Epinephrine in digital blocks has been condemned by traditional medical theory. The authors provide a retrospective review of 1111 cases involving digital block anesthesia with epinephrine in ...conjunction with an extensive literature review.
The authors conducted a retrospective review of 1111 cases involving digital and hand surgery. Observations were made concerning the location of and indication for surgery, age, sex, type of block used, type and dose of anesthetic, use of epinephrine and concentration, use of a tourniquet, follow-up, and complications. Dorsal and transthecal techniques were used exclusively. Patients with vascular compromise did not receive epinephrine and were excluded from the study.
One thousand one hundred eleven cases were reviewed, distributed among 692 male patients and 419 female patients. Sites of surgery ranged throughout the hand and all fingers for a variety of indications. Five hundred patients received injections of 1% plain lidocaine with a dosage range of 2 to 10 cc and an average of 5.7 cc. Six hundred eleven patients received injections of 1% lidocaine with epinephrine (1:100,000) in a dose range of 0.5 to 10 cc and an average dose of 4.33 cc. Nine hundred eighty-six patients (88.75 percent) followed up in the clinic. No patients suffered from digital gangrene in the epinephrine group.
After reviewing 1111 cases, there were no complications associated with the use of epinephrine in digital blocks. The authors suggest that correct application of epinephrine in digital blocks is appropriate, and defend its use.
Environmental constraints imposed on hydropower operation are usually given in the form of minimum environmental flows and maximum and minimum rates of change of flows, or ramp rates. One solution ...proposed to mitigate the environmental impact caused by the flows discharged by a hydropower plant while reducing the economic impact of the above-mentioned constraints consists in building a re-regulation reservoir, or afterbay, downstream of the power plant. Adding pumping capability between the re-regulation reservoir and the main one could contribute both to reducing the size of the re-regulation reservoir, with the consequent environmental improvement, and to improving the economic feasibility of the project, always fulfilling the environmental constraints imposed to hydropower operation. The objective of this paper is studying the contribution of a re-regulation reservoir to fulfilling the environmental constraints while reducing the economic impact of said constraints. For that purpose, a revenue-driven optimization model based on mixed integer linear programming is used. Additionally, the advantages of adding pumping capability are analysed. In order to illustrate the applicability of the methodology, a case study based on a real hydropower plant is presented.
► Environmental constraints may cause significant economic impacts on hydro operation. ► The contribution of a re-regulation reservoir to reducing the economic impact is studied. ► The possibility of adding pumping capability is also studied. ► Detailed revenue-driven optimization models have been used for these purposes. ► A small re-regulation reservoir may allow eliminating the economic impact.
BACKGROUND:Muscle flap reconstruction has become a mainstay of therapy following treatment of sternal wound complications; however, success depends on removing wound exudate and infectious material ...from the wound before reconstruction and closure. Importantly, time to closure is a key factor affecting morbidity/mortality and cost-to-treat for this wound type.
METHODS:A retrospective analysis of 30 patients who were treated for sternal wound complications between June 2015 and October 2017 was performed. After surgical debridement, group 1 patients (n = 15) received negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d), instilling 1/8-strength Dakin’s solution with a 20-minute dwell time followed by 2 hours of NPWT (-125 mm Hg); group 2 patients (n = 15) were treated with wet-to-moist dressings soaked in 1/8-strength Dakin’s solution. After muscle flap reconstruction and closure with sutures, group 1 patients received closed incision negative pressure therapy, and group 2 patients received Benzoin and wound closure strips. Data collected included time to closure, therapy duration, number of debridements/dressing changes, drain duration, and complications.
RESULTS:There was a significantly shorter time to closure (P < 0.0001) for group 1 when compared with group 2. In addition, there were fewer therapy days (P = 0.0041), fewer debridements/dressing changes (P = 0.0011), and shorter drain duration (P = 0.0001) for group 1 when compared with group 2.
