Ultrasound Guidance for Deep Peripheral Nerve Blocks: A Brief Review

Nerve stimulation and ultrasound have been introduced to the practice of regional anesthesia mostly in the last two decades. Ultrasound did not gain as much popularity as the nerve stimulation until a decade ago because of the simplicity, accuracy and portability of the nerve stimulator. Ultrasound is now available in most academic centers practicing regional anesthesia and is a popular tool amongst trainees for performance of nerve blocks. This review article specifically discusses the role of ultrasonography for deeply situated nerves or plexuses such as the infraclavicular block for the upper extremity and lumbar plexus and sciatic nerve blocks for the lower extremity. Transitioning from nerve stimulation to ultrasound-guided blocks alone or in combination is beneficial in certain scenarios. However, not every patient undergoing regional anesthesia technique benefits from the use of ultrasound, especially when circumstances resulting in difficult visualization such as deep nerve blocks and/or block performed by inexperienced ultrasonographers. The use of ultrasound does not replace experience and knowledge of relevant anatomy, especially for visualization of deep structures. In certain scenarios, ultrasound may not offer additional value and substantial amount of time may be spent trying to find relevant structures or even provide a false sense of security, especially to an inexperienced operator. We look at available literature on the role of ultrasound for the performance of deep peripheral nerve blocks and its benefits

Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure

BACKGROUND: Cuff pressure in endotracheal (ET) tubes should be in the range of 20–30 cm H(2)O. We tested the hypothesis that the tube cuff is inadequately inflated when manometers are not used. METHODS: With IRB approval, we studied 93 patients under general anesthesia with an ET tube in place in one teaching and two private hospitals. Anesthetists were blinded to study purpose. Cuff pressure in tube sizes 7.0 to 8.5 mm was evaluated 60 min after induction of general anesthesia using a manometer connected to the cuff pilot balloon. Nitrous oxide was disallowed. After deflating the cuff, we reinflated it in 0.5-ml increments until pressure was 20 cmH(2)O. RESULTS: Neither patient morphometrics, institution, experience of anesthesia provider, nor tube size influenced measured cuff pressure (35.3 ± 21.6 cmH(2)O). Only 27% of pressures were within 20–30 cmH(2)O; 27% exceeded 40 cmH(2)O. Although it varied considerably, the amount of air required to achieve a cuff pressure of 20 cmH(2)O was similar with each tube size. CONCLUSION: We recommend that ET cuff pressure be set and monitored with a manometer

Stress-induced changes in CARF expression determine growth arrest, apoptosis, or malignant transformation in cultured human cells: Molecular evidence and its application

Background: CARF (Collaborator of ARF)/CDKN2AIP is an essential protein, first cloned as a binding partner of ARF. It was subsequently shown to interact with p53, HDM2 proteins and regulate growth arrest and apoptosis by its multimodal mechanism of action. Over-expression of CARF caused senescence like growth arrest of cells, its knock-down triggered apoptosis. Intriguingly, malignantly transformed cells showed high level of CARF expression. Based on these findings, we hypothesized that level of CARF expression may be a key determinant of cell proliferation fates; where an increase in its levels causes growth arrest/senescence, but beyond a threshold it activates carcinogenesis. Methods: We utilized in vitro cell culture models using retrovirus-driven expression of CARF to achieve over-expression and super-expression of CARF. Analysis of CARF levels was undertaken by biochemical and imaging protocols. Cells exposed to a variety of stresses including physiological, environmental, oxidative, radiation and chemotherapeutics was examined for CARF expression and corresponding cell proliferation fates. Results: Induction of Senescence was seen in cells over-expressing CARF. On the other hand, cells compromised for CARF showed apoptosis, and the ones with super-expression of CARF exhibited malignant transformation. CARF expression analysis in these experimental models endorsed the concept of cell-fate determining role of CARF. Conclusions: We present molecular evidence of the bridging role of CARF in stress-aging-cancer phenotypes and its application in pharmaceuticals and nutraceuticals as a diagnostic and prognostic marker for stress and cancer treatments

Embelin inhibits TNF-α converting enzyme and cancer cell metastasis: molecular dynamics and experimental evidence

BACKGROUND: Embelin, a quinone derivative, is found in the fruits of Embelia ribes Burm (Myrsinaceae). It has been shown to have a variety of therapeutic potentials including anthelmintic, anti-tumor, anti-diabetic, anti-bacterial and anti-inflammation. Inflammation is an immunological response to external harmful stimuli and is regulated by an endogenous pyrogen and pleiotropic pro-inflammatory cytokine, tumor necrosis factor alpha (TNF-α). TNF-α production has been implicated in a variety of other human pathologies including neurodegeneration and cancer. Several studies have shown that the anti-inflammatory activity of embelin is mediated by reduction in TNF-α. The latter is synthesized as a membrane anchored protein (pro-TNF-α); the soluble component of pro-TNF-α is then released into the extracellular space by the action of a protease called TNF-α converting enzyme (TACE). TACE, hence, has been proposed as a therapeutic target for inflammation and cancer. METHODS: We used molecular docking and experimental approaches to investigate the docking potential and molecular effects of embelin to TACE and human cancer cell characteristics, respectively. RESULTS: We demonstrate that embelin is a potential inhibitor of TACE. Furthermore, in vitro studies revealed that it inhibits malignant properties of cancer cells through inactivation of metastatic signaling molecules including MMPs, VEGF and hnRNP-K in breast cancer cells. CONCLUSION: Based on the molecular dynamics and experimental data, embelin is proposed as a natural anti-inflammatory and anticancer drug

Co-Creation of Breast Cancer Risk Communication Tools and an Assessment of Risk Factor Awareness: A Qualitative Study of Patients and the Public in India

The incidence of breast cancer (BC) is increasing worldwide, and India reported 179,790 cases in 2020. It is important to inform people of risk factors and methods for risk management through interactive risk communication techniques. Affordable, easy-to-understand transmedia tools for the communication of BC risk were co-created by a multidisciplinary team of doctors, clinical researchers, epidemiologists, health economists, digital designers, and public representatives. Qualitative in-depth interviews were conducted in regional languages to assess the views of patients, relatives, the public, and health professionals in India of these prototypes. There was low awareness of BC, with some understanding of age and hereditary risk factors but limited knowledge of reproductive factors amongst the general public, patients, and relatives. Participants favored storytelling techniques (animation and comic strips/infographics) to explain complex issues such as genetic risk and testing. Co-created BC risk communication transmedia tools should be used to support informed decision making

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background: This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.Methods: A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.Results: The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.Conclusion: A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.</p