Extended release bupivacaine formulations for postoperative analgesia: an update

Purpose of review New formulations of local anesthetics with sustained release and longer duration of action are being developed to improve patient outcomes following surgery. This review summarizes the efficacy and safety of the three most recently developed extended-release formulations of the local anesthetic, bupivacaine. Recent findings Bupivacaine liposome injectable suspension (EXPAREL) encapsulates bupivacaine in biodegradable liposomes. It is currently the only extended-release formulation of bupivacaine approved by the FDA for infiltration of the tissues during surgery and for interscalene nerve block analgesia following shoulder surgery. SABER-Bupivacaine and HTX-011, are extended-release bupivacaine products in active development. Available data suggest relative safety and efficacy of all three formulations, although more data are needed to define their indications and dosing. Summary Extended-release bupivacaine formulations are promising alternatives to prolong duration of analgesia. To date, only EXPAREL has been approved by the FDA for tissue infiltration during surgery and for interscalene nerve block. Correspondence to Admir Hadzic, MD, PhD, Professor, Department of Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Schiepse bos 6, 3600 Genk, Belgium. E-mail: admir@nysora.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Pediatric free flap reconstruction for head and neck defects

Purpose of review The aim of this study was to review recent literature on the use of pediatric free flap reconstruction for head and neck defects with focus on skull base, congenital deformities, mandibular reconstruction and operative considerations. Recent findings Reconstruction of the skull base depends on the defect size, location, bony involvement, and pedicle length with a variety of flaps to choose from. Free flaps may be used to correct congenital anomalies due to facial clefts and syndromic causes requiring bony and tissue bulk. Preservation of the condyle together with free flap mandibular reconstruction has better growth potential. Delayed repair of mandibular defects may be an option especially for patients with malignancy. Chemotherapy and radiation therapy may inhibit the growth potential of the mandible. The use of running or coupled arterial anastomosis is associated with an increased immediate complication. Summary Pediatric free flap reconstruction is a reasonable option for various head and neck defects such as skull base, congenital, and mandibular defects. Correspondence to Daniel Jose C. Mendoza, MD, Department of Otorhinolaryngology-Head and Neck Surgery, Jose R. Reyes Memorial Medical Center, San Lazaro Compound, Rizal Avenue Sta. Cruz, Manila 1003 Philippines. Tel: +632 743 6921; e-mail: danieljosemendoza@yahoo.com.ph Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Ring artefacts in cranial CT

Description 

A ring or arc artefact in a CT is a hardware related artefact that occurs due to a defective or miscalibrated detector. It is more common with third-generation CT scanners with solid-state detectors. It appears as complete circles (sequential scans), annular rings (multiple circles) or partial rings (helical/multislice CT) at the same spot near the isocentre in multiple sections.1 2 Recognising this artefact is important as it may be subtle and misinterpreted as a pathological entity by the novice clinician.3 This artefact is usually more clearly visualised in the soft-tissue window of CT scans (video 1) than in the bone window (video 2).

Video 1

Serial sections of the scan (soft-tissue window) showing ring artefact.

Video 2

Serial sections of the scan (bone window) showing ring artefact.

Presented here is a case where an...

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Rare cause of manic period trigger in bipolar mood disorder: testosterone replacement

Hypogonadotropic hypogonadism is a rare congenital disorder characterised by the deficiency and the absence of puberty and infertility. It is caused by the deficient production, secretion or action of gonadotropin-releasing hormone, which is the master hormone regulating the reproductive axis. Gonadotropin-releasing hormone or gonadotropin injections and testosterone replacement therapy are required in the treatment of this disorder. Psychiatric symptoms and disorders may be seen with the use of anabolic androgenic steroids. In this case report, we present a case report in which a patient had behavioural symptoms in childhood and develops bipolar disorder after testosterone replacement therapy. This patient was reached to the remission by increasing the doses of psychiatric drugs without interfering with hormonal therapy. It should be considered that patients receiving testosterone replacement therapy may develop bipolar disorder or trigger mood changes in bipolar mood disease, so behavioural and mood state changes should be closely followed in patients who have bipolar mood disease.

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Acquired generalised lipodystrophy and type 1 diabetes mellitus in a child: a rare and implacable association

Lipodystrophy syndromes are frequently associated with marked degree of insulin resistance and lipoatrophic diabetes. Although acquired generalised lipodystrophy (AGL) has been known to be associated with various autoimmune disorders, type 1 diabetes mellitus (T1DM) is very rarely reported to occur with AGL. Combination of AGL and T1DM can lead to a totally different phenotype with very difficult-to-treat diabetes and progressive complications of both the conditions. We report a case of AGL with T1DM with poor diabetes control despite high doses of insulin, metformin and pioglitazone. Our case further progressed to develop complication of retroperitoneal fibrosis, not hitherto reported with AGL.

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Patient with native valve infective endocarditis and concomitant bacterial myopericarditis

A 39-year-old man with known mitral regurgitation (MR) presented with chest pain, nausea and dizziness. Troponin of 5801 ng/L and scooped ST segments indicated myopericarditis. Cardiac MRI demonstrated an epicardial late gadolinium enhancement pattern consistent with a significantly myocarditic syndrome. Initially afebrile, the patient reported fevers a week earlier when abroad where he received amoxicillin.

The patient then began spiking temperatures and infective endocarditis (IE) was confirmed following blood cultures positive for Streptococcus sanguinis and Transoesophageal echocardiography (TOE) showing a vegetation on the anterior mitral valve leaflet. Patient underwent 6 weeks of intravenous benzylpenicillin and on resolution he was discharged to await valve surgery.

A model is proposed where septic embolism from IE caused bacterial myopericarditis, triggering the initial presenting complaint. It is suggested that prior antibiotic therapy and paracetamol suppressed the systemic symptoms of IE.

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Neuroleptic malignant syndrome following reintroduction of an antipsychotic after overdose

Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse drug reaction. We report a case of NMS potentially induced by dehydration in a female patient suffering from schizoaffective disorder. We discuss possible aetiologies and triggering factors alongside the existing literature.

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