CONCLUSIONS:We describe a novel regimen consisting of adjunctive NPWTi-d, along with debridement and systemic antibiotics, followed by closed incision negative pressure therapy after muscle flap reconstruction and closure, to help manage preexisting sternal wounds that had failed to close following a previous cardiac procedure.
Background
It is known that melanoma can metastasize and recur many years after the first diagnosis. Although predictive and prognostic factors for melanoma are well defined, there is still ...insufficient information about the factors affecting the recurrence period and the effect of the recurrence time to survival.
Objectives
This study investigates the course of melanoma to show prognostic factors comparing early and late recurrence patients. The main objective is to uncover the effect of the recurrence time on the progression of the disease.
Methods
In this retrospective study, late recurrence (LR) was defined as melanoma recurrence 10 years after the first diagnosis and early recurrence (ER) was defined as recurrence within 10 years. Gender, age, localization of primary tumour, time to first metastasis, survival rates, histological subtype, stage, tumour thickness, invasion level, ulceration and regression of the primary melanoma were documented. Survival curves were evaluated using the Kaplan–Meier and compared with the log‐rank test. Multivariate Cox proportional hazard models were used to identify significant independent prognostic factors for melanoma‐specific survival (MSS).
Results
A total of 1537 melanoma patients were analysed. Early metastasis was developed in 1438 patients (93.6%), and 99 patients (6.4%) developed late metastasis. Late recurrence patients were younger (P < 0.001) and had fewer ulcerated (P = 0.005), fewer head/neck localized (P = 0.009) and thinner (P < 0.001) melanomas than ER patients. The MSS time (mean ± SD) was nearly identical for LR (31 ± 4.4 months 95% CI 22.3–39.7) and ER (32 ± 1.9 months 28.3–35.7). Multivariate regression analysis revealed male gender (hazard ratio HR = 1.4, P < 0.001), truncal tumour localization (HR = 1.7, P < 0.001), tumour thickness (HR = 1.4, P < 0.045) and ulceration (HR = 1.3, P < 0.008) as significant independent prognostic factors for MSS.
Conclusion
Although ER and LR patients are found to have different clinicopathologic features, the time of the first recurrence after diagnosis do not seem to have an effect on the survival.
Reactor neutrino experiments have seen major improvements in precision in recent years. With the experimental uncertainties becoming lower than those from theory, carefully considering all sources of
...is important when making theoretical predictions. One source of
that is often neglected arises from the irradiation of the nonfuel materials in reactors. The
rates and energies from these sources vary widely based on the reactor type, configuration, and sampling stage during the reactor cycle and have to be carefully considered for each experiment independently. In this article, we present a formalism for selecting the possible
sources arising from the neutron captures on reactor and target materials. We apply this formalism to the High Flux Isotope Reactor (HFIR) at Oak Ridge National Laboratory, the
source for the the Precision Reactor Oscillation and Spectrum Measurement (PROSPECT) experiment. Overall, we observe that the nonfuel
contributions from HFIR to PROSPECT amount to 1% above the inverse beta decay threshold with a maximum contribution of 9% in the 1.8-2.0 MeV range. Nonfuel contributions can be particularly high for research reactors like HFIR because of the choice of structural and reflector material in addition to the intentional irradiation of target material for isotope production. We show that typical commercial pressurized water reactors fueled with low-enriched uranium will have significantly smaller nonfuel
contribution.
Platysma innervation has various clinical applications. Although some patients have unsightly platysmal bands, others suffer from hyperkinetic motility disorders of the platysma that constitute both ...an aesthetic and functional impairment. Recently, the cervical motor branch has been used to reconstruct brachial plexus injuries. Dissection in this area can be precarious. The authors describe surface landmarks to help predict the location of the cervical motor branch of the facial nerve to more efficiently and safely operate in this area.
Sixteen fresh heminecks were dissected with the aid of loupe magnification. Measurements were taken to the branching point of the cervical nerve from the angle of the mandible and to a line from the mentum to the mastoid process.
