BackgroundDuring the postoperative period of elective cesarean section, intrathecal morphine is effective in the multimodal analgesic regimen, but can cause significant adverse effects. Bilateral posterior quadratus lumborum block could be alternatively used. The aim of this study was to compare efficacy and safety of both strategies as part of a multimodal analgesic regimen.MethodsThis was a prospective, randomized, blinded, controlled study. 104 parturients were randomly selected to receive intrathecal morphine or posterior quadratus lumborum block during cesarean section under spinal anesthesia. The primary endpoint was patient-controlled 24-hour cumulative intravenous morphine use. Secondary endpoints were 48-hour cumulative morphine use, static/dynamic pain scores, functional recovery (ObsQoR-11 questionnaire) and adverse effects.ResultsThere was no statistical difference in the mean cumulative morphine dose at 24-hour between groups (posterior quadratus lumborum block group, 13.7 (97.5% CI 10.4 to 16.9) mg; intrathecal morphine group, 11.1 (97.5% CI 8.4 to 13.8) mg, p=0.111). Pain scores did not show any difference between groups, excepted at 6 hours for the pain at cough/movement in favor of the posterior quadratus lumborum block group (p=0.013). A better recovery quality was observed at 24 hours in the posterior quadratus lumborum block group (p=0.009). Pruritus was more frequent in intrathecal morphine group parturients (35% vs 2%)ConclusionsNo difference in cumulative morphine dose at 24 hours was observed in posterior quadratus lumborum block group compared with intrathecal morphine group. Posterior quadratus lumborum block can be considered an alternative to intrathecal morphine in cesarean postoperative analgesia, especially in cases of intolerance to morphine.Trial registration numberNCT04755712.

La chirurgie de l’épaule se fait fréquemment sous arthroscopie. Elle peut être pratiquée sous anesthésie régionale avec ou sans sédation. L’innervation de l’épaule est complexe et dépend des premières racines du plexus brachial aussi en partie du plexus cervical. Le bloc interscalénique (BIS) est la technique de référence complété par un bloc supraclaviculaire si l’intervention s’effectue uniquement sous ALR avec de plus une anesthésie sous-cutanée du point d’entrée postérieur du trocart. Le BIS provoque systématiquement une paralysie de l’hémidiaphragme. La position semi-assise expose au risque d’hypoperfusion cérébrale si la pression artérielle n’est pas maintenue. Un cathéter peut être mis en place pour l’analgésie postopératoire.

In the axillary fossa, the musculocutaneous nerve (MC) is generally distant from the axillary artery and from the other brachial plexus nerves. In that way, MC requires a specific block. We observed that the location of MC is influenced by the position of the patient's arm and shoulder. Abduction of the shoulder significantly reduced the distance between the MC and the axillary artery. This change in the location of the MC is probably due to the moving of the nerve because of muscle rearrangements and the ability to achieve better proximity of the probe in the axillary fossae.

A 29-year-old patient was scheduled for bilateral halllux valgus surgery and a lateral sciatic popliteal nerve block was performed on each side using ropivacaine and lidocaine using nerve stimulation. Although the sensory and motor block had usual duration on the left side, the block lasted more than 48 hours on the right side with both sensory and motor impairment. An MRI performed on day 2 on the blocked side showed extra- and intraneural fluid accumulation with cephalad and distal spread. Sensory and motor function progressively recovered within the next day and was complete on the fourth day. We postulate that this case of extremely long duration of a peripheral nerve block can be ascribed to subepineural trapping of the local anaesthetic. Part of the variability in the duration of the sensory and motor block after peripheral nerve blocks might be explained by the variable amount of drug injected intraneurally.Un bloc sciatique poplité latéral bilatéral a été réalisé chez une patiente de 29 ans sans antécédents pour permettre la cure d’un hallux valgus bilatéral. Un mélange de ropivacaïne et lidocaïne a été utilisé de chaque côté après détection par neurostimulation. Bien que le bloc sensitif et moteur ait eu une durée usuelle du côté gauche, le bloc a perduré plus de 48 heures du côté droit. Une imagerie par IRM réalisée au second jour montrait la persistance péri- et intraneurale de liquide qui diffusait en direction céphalique et caudale sur plusieurs centimètres. La fonction sensitive-motrice revenait progressivement à la normale au troisième jour et était complète au quatrième jour. Nous proposons l’hypothèse que la durée extrêmement prolongée d’un bloc nerveux périphérique peut être la conséquence d’un piégeage subépineural (intraneural et extrafasciculaire) de l’anesthésique local avec diffusion le long du nerf. Une partie de la variabilité de la durée des blocs nerveux périphériques pourrait ainsi être expliquée par le degré variable d’injection intraneurale.

