Functional recovery of wrist surgery with regional versus general anesthesia: a prospective observational study

PURPOSE

Regional anesthesia may favour postoperative rehabilitation by inhibiting peripheral sensitization and secondary hyperalgesia. The literature on this subject is limited. In the present FUNCTION study, we sought to compare the functional recovery post orthopedic wrist surgery with regional versus general anesthesia.

METHODS

We conducted a single-centre prospective observational cohort study in adult patients with a distal radial fracture. Functional recovery was assessed with validated psychometrics questionnaires (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Patient-Rated Wrist Evaluation [PRWE]), range of motion, and grip strength. We used a linear mixed regression model to assess the impact of the anesthesia technique on functional recovery. Postoperative pain and patient satisfaction were evaluated using a visual analog scale.

RESULTS

We recruited 76 patients. At 12 weeks post surgery, there was no difference between the type of anesthesia and functional recovery with the QuickDASH (higher scores worse; regional anesthesia [RA], 22.7 vs general anesthesia [GA], 19.3; adjusted mean difference [aMD], -0.3; 95% confidence interval [CI], -9.6 to 9.0; P = 0.9) and PRWE (higher scores worse; RA group, 21.0 vs GA group, 20.5; aMD, -3.3; 95% CI, -12.1 to 5.6; P = 0.93) questionnaires. Range of motion, satisfaction, and postoperative pain were similar between groups. Right-hand grip strength was higher in the GA group.

CONCLUSION

Regional anesthesia was not associated with improved functional recovery compared with general anesthesia. The dominance of the operated limb was a confusion factor in all evaluation modalities. Further research taking into account the dominance of the hand is necessary to establish the effects of regional anesthesia on functional recovery.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04541745); registered 9 September 2020.

Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review

BACKGROUND

Peripheral nerve block is a common anesthetic technique used during orthopedic upper limb surgery. Injection of local anesthetics around the target nerve inhibits the action of voltage-dependent sodium channels, inhibiting neurotransmission of pain impulses and providing motor immobility. Compared to general anesthesia, it could improve functional recovery by inhibiting nociceptive impulses and inflammation, thus reducing postoperative pain and immobilization and improving postoperative rehabilitation. This systematic review evaluates the impact of peripheral nerve block versus general anesthesia on postoperative functional recovery following orthopedic upper limb surgery.

METHODS

We searched CENTRAL, MEDLINE, CINHAL, EMBASE, and Scopus trial databases from inception until September 2021 for studies comparing peripheral nerve block to general anesthesia. We collected data on functional recovery, range of motion, patient satisfaction, quality of life, and return to work. We pooled studies using a random-effects model and summarized the quality of evidence with the GRADE approach.

RESULTS

We assessed 373 citations and 19 full-text articles for eligibility, and included six studies. Six studies reported on functional recovery, but failed to detect a significant superiority of peripheral nerve block over general anesthesia (3 RCT studies, N = 160; SMD -0.15; CI at 95% -0.60-0.3; I² = 45%; p = 0.07; low quality of evidence and 3 observational studies, N = 377; SMD -0.35; CI at 95% -0.71-0.01; I² = 64%; p = 0.06; very low quality of evidence).

CONCLUSIONS

Current literature is limited and fails to identify the benefit of peripheral nerve block on functional recovery. More studies are needed to assess the impact on long-term recovery. Considering the potential impact on clinical practice and training, a prospective study on functional recovery is ongoing (NCT04541745).

TRIAL REGISTRATION

PROSPERO ID CRD42018116298. Registered on December 4, 2018.

Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review protocol

BACKGROUND

Peripheral nerve block is a single injection that inhibits the transmission of peripheral nerve impulses to the central nervous system. The inhibition of the nociceptive impulse may decrease the occurrence of muscle spasm following mobilization postoperatively. This mechanism may contribute to a better functional recovery following upper limb surgery. This systematic review will investigate the impact of peripheral nerve block on functional recovery after an upper limb surgery.

METHODS

We will search studies comparing peripheral nerve block to general anesthesia for upper limb surgery in the following databases: CENTRAL, MEDLINE (Ovid), CINAHL, EMBASE, and Scopus. In duplicate, independent reviewers will assess eligibility, evaluate risk of bias, and abstract data on type of peripheral nerve block and functional outcome. Where possible, we will pool results using a random effects model. For each outcome, we will assess the quality of evidence using GRADE methodology.

DISCUSSION

We aim to summarize the available evidence comparing functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery. These data will inform the design of a trial on the topic.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018116298.

Oestrogen metabolism in lymphangioleiomyomatosis: catechol-O-methyltransferase pathway is not involved

BACKGROUND

Lymphangioleiomyomatosis (LAM) is an uncommon lung disease for which no effective method of treatment has been found. The predilection of LAM for premenopausal women has led to the assumption that hormonal factors play an important role in the pathogenesis of this disease. The aim of this study was to determine if women with LAM manifest alterations in the catechol-O-methyltransferase (COMT) pathway which is essential for preventing the generation of oestrogen derived reactive oxygen species (ROS).

