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Breast cancer-related lymphedema is a lifelong disease associated with decreased quality of life and increased healthcare costs. Evidence supports early detection and prompt treatment through prospective surveillance models.

Objective: To conduct a randomized controlled trial (RCT) on the efficacy of immediate lymphatic reconstruction (ILR) for decreasing the incidence of breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND)., Background: Despite encouraging results in small studies, an appropriately powered RCT on ILR has not been performed., Methods: Women undergoing ALND for breast cancer were randomized in the operating room 1:1 to either ILR, if technically feasible, or no ILR (control). The ILR group underwent lymphatic anastomosis to a regional vein using microsurgical techniques; control group had no repair and cut lymphatics were ligated. Relative volume change (RVC), bioimpedance, quality of life (QoL), and compression use were evaluated at baseline and every 6 months postoperatively up to 24 months. Indocyanine green (ICG) lymphography was performed at baseline and 12 and 24 months postoperatively. The primary outcome was the incidence of BCRL, defined as ≥10% RVC from baseline in the affected extremity at 12-, 18-, or 24-month follow-up., Results: Of 72 patients randomized to ILR and 72 to control from January 2020 to March 2023, our preliminary analysis includes 99 patients with 12-month follow-up, 70 with 18-month follow-up, and 40 with 24-month follow-up. The cumulative incidence of BCRL was 9.5% in the ILR group and 32% in the control group ( P =0.014). The ILR group had lower bioimpedance values, decreased compression usage, better lymphatic function on ICG lymphography, and better QoL than the control group., Conclusions: Preliminary results of our RCT show that ILR after ALND decreases BCRL incidence. Our goal is to finish the accrual of 174 patients with 24-month follow-up., Competing Interests: B.M. is the recipient of investigator-initiated research awards from Regeneron Corp and Pfizer and royalty payments from PureTech and is a consultant with Mediflix Corp. J.D. is an advisor to Stryker Corporation, is on the board of Welwaze Medical LLC, and has a royalty agreement with Springer publishers for the book, Multimodal Treatment of Upper and Lower Extremity Lymphedema. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The effects of animation on transparency, name agreement, and identification of graphic symbols for verbs and prepositions were evaluated in preschoolers of 3 age groups. Methods A mixed-group design was used; in each age group, half of the children were randomly allocated to 1 of 2 orders of symbol formats. The 52 children were asked to guess the meaning of symbols and to identify a target symbol among foils given the spoken label., Results: Animated symbols were more transparent than static symbols, although this was more pronounced for verbs. Animated verbs were named more accurately than static verbs, but there was no difference between animated and static prepositions. Verbs were identified more accurately compared with prepositions, but there was no difference between symbol formats. Older children guessed, named, and identified symbols more effectively than younger children., Conclusion: Animation enhances transparency and name agreement, especially for verbs, which reduces the instructional burden that comes with nontransparent symbols. Animation does not enhance identification accuracy. Verbs are easier to identify than prepositions. A developmental effect was observed for each measure. Limitations and implications for future research are discussed.

The purpose of this study was to identify graphic symbols for verbs and prepositions that were performing and underperforming in static and animated formats in a recent experiment on the effects of animation on transparency, name agreement, and identification of graphic symbols. Variable-specific criteria were developed in order to define when a symbol is considered to be performing in terms of its transparency, name agreement, and identification accuracy. Additionally, across-variable heuristic criteria were developed that allowed classification of symbols into four categories: (a) performing exceptionally, (b) performing effectively, (c) performing adequately, and (d) performing inadequately. These criteria were applied to 24 symbols for verbs and 8 symbols for prepositions in both animated and static formats. Results indicated that the vast majority of the symbols performed adequately or better while a few did not. Potential reasons as to why some of the symbols may have underperformed are discussed. Where appropriate, implications for modifying existing symbols and future research are drawn. Although the fact that the heuristic criteria were developed post-hoc is discussed as a limitation, the benefits of the proposed categories bode well for future applications.