Functional studies have demonstrated a role for the Anopheles gambiae APL1A gene in resistance against the human malaria parasite, Plasmodium falciparum. Here, we exhaustively characterize the structure of the APL1 locus and show that three structurally different APL1A alleles segregate in the Ngousso colony. Genetic association combined with RNAi-mediated gene silencing revealed that APL1A alleles display distinct protective profiles against P. falciparum. One APL1A allele is sufficient to explain the protective phenotype of APL1A observed in silencing experiments. Epitope-tagged APL1A isoforms expressed in an in vitro hemocyte-like cell system showed that under assay conditions, the most protective APL1A isoform (APL1A(2)) localizes within large cytoplasmic vesicles, is not constitutively secreted, and forms only one protein complex, while a less protective isoform (APL1A(1)) is constitutively secreted in at least two protein complexes. The tested alleles are identical to natural variants in the wild A. gambiae population, suggesting that APL1A genetic variation could be a factor underlying natural heterogeneity of vector susceptibility to P. falciparum.

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Host-pathogen interactions can be powerful drivers of adaptive evolution, shaping the patterns of molecular variation at the genes involved. In this study, we sequenced alleles from 28 immune-related loci in wild samples of multiple genetic subpopulations of the African malaria mosquito Anopheles gambiae, obtaining unprecedented sample sizes and providing the first opportunity to contrast patterns of molecular evolution at immune-related loci in the recently discovered GOUNDRY population to those of the indoor-resting M and S molecular forms. In contrast to previous studies that focused on immune genes identified in laboratory studies, we centered our analysis on genes that fall within a quantitative trait locus associated with resistance to Plasmodium falciparum in natural populations of A. gambiae. Analyses of haplotypic and genetic diversity at these 28 loci revealed striking differences among populations in levels of genetic diversity and allele frequencies in coding sequence. Putative signals of positive selection were identified at 11 loci, but only one was shared by two subgroups of A. gambiae. Striking patterns of linkage disequilibrium were observed at several loci. We discuss these results with respect to ecological differences among these strata as well as potential implications for disease transmission.

Population subgroups of the African malaria vector Anopheles gambiae have not been comprehensively characterized owing to the lack of unbiased sampling methods. In the arid savanna zone of West Africa, where potential oviposition sites are scarce, widespread collection from larval pools in the peridomestic human habitat yielded a comprehensive genetic survey of local A. gambiae population subgroups, independent of adult resting behavior and ecological preference. A previously unknown subgroup of exophilic A. gambiae is sympatric with the known endophilic A. gambiae in this region. The exophilic subgroup is abundant, lacks differentiation into M and S molecular forms, and is highly susceptible to infection with wild Plasmodium falciparum. These findings might have implications for the epidemiology of malaria transmission and control.

OBJECTIVES:Ultrasound-guided regional anesthesia is commonly used for block placement. At present, the risk of cross contamination from probes is not well documented. To avoid transmission of infectious agents, several methods have been used for probe disinfection and protection. The aim of this study was to evaluate the antibacterial efficacy of a new high-level disinfection method based on ultraviolet C (UV-C) light under routine conditions after block placement with an unprotected probe. METHODS:The study was after approval by the local Ethics Committee. In the first part of the study, 15 ultrasound probes were exposed to a large inoculum of 3 bacteria. Ultraviolet C disinfection consisted of cleaning the probe with dry and disinfectant-impregnated paper followed by a 90-second UV-C disinfection cycle in a decontamination chamber. A protocol was established to retrieve the probe with sterile gloves after opening the door of the chamber. In the second part, 50 blocks were placed with ultrasound-guided regional anesthesia. The skin was first prepared with an antiseptic solution, and sterile gel was applied; no covers were used to protect the probes. The blocks were then disinfected with UV-C light. Bacteriologic samples were collected before and after the UV-C method and inoculated on chocolate agar plates. RESULTS:During the first part of the study, all probes were infected after inoculation (>150 colony-forming units) but were considered sterile (<10 colony-forming units) after disinfection. During the second part of the study, all probes were considered sterile before and after disinfection. CONCLUSIONS:Ultraviolet C disinfection seems relevant for ultrasound-guided regional anesthesia just before block placement. It offers simple, fast, and effective high-level disinfection. Moreover, this method should obviate the use of sterile probe covers, which can improve echogenicity.

Nat. Genet. 41, 1282–1289 (2009); published online 1 November 2009; corrected after print 5 February 2010. In the version of this article initially published 1 November 2009, Ali Khamesipour was misspelled in the author list. The error has been corrected in the HTML and PDF versions of the article.