METHODS

Blood samples were collected from 15 women with LAM and compared with appropriate controls. The distribution of high and low activity alleles of COMT was determined with a PCR based RFLP assay. The enzymatic activity of COMT was measured in each sample and the potential presence of a circulating inhibitor of COMT was determined. Since an alteration in the COMT pathway could increase the oxidative stress, the plasma concentration of malondialdehyde (MDA), a secondary product generated from lipid peroxidation, has been used as an internal marker.

RESULTS

The distribution of high and low activity alleles of COMT (named COMT(HH), COMT(LL), and COMT(HL)) was similar in the two groups with proportions of 40%, 7%, and 53%, respectively, in the women with LAM and 38%, 6%, and 56% in the control subjects. The mean (SD) COMT activity was 24.2 (12.3) pmol/min/mg protein in women with LAM and 24.1 (6.3) pmol/min/mg protein in the control group. Incubation of plasma from women in the two groups with a preparation of commercial COMT showed that no detectable COMT inhibitor was present. The plasma concentration of MDA in the women with LAM was also not significantly different from control subjects.

CONCLUSIONS

This study shows that there are no significant alterations in the COMT pathway of women with LAM. It is therefore unlikely that alterations in oestrogen mediated cell signalling pathways are mediated by oxidants derived from an excess of catecholoestrogens in LAM.

Spectrofluorimetric and image recordings of spontaneous and lectin-induced cytosolic calcium oscillations in Jurkat T cells

Intracellular variations in Ca2+ concentrations have been measured in single Jurkat T lymphocyte variants (77 6.8 and E6.1) using Fura-2 as a probe. Under basal conditions, the cytosolic Ca2+ level is stable but some cells show spontaneous Ca2+ oscillations (frequency, 0.30 +/- 0.06 Hz). These oscillations are sensitive to the external concentration of Ca2+ since they can no longer be observed when the bathing solution is replaced (superfusion) with a Ca(2+)-free medium or when a Ca2+ chelator (EGTA) is added. Various changes in the cytosolic concentration of Ca2+ ([Ca2+]i) can be observed when the cells are exposed to the mitogenic lectin phytohemagglutinin (PHA, 80 nM). For instance, in the case of non-oscillating cells, the lectin induces either a rapid increase in [Ca2+]i that is followed by a sustained response (plateau) or it triggers Ca2+ spikes. In the case of experiments done in Ca(2+)-free medium, only the initial spike was observed. In the case of spontaneously oscillating cells, PHA induces a rapid increase in [Ca2+]i that is followed by a plateau where oscillations are absent. In every case, the PHA-dependent Ca2+ response is abrogated in a Ca(2+)-free medium. Computer simulations based on the model of Goldbeter et al. [27] show that the various Ca2+ responses of Jurkat cells are related to the cytosolic level of free Ca2+. Video imaging analyses show that the cellular Ca2+ responses are not homogeneous whether the observations are made in spontaneously oscillating Jurkat cells or when they are exposed to PHA.

Characterization of Ca2+ and K+ currents in the human Jurkat T cell line: effects of phytohaemagglutinin

1. Inward and outward currents were recorded in the human Jurkat T cell line using the whole-cell configuration of the patch-clamp technique. 2. The transient outward current was activated at membrane potentials positive to -60 mV. The activation time constant-voltage relationship decreased from 17 ms to 2 ms for membrane potentials ranging from -40 to +40 mV. The inactivation phase could be fitted by a single-exponential function and the inactivation time constant decreased from 250 ms to 150 ms for membrane potentials ranging from -20 to +100 mV. 3. The steady-state inactivation-voltage relationship showed a mid-point potential of -32 +/- 2.6 mV, and the slope factor was 10.8 +/- 1.8 mv (n = 3). 4. The calcium ionophore A23187 provoked a decrease in the amplitude of the outward current, suggesting a dependence of this current on the cytosolic concentration of Ca2+. 5. The K+ outward current was blocked by tetraethylammonium (TEA, Michaelis-Menten constant (Km), 6 mM) and by the calcium channel blockers Ni2+, Co2+, Mn2+ and Cd2+. 6. Forty per cent (n = 120) of the patched Jurkat cells displayed an inward current. In a physiological medium containing Ca2+ (2.2 mM), the inward current threshold voltage was -60 mV, the maximum current was observed at -40 mV and the zero current voltage was positive to +20 mV. At negative membrane potentials, the time required to reach 50% of the maximum amplitude was 60 ms and grew shorter with increasing depolarization, reaching a value of 5 ms at -5 mV. The inactivation of the inward current was very slow and the time constant varied from 1200 ms at -35 mV to approximately 250 ms for potentials positive to -10 mV. 7. The current availability had a value of one for potentials negative to -50 mV and zero for potentials positive to -15 mV. The mid-point potential was -31 +/- 3.4 mV and the slope factor was 3.3 +/- 0.2 mV (n = 3). 8. The inward channels were permeable to Sr2+, but were blocked by classical Ca2+ channel inhibitors such as Co2+, Mn2+ and Ni2+. 9. Phaseolus vulgaris phytohaemagglutinin (PHA), an inducer of interleukin-2 production in Jurkat cells, increased the inward current amplitude by 32 +/- 20% (n = 4). This increase was concomitant with a decrease (45 +/- 12%) in the amplitude of the outward current, but only when the current was carried by Ca2+.(ABSTRACT TRUNCATED AT 400 WORDS)