Unlabelled: After craniotomy, hypertension may contribute to intracerebral hemorrhage. We studied whether scalp infiltration with bupivacaine during craniotomy reduces postoperative pain and hypertension. In a double-blind fashion, 36 adult patients (ASA physical status II or III) undergoing elective craniotomy were randomly assigned to receive scalp infiltration with either bupivacaine (0.25%) and epinephrine (1:200,000) or saline/ epinephrine (1:200,000) for skeletal fixation, skin incision, and wound closure. Heart rate (HR) and mean arterial pressure (MAP) were measured after anesthesia induction, after skull-pin insertion, after scalp infiltration, during dural closure, during skin closure, on admission to postanesthesia care unit (PACU), and 1 h after admission. Visual analog pain scores were recorded in the PACU. MAP was significantly greater in the saline group at scalp infiltration. HR was significantly faster in the saline group at dural and skin closure. The bupivacaine group reported significantly less pain than the saline group at PACU admission and 1 h after admission. Pain scores did not correlate with hemodynamic measurements. We conclude that scalp infiltration with 0.25% bupivacaine with 1:200,000 epinephrine blunts certain intraoperative hemodynamic responses and reduces postoperative pain but has no effect on postoperative hemodynamics., Implications: We sought to evaluate whether scalp infiltration with bupivacaine and epinephrine at the beginning and end of craniotomy would afford more intra- and postoperative hemodynamic stability and influence immediate postoperative pain. We found that intraoperative hemodynamics were not influenced greatly; however, craniotomy patients do have significant postoperative pain, which does not seem to have an influence on hemodynamics in the postanesthesia care unit.

Postoperative nausea and vomiting have been associated with the use of nitrous oxide. Alfentanil, when combined with nitrous oxide, also results in a high incidence of postoperative nausea and vomiting. To further define this emesis-potentiating effect of N2O, 119 patients were chosen for study and divided into two groups: group A (n = 59) was administered a mixture of alfentanil, N2O, and O2 with 0.25% isoflurane, group B (n = 60) was administered a mixture of oxygen, room air, isofluorane, and alfentanil. The incidence of postoperative nausea and vomiting was ascertained by a blinded observer in the recovery room. All 119 patients were scheduled for extra-abdominal procedures (excluding thoracotomial, intracranial, ophthalmologic, and middle ear surgery). Patients with a previous history of nausea and vomiting, hiatal hernias, reflux esophagitis, or morbid obesity were excluded. The incidence of vomiting was 5% (3/60) in group B and 15% (8/59) in group A (P = 0.067). Forty-four percent (26/59) of the patients in group A and 20% (12/59) in group B were nauseated postoperatively (P = 0.005). Our data suggest that elimination of N2O from alfentanil-based anesthetics lessens the incidence of nausea.

Background: Knowing which neurosurgical patients are at risk for delayed awakening may lead to better utilization of intensive care resources and avoid the risk and cost of pharmacologic reversal and diagnostic tests., Methods: The authors compared anesthetic emergence from complex spinal surgery (spine; n = 47) with that from craniotomy for supratentorial nonfrontal (n = 22), frontal (n = 34), or posterior fossa tumor (n = 28). A further comparison involved patients with small versus large (diameter > 30 mm, mass effect) tumors. The standardized anesthetic regimen consisted of induction with 2-4 mg/kg-1 thiopental and 1-2 micrograms/kg-1 sufentanil, followed by maintenance with nitrous oxide, 0.2-0.5 micrograms.kg-1.h-1 sufentanil and < or = 0.5% isoflurane. Sufentanil administration was terminated on dural or spinal muscle closure, isoflurane during skin closure, and nitrous oxide during dressing application. After discontinuing nitrous oxide, a minineurologic examination was performed every 15 min for 1 h, then hourly for 4 h and at 24 h., Results: Craniotomy patients performed less well than spinal surgery patients on the minineurologic examination 15 and 30 min after discontinuing nitrous oxide. At 15 min, fewer patients with large (vs. small) tumors were oriented to time (58% vs. 87%; P < 0.01) or place (67% vs. 90%; P < 0.01). Forty-two percent of patients with large tumors still had an abnormal minineurologic examination score versus 15% of patients with small tumors. At 30 min, these values were 28% and 8%, respectively (P < 0.05). Seventy-one percent of patients with large tumors were oriented to time compared to 97% for small lesions (P < 0.01). Emergence from anesthesia was similar for spinal surgery patients and patients with small brain tumors., Conclusion: Patients undergoing craniotomy for large intracranial mass lesions awaken more slowly than patients after spinal surgery or craniotomy for small brain tumor.