Background Axillary brachial plexus block under neurostimulation is commonly used for upper limb surgery, but it is sometimes recognized as an uncomfortable technique, with most patients identifying electrical stimulation as an unpleasant moment. Ultrasound-guided regional anaesthesia, which becomes an increasingly popular technique, does not require electrical stimulation and then should theoretically improve axillary block placement comfort. The aim of this study was to compare the comfort of the patients during axillary block placement with neurostimulation and ultrasound guidance using either the out-of-plane or the in-plane approach. Methods Consecutive patients were prospectively enrolled in three equal groups: neurostimulation, ultrasound out-of-plane and ultrasound in-plane approaches. A score was used to measure the comfort of the patients during axillary blocks placement. This score included three criteria: maximum pain intensity perceived during block placement measured using a visual analogue scale (0, no pain and 100, maximal or worse imaginable pain), the number of unpleasant events declared by the patients and the satisfaction of the patient (unsatisfied, acceptable, satisfied, very satisfied). The comfort score was calculated as the sum of each criterion, which was attributed a value of 0 or 1: visual analogue scale (≤30/100, 1; >30/100, 0), number of unpleasant events (0, 1; ≥1, 0) and satisfaction (satisfied or very satisfied, 1; acceptable or unsatisfied, 0). Procedures of axillary blocks placement resulting in a comfort score of 3 and 2 were arbitrary considered as very comfortable and comfortable, respectively. Success rate of axillary blocks, time to perform block and complications related to procedures were noted. Results One hundred and twenty patients were included. In the ultrasound out-of-plane group, 55% (22/40) and 25% (10/40) of the procedures were very comfortable and comfortable as compared with 32% (13/40, P < 0.05) and 20% (8/40, P < 0.01) in the ultrasound in-plane group and 25% (10/40, P < 0.01) and 8% (3/40, P < 0.01) in the neurostimulation group, respectively. Duration of axillary placement was significantly smaller in the ultrasound out-of-plane group as compared with that of in-plane approaches (P < 0.05) and neurostimulation (P < 0.01). Conclusion The present study showed that the ultrasound approaches were less painful and more comfortable than neurostimulation to place axillary blocks. We also showed that, although pain intensity resulting from blocks placement was similar with the ultrasound approaches, very comfortable procedures were more frequent with the out-of-plane than with the in-plane approach.

Objective. - The monitoring in the postanaesthesia care unit (PACU) improves the safety, the comfort and the analgesia of patients. At present, studies suggest the possibility to bypass the PACU according to the principle of fast-tracking (FT). The aim of this study was to evaluate the feasibility and the safety of a simulated protocol of FT after a regional anaesthesia.Patients and methods. - Seven hundred patients were prospectively included in this study over a period of 6 months.Methods. - The Withes' scoring system was used for determining when patients could be safely discharged from PACU. We added a variable concerning the monitoring of surgical site. A minimum score of 14 was required on arrival to the PACU to consider a FT. The success rate of blocks, the use of sedation or general anaesthesia were noted. Adverse events were recorded.Results. - The success rate of blocks was 93%. The score was higher than 14 in 98% of case on arrival to the PACU. Thirteen adverse events were reported before surgery and/or operating room. No adverse events were reported during the stay in the PACU.Conclusion. - Regional anaesthesia seems to be an appropriate principle to fast-track the PACU. It could be a way to reduce health care costs, and can offer solution for the PACU congestion problem. In France, the fast-tracking is a marginal concept without any support regulatory. An evolution to such a practice could be considered. (C) 2010 Elsevier Masson SAS. All rights reserved.

Background: Because poor echogenicity of the needle remains a safety issue, we decided to analyze the learning process of the hydrolocalization technique (Hloc) performed to continuously identify needle‐tip anatomical position during many ultrasound‐guided regional anesthesia procedures.Methods: Ten senior anesthesiologists naïve to the Hloc agreed to participate in the study. They were requested to perform 40 out‐of‐plane (OOP) approach ultrasound‐guided axillary blocks (AB) each using the Hloc. The Hloc, which is a needle‐tip localization principle, was performed by means of repetitive injections of a small amount of a local anesthetic solution (0.5–1 ml) under an ultrasound beam. Details of the learning process and skill acquisition of the Hloc were derived from the following parameters: the duration of block placement, a measure of the perceived difficulty of needle‐tip visualization, a measure of block placement difficulty, and the amount of local anesthetics solution required for the technique.Results: Four hundred ABs were performed. The success rate of an ultrasound‐guided AB was 98%. The Hloc was successful in all patients. Skill acquisition over time of the Hloc was associated with a significant reduction of both the duration and the perceived difficulty of ABs placement. Apprenticeship data revealed that 20 blocks were required to successfully place AB within 5 min in most cases using the Hloc.Conclusion: The Hloc performed during the OOP approach of ultrasound‐guided regional anesthesia is a simple technique with a relatively short learning process feasible for efficient placement of ABs.