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Interscalene brachial plexus block is associated with 100% incidence of hemidiaphragmatic paresis as a result of phrenic nerve block. We examined whether an ultrasound (US)-guided interscalene brachial plexus block performed at the level of root C7 versus a nerve stimulation interscalene brachial plexus block, both using 10 mL of ropivacaine 0.75%, resulted in a lower incidence of hemidiaphragmatic paresis. In a prospective randomized controlled trial, 30 patients scheduled for elective shoulder surgery under combined general anesthesia and interscalene brachial plexus block were included. Interscalene brachial plexus block using the same dose was performed using either US or nerve stimulation guidance of ropivacaine for both groups. General anesthesia was standardized. Ventilatory function was assessed using spirometry, and movement of the hemidiaphragm was assessed by US. Two patients in the US group showed complete paresis of the hemidiaphragm, but in the nerve stimulation group, 12 patients showed complete and 2 patients had partial paresis of the hemidiaphragm (13% versus 93%, respectively; P < 0.0001). Ventilatory function (forced expiratory volume at 1 second, forced vital capacity, and peak expiratory flow) was significantly reduced in the nerve stimulation group compared with the US-guided group (P < 0.05). One block failure occurred in the nerve stimulation group compared with none in the US group. No adverse effects occurred in either group. Ultrasound-guided interscalene brachial plexus block performed at the level of root C7 using 10 mL of ropivacaine 0.75% reduces the incidence of hemidiaphragmatic paresis.

Background and Objectives:This prospective, randomized, double-blind study was designed to determine whether reduction in volume from 20 to 10 mL of ropivacaine 0.5% for ultrasound-guided interscalene block might decrease the incidence of diaphragmatic paresis and preserve pulmonary function.Method:Thirty patients scheduled for arthroscopic shoulder surgery were randomized to receive either 10 or 20 mL of ropivacaine 0.5% for interscalene block at the level of the cricoid cartilage. General anesthesia was administered for surgery, and the surgeon infiltrated lidocaine at the port sites. Hemidiaphragmatic excursion and pulmonary function tests were measured before block, 15 mins after block, and at the time of discharge from recovery room. Onset and duration of sensory dermatomal spread, motor block, pain scores, and analgesic consumption were recorded.Results:Hemidiaphragmatic paresis occurred 15 mins after block performance in 14 of 15 patients in each group. At postanesthesia care unit discharge, 13 of 15 patients in each group continued to demonstrate hemidiaphragmatic paresis. Significant reduction of spirometric values (forced vital capacity, forced expiratory volume at 1 sec, and peak expiratory flow) occurred to a similar degree in both groups after block. Sensory dermatomal spread, motor block, pain scores, and analgesic consumption were not significantly different between groups.Conclusions:Decreasing the volume for interscalene block from 20 to 10 mL did not reduce the incidence of hemidiaphragmatic paresis or impairment in pulmonary function, which persisted at discharge from recovery room. No significant differences in quality or duration of analgesia were observed.

In septic mice, 3-hydroxybutyrate-sodium-salt has shown to partially prevent sepsis-induced muscle weakness. Although effective, the excessive sodium load was toxic. We here investigated whether ketone ester 3-hydroxybutyl-3-hydroxybutanoate (3HHB) was a safer alternative. In a mouse model of abdominal sepsis, the effects of increasing bolus doses of 3HHB enantiomers on mortality, morbidity and muscle force were investigated (n = 376). Next, plasma 3HB - clearance after bolus d -3HHB was investigated (n = 27). Subsequently, in septic mice, the effect on mortality and muscle force of a continuous d , l -3HHB infusion was investigated (n = 72). In septic mice, as compared with placebo, muscle force was increased at 20 mmol/kg/day l -3HHB and at 40 mmol/kg/day d - and d , l -3HHB. However, severity of illness and mortality was increased by doubling the effective bolus doses. Bolus 3HHB caused a higher 3HB − plasma peak and slower clearance with sepsis. Unlike bolus injections, continuous infusion of d , l -3HHB did not increase severity of illness or mortality, while remaining effective in improving muscle force. Treatment of septic mice with the ketone ester 3HHB partly prevented muscle weakness. Toxicity of 3HHB administered as bolus was completely avoided by continuous infusion of the same dose. Whether continuous infusion of ketone esters represents a promising intervention to also prevent ICU-acquired weakness in human patients should be investigated.

