the prophylaxis of PONV. All female patients now receive a triple prophylaxis (consisting of dexamethasone, ondansetron plus either a target controlled infusion with propofol or droperidol) and all male patients obtain double prophylaxis with dexamethasone and ondansetron. This simplification of our algorithm for the prevention of PONV resulted in a significant reduction of the PONV-incidence and in a better compliance with the algorithm.
Lidocaine is an amide local anesthetic with analgesic, anti-inflammatory and antihyperalgesic properties. Systemic lidocaine has been successfully used as a co-analgesic for the treatment of acute postoperative pain, especially in abdominal surgery.
We studied in a randomized placebo-controlled trial the effect of systemic lidocaine on postoperative pain in patients undergoing laparoscopic sterilization in day-case surgery.
Patients received an intravenous bolus injection of lidocaine 1.5 mg kg-1 at induction of anesthesia followed by a continuous infusion of 1.5 mg kg-1h-1 until 30 minutes after arrival on the PACU. The proportion of patients with a numeric rating scale >3, the mean numeric rating scales for pain and the opioid consumption could not be reduced by an intravenous lidocaine infusion. The median time to meet the criteria for hospital discharge were lower in patients receiving systemic lidocaine, a finding with statistical significance but questionable clinical relevance for which we were unable to elucidate the underlying mechanisms. Plasma levels of lidocaine measured when stopping the lidocaine infusion were all under the toxic dose of 5 µg ml-1. From this study, we concluded that systemic lidocaine shortens time to discharge readiness, but has no additional analgesic value in laparoscopic sterilization.
In addition, we studied the effect of systemic lidocaine on postoperative morphine requirements in patients undergoing posterior spinal arthrodesis in a randomized placebo-controlled trial. The patients received a bolus of lidocaine (1.5 mg kg-1) and an intravenous lidocaine infusion (1.5 mg kg-1h-1) until 6 hours after arrival on the PACU. Systemic lidocaine had no influence on morphine consumption during the first 24 postoperative hours. Regarding the numeric rating scores for postoperative pain, PONV-incidence, return of intestinal function, length of hospital stay and inflammatory properties no effect of systemic lidocaine could be shown. We concluded from this trial that systemic lidocaine has no analgesic efficacy and place in multimodal pain management in spinal surgery.
A transversus abdominis block or quadratus lumborum block is a rather new peripheral nerve block providing analgesia to the skin and muscles of the anterior abdominal wall. It is known from the literature that a quadratus lumborum block can reduce cumulative opioid consumption in the first 24 postoperative hours after laparoscopic colorectal surgery. The same effects are reported for systemic lidocaine in the literature.
We studied the superiority of a quadratus lumborum block in comparison with perioperative systemic lidocaine for postoperative analgesia after laparoscopic colorectal surgery in a randomized placebo-controlled trial. Patients received either a quadratus lumborum block preoperatively, a systemic lidocaine infusion perioperatively until four hours after arrival on the PACU or placebo. There was no significant difference between the quadratus lumborum group and the lidocaine group in morphine requirements during the first 24 hours. Significant differences were however observed for total morphine requirements on the PACU, for the total number of PCIA-boli demanded by the patients and the number of PCIA-boli delivered by the pump the first 24 postoperative hours between the three groups: Interestingly, the placebo-group received less morphine compared to the quadratus lumborum and lidocaine group.
PONV and postoperative pain remain two important complaints with a great impact on postoperative outcome. We investigated new approaches to prevent PONV and postoperative pain. In summary, our studies revealed that these new approaches, i.e., the use of alizapride for PONV prophylaxis, the use of systemic lidocaine and the quadratus lumborum block in concepts of multimodal analgesia, had not the hypothesized efficacy. In contrast, following the introduction of the new PONV algorithm we observed an improved compliance of anesthetic care providers with the departmental PONV guidelines.status: Publishe
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations.
No full textBACKGROUND/IMPORTANCE
Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery.
OBJECTIVES
The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology.
EVIDENCE REVIEW
MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023.
FINDINGS
Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown.
CONCLUSION
The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients.
PROSPERO REGISTRATION NUMBER
CRD42022364788
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Dispelling the Myths Behind First-author Citation Counts
Full text linkWe conducted a full-scale evaluative citation analysis study of scholars in the XML research field to explore just how different from each other author rankings resulting from different citation counting methods actually are, and to demonstrate the capability of emerging data and tools on the Web in supporting more realistic citation counting methods. Our results contest some common arguments for the continued
use of first-author citation counts in the evaluation of scholars, such as high correlations between author rankings by first-author citation counts and other citation
counting methods, and high costs of using more realistic citation counting methods that are not well-supported by the ISI databases. It is argued that increasingly available digital full text research papers make it possible for citation analysis studies to go beyond what the ISI databases have directly supported and to employ more
sophisticated methods
koamabayili/VECTRON-author-checklist: VECTRON author checklist
No full textWe have done our best to complete the author checklist relating to the use of animals in the hut study. Note that the objective for the hut study was to evaluate the IRS treatment applications for residual efficacy against Anopheles mosquitoes, including the local An. coluzzii mosquito population. Cows were only used to attract mosquitoes into the huts and no tests were carried out directly on the cows. The author checklist is intended for use with studies where experiments are carried out on animals, which is why we have had such difficulty in completing this for the hut study, as many of the questions do not relate to how the cows were used
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