A 55-year-old white woman with pulmonary lymphangioleiomyomatosis (LAM) presented to the emergency department with odynophagia and subplatysmal emphysema after a paroxysm of coughing. Lateral neck films showed subcutaneous emphysema and a retropharyngeal air stripe. Chest radiographs showed neither pneumothorax nor pneumomediastinum. Patients with LAM frequently develop pulmonary barotrauma and pneumothoracies. This patient, however, had undergone prior bilateral talc pleuradesis as treatment for recurrent pneumothoracies and, thus, could not manifest this complication of barotrauma. This case illustrates the uncommon occurrence of superior dissection of air after pulmonary barotrauma.

The rapid administration of vancomycin is associated with flushing and hypotension, a consequence of histamine release. The manufacturer discourages administering vancomycin to anesthetized patients, stating that vancomycin aggravates the hypotensive effects of anesthetics. To test this, we randomly assigned 36 adults (ASA classes I through III) to one of two groups: preinduction (Preind, n = 19) and postinduction (Postind, n = 17). Both groups received two different infusions: vancomycin (1 g/250 mL normal saline) and saline (250 mL normal saline) over 30-60 min. The Preind group received vancomycin before anesthesia was induced and saline was administered immediately after anesthesia was induced; for the Postind group, this order was reversed. This was done in a double-blind fashion. The anesthetic induction was standardized by the intravenous administration of thiopental and vecuronium and anesthetic maintenance by inhalation of nitrous oxide and enflurane. End-tidal enflurane, heart rate (HR), and blood pressure (BP) were measured every 3 min. Independent (unpaired) t-test was used in data analysis. The groups did not differ significantly. We conclude that vancomycin infusion may be given under anesthesia without significant adverse hemodynamic consequences if administered over a 30-60 min period of time.

Pulmonary edema can be a complication of acute cocaine abuse. However, no one has ever reported pulmonary edema in a patient who stopped abusing the drug 2 weeks before surgery. This is a report of such a case.

Postoperative nausea and vomiting have been associated with the use of intravenous narcotics, and nitrous oxide may worsen the emetic effects of narcotics. Alfentanil and sufentanil are two synthetic derivatives of fentanyl; alfentanil has a shorter wake-up time than fentanyl, and sufentanil is equivalent to fentanyl. In order to study comparative emetic properties of these two drugs, patients in two different cities were randomly allocated to two different groups and retrospectively compared. Group I received sufentanil N2O/O2 with 0.25% isoflurane. Group II received alfentanil N2O/O2 with 0.25% isoflurane. With group I, the overall incidence of nausea was 31% and of vomiting was 6.2%. For group II, the overall rate for nausea was 38.2% and 8.8% for vomiting. Statistically, there was no significant difference in nausea or vomiting between groups.

General practitioner trainees from the period 1963-80 were followed up with a postal questionnaire, yielding a 62 per cent response rate. Questions were asked about their training and their current posts. Of the ex-trainees, 62 per cent were graduates from overseas medical schools, 92 per cent were now general practitioner principals in the United Kingdom and 25 per cent had experienced difficulty in finding a practice. Trainees from a three-year vocational training scheme (VTS), predominantly from UK medical schools, scored higher on an Index of Attainment than those not from a VTS. Sixty-three per cent of trainees had settled within 10 miles of training area. Only 27 per cent of trainees now worked in a health centre, compared with 61 per cent of trainers. Comments on the training programme suggested financial matters were inadequately dealt with. Twelve per cent would have preferred a longer period in the training practice and 18 per cent made negative comments about their training.

Five British general practitioners spent a week with French colleagues in various parts of France. We report results of the observations which we agreed in advance to make about some aspects of clinical practice in France.

Numerous complications accompany CNS injury. Control of pulmonary, cardiovascular, gastrointestinal, metabolic, hematologic, and infectious complications is essential to ensure the best possible outcome for these seriously injured patients.