Background:Effective treatment for neuralgic amyotrophy (NA), a disabling brachial plexus syndrome of supposed immunomediated origin, is currently lacking. Given the circumstantial evidence of a beneficial effect of prednisolone on pain and paresis, this report evaluates the effects of prednisolone treatment administered in the acute phase in a retrospective case series of 50 NA patients.Methods:Baseline variables (eg, age, sex, type of NA and number of attacks), treatment variables (eg, time until treatment, regimen and use of analgesics) and outcome measures (eg, duration and severity of pain, time course and severity of paresis and functional outcome) were statistically analysed and compared with a historical control group of 203 untreated NA patients.Results:The baseline characteristics of the two patient groups were comparable. The median time until initial pain relief was lower in the study group (12.5 days vs 20.5 days), and a significantly higher percentage already recovered strength in the first month of treatment (18% vs 6.3%; p = 0.011). Twelve per cent had fully recovered within 1 year, while this was 1% for the controls (p<0.001), with the proportion reporting a “good” 12-month outcome also being higher (44% vs 10.7%; p<0.001). Side effects were reported by 20%, but none led to a discontinuation of treatment.Conclusion:Oral prednisolone seems effective in the acute phase of neuralgic amyotrophy with the current results supporting previous case reports. A regimen of oral prednisolone is therefore recommended in the acute phase of the syndrome pending a prospective, randomised trial verifying the results obtained.

The Journal of Dairy Science has increasingly become a primary outlet for scientific research concerning the health of the dairy cow and her calf. This paper attempts to highlight Journal of Dairy Science articles that have linked nutrition and nutritional strategies to reduce disease incidence on the dairy farm. Disorders associated with an animal's inability to cope with the demands of high production include diseases such as milk fever and ketosis, which clearly are related to the cow's inability to maintain bodily functions in the face of negative calcium or energy balance. Improved nutrition of the late gestation cow can reduce the incidence of some of these disorders. Susceptibility to infectious disease is dependent on the integrity of the immune system, and recent studies have shed light on nutritional factors that affect leukocyte function. Other disorders, such as retained fetal membranes, udder edema, and displacement of the abomasum are not easily categorized as to their cause, but nutritional strategies have been developed to help prevent these disorders as well.

A meta-analysis of previous studies was performed to clarify the response of prepartum dairy cows to lowering dietary cation-anion difference (DCAD) and to compare different equations that have been proposed to calculate DCAD. Twenty-two published studies containing 75 treatment groups met criteria for inclusion in the meta-analysis. Five different equations used to calculate DCAD were compared for their association with clinical milk fever and urinary pH. The DCAD equation (Na + K)−(Cl + 0.6 S) was the most highly associated with clinical milk fever (R2 = 0.44) and urinary pH (R2 = 0.85). Lowering DCAD reduced clinical milk fever but also reduced DM intake. Lowered DCAD was associated with reduced urinary pH, blood bicarbonate, and blood CO2, suggesting a metabolic acidosis with respiratory compensation. Blood pH was very slightly lowered by lowered DCAD. Lowering DCAD increased ionized Ca in blood before and at calving. The model predicted that lowering DCAD from +300 to 0 mEq/kg reduced risk for clinical milk fever from 16.4 to 3.2%, reduced urinary pH from about 8.1 to 7.0, and reduced DM intake by 11.3%.

