The aim of this study was to compare the efficacy and safety of 4% articaine with a mixture containing equal volumes of 2% lidocaine and 0.5% levobupivacaine without hyaluronidase for sub-Tenon's anaesthesia in phacoemulsification cataract surgery.
Methods:
The study was a prospective, randomised double-masked clinical trial of 65 patients allocated to receive either 4% articaine or a mixture containing equal parts of 2% lidocaine and 0.5% levobupivacaine. All patients had pre- and postoperative Hess charting to document ocular motility dysfunction. Ocular and eyelid movements were scored at 2 min intervals from 2 to 10 min after injection of the anaesthetic agent, and at the end of surgery. Complications related to injection, including pain, chemosis and subconjunctival haemorrhage, were recorded. Patients rated pain (none/mild/moderate/severe) during surgery. The operating surgeon masked to the anaesthetic agent assessed proptosis/chemosis at the start of the operation and the degree of ocular akinesia and analgesia at the end of surgery.
Results:
The articaine group demonstrated a rapid onset of ocular akinesia with a mean time to readiness for surgery (achieving a score of ⩽5) of 4.0 min compared with 10 min for the lidocaine/levobupivacaine group (p = 0.001). The effectiveness of block was significantly greater in the articaine group at all points (p<0.01). Surgeons rated ocular akinesia to be superior in the articaine group (p<0.001). Patients and surgeons rated the analgesic effect as comparable in either group. Eyelid scores, subconjunctival haemorrhage and chemosis were comparable in either group. Hess chart was performed on all patients pre- and postoperatively. There was no clinically significant motility disturbance in the articaine group, whereas one patient in the lidocaine/levobupivacaine group developed diplopia with abnormal ocular motility on the Hess chart.
Conclusion:
Articaine (4%) is a safer and a superior anaesthetic agent than a mixture of 2% lidocaine and 0.5% levobupicaine in achieving ocular akinesia for sub-Tenon's block in phacoemulsification cataract surgery.
Brain natriuretic peptide (BNP) is a marker of diagnosis and prognosis in patients with chronic heart failure. Stored in ventricular myocytes, it is released during ventricular stretch and increased transmural pressure. However, BNP behaves unusually after cardiac transplantation, with a failure to return to normal levels. This raises a question over whether other processes are involved in both its production and secretion. Several studies suggest BNP levels are associated with allograft rejection and coronary graft vasculopathy. Both of these processes have a single denominator in common, the activated immune system. This overview considers further evidence suggesting that BNP interacts with the immune system after cardiac transplantation.
Sodium-glucose co-transporter (SGLT2) inhibition has been shown to reduce the risk of cardiovascular death or hospitalisation in patients with heart failure with reduced ejection fraction (HFrEF) with or without type 2 diabetes mellitus (T2DM). Since publication of the DAPA-HF1 and EMPEROR-HF2 trials and UK NICE approval,3 SGLT2 inhibitor prescription has been increasing for patients with HFrEF.
Methods
Electronic medical records were examined for all patients reviewed in heart failure clinic (including virtual consultation) at Wythenshawe hospital, Manchester over a 4 week period (25/01/21 - 19/02/21). Data obtained was stratified according to NYHA class, LV ejection fraction (LVEF) and presence or absence of T2DM.
Results
232 patients with a diagnosis of heart failure had either face to face or virtual telephone review over the specified time period. Patient baseline characteristics were comparable to patients recruited into the DAPA-HF and EMPEROR-HF trials*. Mean age 67 years (ranging from 20-94 years). 68% were male. 25% had T2DM. 19% (n=45) were subsequently excluded from further analysis due to improvement in LVEF >40% (mean time since last echo 5.4 months) or heart failure with preserved ejection fraction, along with 84 patients who were asymptomatic (NYHA I). 122 patients met the eligibility criteria* for SGLT2 inhibition: of whom 93% were already established on standard HF treatment (the combination of a beta-blocker, an aldosternone antagonist or either an ACE inhibitor, or angiotensin II receptor blocker ± neprolysin inhibitor. 8% were continuing uptitration of their standard heart failure treatments. In those not on standard HF therapy, a contraindication for the absent therapy was recorded in 50% of cases. 24% (n=29) were already prescribed SGLT2 inhibitors. Of the 30% (n=37) of patients who had T2DM, 43% (n=16) were prescribed SGLT2 inhibitors, leaving over half without. Amongst the non-diabetic population of eligible patients (n=86), only 15% were taking SGLT2 inhibitors. Eligible patients taking SGLT2 inhibitors (n=29) were prescribed Dapagliflozin in 79.3% of cases, with Empagliflozin and Canagliflozin prescribed much less commonly (10.3% and 10.3% respectively). Of those in the SGLT2 cohort, Dapagliflozin was commenced at the most recent clinic appointment in 45% of cases indicating a rapid uptake in the prescription of these agents.
