Articles: patients.
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Two major portals are available for delivery of medication into the cervical epidural space: interlaminar and transforaminal. The choice of which approach to use is commonly made by assessing the patient's structural pathology, one's skill in performing each procedure, and then weighing the advantages versus the risk associated with the particular technique. Over the past several years, a growing number of cases involving serious complications following cervical transforaminal epidural steroid injections have led some to question the safety of the procedure and to preferentially perform interlaminar epidural injections. ⋯ When performed by experienced interventionalists, major complications are probably rare and it could take years for a significant complication to occur. We must however all be aware that these complications can occur.
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The purpose of this review is to present the most important recent studies into the clinical use of peripheral nerve blocks for anesthesia and postoperative analgesia of the lower limb surgery. ⋯ Introduction of new methods and techniques are increasing and improving the use of lower peripheral nerve blocks. These techniques are gaining interest after the important increase of the lower molecular weigh heparins.
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In many studies investigating measures to attenuate the hemodynamic and humoral stress response during induction of anaesthesia, primary attention was paid to the period of endotracheal intubation since it has been shown that even short-lasting sympathetic cardiovascular stimulation may have detrimental effects on patients with coronary artery disease. The aim of this analysis was, however, to identify the influencing factors on high catecholamine levels before induction of anaesthesia. ⋯ The oral administration of clonidine is the only significant predictor for the observed variation of norepinephrine levels during the preoperative period. Lack of significant dose responsiveness suggests that even a low dose of the drug can attenuate the preoperative stress response and thus is recommended in cardiovascular high risk patients.
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Specific search criteria identified 55 articles for review, of which 22 were eligible randomized, controlled clinical trials. The articles' scores on the PEDro scale were low, ranging from 1 to 5, with an average score of 3.4. Five studies provided adequate information on the subjects' baseline data, and only 3 studies concealed allocation during subject recruitment. No studies blinded their therapist's administration of therapy, and just 1 study blinded subjects. Only 1 study included an intention-to-treat analysis. The average number of subjects in the studies was 66.7; however, only 1 group undertook a power analysis. The types of injuries varied widely (eg, acute or surgical). No authors investigated subjects with muscle contusions or strains, and only 5 groups studied subjects with acute ligament sprains. The remaining 17 groups examined patients recovering from operative procedures (anterior cruciate ligament repair, knee arthroscopy, lateral retinacular release, total knee and hip arthroplasties, and carpal tunnel release). Additionally, the mode of cryotherapy varied widely, as did the duration and frequency of cryotherapy application. The time period when cryotherapy was applied after injury ranged from immediately after injury to 1 to 3 days postinjury. Adequate information on the actual surface temperature of the cooling device was not provided in the selected studies. Most authors recorded outcome variables over short periods (1 week), with the longest reporting follow-ups of pain, swelling, and range of motion recorded at 4 weeks postinjury. Data in that study were insufficient to calculate effect size. Nine studies did not provide data of the key outcome measures, so individual study effect estimates could not be calculated. A total of 12 treatment comparisons were made. Ice submersion with simultaneous exercises was significantly more effective than heat and contrast therapy plus simultaneous exercises at reducing swelling. Ice was reported to be no different from ice and low-frequency or high-frequency electric stimulation in effect on swelling, pain, and range of motion. Ice alone seemed to be more effective than applying no form of cryotherapy after minor knee surgery in terms of pain, but no differences were reported for range of motion and girth. Continuous cryotherapy was associated with a significantly greater decrease in pain and wrist circumference after surgery than intermittent cryotherapy. Evidence was marginal that a single simultaneous treatment with ice and compression is no more effective than no cryotherapy after an ankle sprain. The authors reported ice to be no more effective than rehabilitation only with regard to pain, swelling, and range of motion. Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain. Additionally, ice, compression, and a placebo injection reduced pain more than a placebo injection alone. Lastly, in 8 studies, there seemed to be little difference in the effectiveness of ice and compression compared with compression alone. Only 2 of the 8 groups reported significant differences in favor of ice and compression. ⋯ Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated. Additionally, the low methodologic quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.