The cervical branch of the facial nerve was identified to branch below the mandible in all specimens. The branching point of the cervical nerve was consistently found in line with a perpendicular line from the angle of the mandible to the mastoid-mentum line. The branching point was located within 1.75 +/- 0.26 cm of this line. Dividing the mastoid-mentum line by the length of the ramus accurately predicted the distance from the angle of the mandible to the branching point.
The cervical branch of the facial nerve can be reliably located within 1 cm below a perpendicular line from the angle of the mandible to a line drawn from the mentum to the mastoid process. Clinical applications of these findings range from cosmetic face-lift procedures to brachial plexus reconstructions.
The umbilicus is often not a midline structure. Centralization of the umbilicus during an abdominoplasty is routinely performed at the level of the skin; however, this is associated with a high rate ...of postoperative reversion. The authors propose using an eccentric fascial plication centered on the true midline to maintain postoperative centralization of the umbilicus in addition to correction at the skin level.
A retrospective study was conducted of all patients between 2015 and 2019 who underwent abdominoplasty with either skin only (concentric plication) or fascial (eccentric plication) umbilical centralization. The Fisher exact test and t test were used to compare the two groups and assess differences in rates of umbilical reversion.
A total of 71 patients were included in the study; the majority of patients were women n = 69 (97%) and White n = 50 (70%). There were 28 (39%) patients who underwent concentric plication, and 43 (61%) had eccentric plication. Mean body mass index in the concentric and eccentric groups was 32 kg/m 2 and 28.5 kg/m 2 , respectively. Average follow-up was 51.6 months for concentric plication and 27.8 months for eccentric plication. Of those who received concentric plication, 10 patients (36%) had their umbilicus revert to the preoperative position; none in the eccentric plication group reverted ( P < 0.0001).
Midline placement of the umbilicus during an abdominoplasty is important in providing symmetry to optimize aesthetics. Eccentric fascial plication maintains the centralization of the umbilicus when compared with concentric fascial plication with skin-only centralization.
Therapeutic, III.
This paper presents a dynamic model for variable speed wind energy conversion systems, equipped with a variable pitch wind turbine, a synchronous electrical generator, and a full power converter, ...specially developed for its use in power system stability studies involving large networks, with a high number of buses and a high level of wind generation penetration. The validity of the necessary simplifications has been contrasted against a detailed model that allows a thorough insight into the mechanical and electrical behavior of the system, and its interaction with the grid. The developed dynamic model has been implemented in a widely used power system dynamics simulation software, PSS/E, and its performance has been tested in a well-documented test power network.
The origins of wound care date back to ancient civilizations. From boiling oil to honey to wine, healers and caregivers have adopted a fascinating array of items to cleanse, dress, and bandage wounds ...over the ages. While wound care practices have developed over time, the physicians and surgeons of ancient times and the Middle Ages helped build the foundation for present-day wound care. A modern scientific understanding of these treatments illustrates why practitioners abandoned some practices while others remain in use today.
The purpose of this study was to examine the role for epinephrine augmentation of digital block anesthesia by safely prolonging its duration of action and providing a temporary hemostatic effect. ...After obtaining approval from the review board of the authors' institution, 60 digital block procedures were performed in a prospective randomized double-blinded study. The digital blocks were performed using the dorsal approach. All anesthetics were delivered to treat either posttraumatic injuries or elective conditions. Of the 60 digital block procedures, 31 were randomized to lidocaine with epinephrine and 29 to plain lidocaine. Of the procedures performed using lidocaine with epinephrine, one patient required an additional injection versus five of the patients who were given plain lidocaine (p = 0.098). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (p < 0.002). Two patients experienced complications after plain lidocaine blocks, while no complications occurred after lidocaine with epinephrine blocks (p = 0.23). By prolonging lidocaine's duration of action, epinephrine may prevent the need for an additional injection and prolong post-procedure pain relief. This study demonstrated that the temporary hemostatic effect of epinephrine decreased the need for, and thus the potential risk of, using a digital tourniquet (p < 0.002). As the temporary vasoconstrictor effect is reversible, the threat of complication from vasoconstrictor-induced ischemia is theoretical.
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