Conclusion
In line with recent NICE guidance, the use of SGLT2 inhibition in the HFrEF population is beginning to increase. There is scope for optimisation in treatment. In our cohort of an unselected group of consecutive patients In heart failure, 122/232 (53%) patients were eligible for the treatment. Of the patients with T2DM, 57% were not yet treated with SGLT2 inhibitors. The proportion of non-diabetic eligible patients not treated with SGLT2 inhibition was predictably higher (85%). However, this figure is likely to fall significantly over the next year as awareness of this new treatment increases and local guidance includes this class of agent.Eligibility criteria* for SGLT2 inhibition included: LV ejection fraction <40%, symptomatic heart failure (NYHA II or above) and an eGFR >30. Those with type 1 diabetes and a history of recurrent UTI were not deemed as eligible.
Conflict of Interest
No
References
McMurray JJV, Solomon SD, Inzucchi SE, Kober L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Anand IS, Belohlavek J, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 2019;381:1995–2008. doi: 10.1056/NEJMoa1911303 Packer M, Anker SD, Butler J, Filippatos G, Pocock SJ, Carson P, Januzzi J, Verma S, Tsutsui H, Brueckmann M, et al; EMPEROR-Reduced Trial Investigators. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med 2020;383:1413–1424. doi: 10.1056/NEJMoa2022190 National Institute for Health and Care Excellence NICE technology appraisal guidance TA679.
on Intensive Care and Emergency Medicine seal is maintained by gentle pressure on the TT keeping the cuff pressing on the vocal cords.During percutaneous tracheostomy the bougie remains in the trachea.When ventilation through the tracheostomy tube (cuff inflated) is confirmed, the TT and bougie are withdrawn.Throughout the procedure, if ventilation difficulties occur, the TT can be easily re-inserted using the bougie as a guide.Results Three different bougies were used: types (number used) were Eschmann (29), size 10 Portex disposable (four) and size 12 Portex disposable (13).Three patients were trauma cases: a neutral cervical position was maintained.In 33 cases the Blue Rhino dilator and in 12 cases the Ultra-Perc (White Rhino) dilator was used.One case was a serial dilator (see later). ConclusionThe bougie for airway control for percutaneous tracheostomy was associated with zero hypoxic episodes in 46 cases.Minor bougie damage in two cases caused no problems.Other complications seen were either minor or unlikely to be due to the bougie. P3Percutaneous dilational tracheostomy in critically ill patients: progressive vs single dilatation techniques
Chronic heart failure (CHF) involves derangements in multiple neurohormonal axes leading to a procatabolic state and wasting syndrome associated with significant mortality. Catabolic abnormalities include excess catecholamines and glucocorticoids. Anabolic defects include deficiencies of sex steroids, insulin resistance, and growth hormone (GH) resistance. These abnormalities are also correlated with increased morbidity and mortality in CHF. Anabolic axes have been augmented in pilot studies in CHF with testosterone, GH, insulin‐like growth factor‐1, and GH secretagogues. Results have been varied although some treatments have been associated with improved surrogate endpoints. This review article explores the current understanding of metabolic derangements in CHF and highlights potential neuroendocrine treatment strategies.
To study the clinical features, management and outcomes of displacement of nuclear fragments into the vitreous (DNFV) complicating phacoemulsification in the UK.Cases were collected prospectively between March 2003 and March 2004 inclusive by active surveillance through the British Ophthalmological Surveillance Unit. Details were obtained using incidence questionnaires and follow-up questionnaires after 6 months. The data used in this paper were obtained from the follow-up questionnaires.610 cases were confirmed during the reporting period, for which 387 follow-up questionnaires were received. In 67% of cases, a best-corrected visual acuity of 6/12 or better was reported at final follow-up. The most common immediate sequelae of DNFV were intraocular inflammation (85%), corneal oedema (55%) and an intraocular pressure >30 mm Hg (34%). Pars plana vitreolensectomy was used in 97% of cases, and fragmatome ultrasound lensectomy was used in over half of these procedures. The median time from cataract surgery to pars plana vitrectomy for the removal of DNFV was 3 days, and most patients (68%) had vitrectomy within 1 week of the first procedure. An intraocular lens had been inserted at the time of the complicated cataract surgery (defined as a "primary IOL") in 40% of cases, and over three-quarters of these primary IOLs were subsequently removed (with or without a replacement IOL). Only 67% of eyes that had a primary IOL inserted after DNFV were pseudophakic at final follow-up, in contrast with 79% of eyes that were left aphakic after DNFV (p = 0.008). A best-corrected visual acuity of 6/60 or worse was reported in 14% of cases at final follow-up and was most commonly associated with persistent uveitis, corneal oedema, cystoid macular oedema, optic atrophy or retinal detachment.DNFV complicating cataract surgery was followed by a secondary procedure in 97% of cases. About three-quarters (77%) of "primary IOLs" inserted at the time of DNFV were subsequently removed or replaced, and eyes that had received a primary IOL had significantly less chance of being pseudophakic at final follow-up than eyes that had been left primarily aphakic at the time of the complicated cataract surgery. The delay before secondary intervention was shorter, fragmatome ultrasound lensectomy use was higher, and the retinal detachment rate was lower than in previous studies. Affected eyes still had a worse outcome in terms of visual acuity compared with eyes after uncomplicated cataract surgery.
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