Noninvasive cortical stimulation (NICS) has been used during the acute, postacute and chronic poststroke phases to improve motor recovery in stroke patients having upper- and/or lower-limb paresis. This paper reviews the rationale for using the different NICS modalities to promote motor stroke rehabilitation. The changes in cortical excitability after stroke and the possible mechanisms of action of cortical stimulation in this context are outlined. A number of open and placebo-controlled trials have investigated the clinical effect of repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) of the primary motor cortex in patients with motor stroke. These studies attempted to improve motor performance by increasing cortical excitability in the stroke-affected hemisphere (via high-frequency rTMS or anodal tDCS) or by decreasing cortical excitability in the contralateral hemisphere (via low-frequency rTMS or cathodal tDCS). The goal of these studies was to reduce the inhibition exerted by the unaffected hemisphere on the affected hemisphere and to then restore a normal balance of interhemispheric inhibition. All these NICS techniques administered alone or in combination with various methods of neurorehabilitation were found to be safe and equally effective at the short term on various aspects of poststroke motor abilities. However, the long-term effect of NICS on motor stroke needs to be further evaluated before considering the use of such a technique in the daily routine management of stroke.

To describe the surgical approaches, the radiographic and clinical outcomes, and the long-term follow-up of patients harboring thalamic pilocytic astrocytomas after radical resection by means of a stereotactic volumetric technique. Seventy-two patients with thalamic pilocytic astrocytomas underwent stereotactic volumetric resection by the senior author (PJK) at the Mayo Clinic between 1984 and 1993 (44 patients) and at New York University Medical Center between 1993 and 2005 (28 patients). Patient demographics, presenting symptoms, surgical approaches, neurological outcomes, pathology, initial postoperative status, and long-term clinical and radiographic follow-up were retrospectively reviewed. On preoperative neurological examinations, 54 of the 72 patients had neurological deficits; of these, 48 had hemiparesis. Postoperative imaging demonstrated gross total resection in 58 patients and minimal (<6 mm) residual tumor in 13 patients. Tumor resection was aborted in one patient. On immediate postoperative examination, 16 patients had significant improvements in hemiparesis. Six patients had worsening of a preexisting hemiparesis and one had a new transient postoperative hemiparesis. There was one postoperative death. After 13 to 20 years of follow-up in the Mayo group (mean, 15 +/- 3 yr) and 1 to 13 years of follow-up in the New York University group (mean, 8 +/- 3 yr), 67 patients were recurrence/progression-free, one had tumor recurrence, and three had progression of residual tumor. There were two shunt-related deaths. On long-term neurological follow-up, 27 patients had significant improvements in hemiparesis; one patient with a postoperative worsening of a preexisting hemiparesis remained unchanged. There were no patients with new long-term motor deficits after stereotactic resection. Gross total removal of thalamic pilocytic astrocytomas with low morbidity and mortality can be achieved by computer-assisted stereotactic volumetric resection techniques. Gross total resection of these lesions confers a favorable long-term prognosis without adjuvant chemotherapy and/or radiation therapy and leads to the improvement of neurological deficits.

Objective: The objective of this study is to evaluate the safety and efficacy of a tumor-specific apoptosis-inducing gene, apoptin, as delivered by the non-viral carrier, PAM-RG4, in an animal model of spinal cord tumor. Methods: Male Sprague–Dawley rats were given a 2.5-μl intramedullary injection of C6 glioma (100 000) cells and randomized into three groups (day 0). On day 5, animals received a 7.5-μl intramedullary injection of Dulbecco’s modified Eagle’s medium (Group 1; n =7), PAM-RG4/control gene polyplex (Group 2; n =7), or PAM-RG4/apoptin gene polyplex (Group 3; n =8). Hindlimb functional strength was assessed every other day for the duration of the study. The spinal cords of killed animals were collected and hematoxylin-eosin stained. Results: Following treatment, animals that received apoptin had significantly higher mean functional hindlimb scores than those of sham control animals, showing a level of preserved hindlimb function throughout the study. In addition, Group 1 (sham control) and Group 2 (control gene) animals had median survival scores lower than those of animals receiving apoptin. Histopathological analysis showed marked retardation of tumor progression in apoptin-treated animals compared with sham controls. Conclusion: Our study suggests that apoptin is safe for use in the mammalian spinal cord as well as effective in slowing the progression of tumor growth in the spinal cord. The significant slowing of tumor progression, as manifested by the preserved hindlimb function, coupled with the reduction in tumor volume, shows local non-viral delivery of apoptin could serve as an emerging therapy for the treatment of intramedullary spinal cord tumors.