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The reference range for lacosamide (LCM) has been updated from 1 to 10 mg/L to 10 to 20 mg/L. Historically, LCM range was defined from trough-level measurements, but the newer ranges were obtained from peak-level measurements. The purpose of the study was to evaluate the relationship between LCM plasma levels higher than 10 mg/L and the incidence of adverse effects.This was a single-center, retrospective, observational study of adult outpatients with epilepsy who were prescribed LCM and had LCM serum concentrations (LCM-SCs)10 mg/L on drug-fasting samples, measured from June 2017 to December 2020.A total of 55 LCM-SC samples corresponding to 44 patients (25 women [57%]) were analyzed. The median age was 47 (39-61) years. The median LCM-SC was 13.4 (11.2-17.8) mg/L. Adverse effects were reported in 18 patients (41%). Forty-eight percent (21 of 44) of patients required an LCM dose reduction, with a mean LCM-SC of 16.0 (13.2-18.1) mg/L, whereas, in the remaining patients (23 of 44), LCM dose was not modified, with a mean LCM-SC of 12.2 (10.7-14.2) mg/L (P = 0.0244). Forty-one percent (18 of 44) of patients reported adverse effects related to LCM, with a mean LCM-SC of 15.6 (12.7-18.4) mg/L, whereas, in the remaining patients (26 of 44), adverse effects did not occur, with a mean LCM-SC of 12.6 (10.7-16.5) mg/L (P = 0.0495).The 10 to 20 mg/L reference range clearly increases toxicity in patients treated with LCM. Adjusting the reference range upper limit to 12 mg/L with a routine therapeutic drug monitoring program is suggested, to achieve a reasonable probability of efficacy and decrease toxicity.

Purpose Several authors have described methods to predict the sural nerve pathway with non-proportional numerical distances, but none have proposed a person-proportional, reproducible method with anatomical references. The aim of this research is to describe ultrasonographically the distance and crossing zone between a surface reference line and the position of the sural nerve. Methods Descriptive cross-sectional study, performed between January and April 2022 in patients requiring foot surgery who met inclusion criteria. The sural nerve course in the posterior leg was located and marked using ultrasound. Landmarks were drawn with a straight line from the medial femoral condyle to the tip of the fibula. Four equal zones were established in the leg by subdividing the distal half of the line. This way, areas based on simple anatomical proportions for each patient were studied. The distance between the marking and the ultrasound nerve position was measured in these 4 zones, creating intersection points and safety areas. Location and distances from the sural nerve to the proposed landmarks were assessed. Results One-hundred and four lower limbs, 52 left and 52 right, assessed in 52 patients were included. The shortest median distance of the nerve passage was 2.9 mm from Point 2. The sural nerve intersection was 60/104 (57.7%) in Zone B, 21/104 (20.1%) in Zone C and 19/104 (18.3%) in Zone A. Safety zones were established. Average 80.5% of coincidence in sural nerve localization was found in the distal half of the leg, in relation to the surface reference line when comparing both legs of each patient. Conclusions This study proposes a simple, reproducible, non-invasive and, for the first time, person-proportional method, that describes the distance and location of the main areas of intersection of the sural nerve with points and zones (risk and safe zones) determined by a line guided by superficial anatomical landmarks. Its application when surgeons plan and perform posterior leg approaches will help to avoid iatrogenic nerve injuries. Level of evidence IV.

IntroductionInadvertent intraneural injection is not infrequent during peripheral nerve blocks. For this reason, injection pressure monitoring has been suggested as a safeguard method that warns the clinician of a potentially hazardous needle tip location. However, doubts remain whether it is superior to the sonographic nerve swelling in terms of earlier detection of the intraneural injection.MethodsAn observational cadaveric study was designed to assess injection pressures during an ultrasound-guided intraneural injection of the median nerve. We hypothesized that the evidence of nerve swelling occurred prior to an elevated injection pressure (>15 pound per square inch) measured with a portable in-line monitor. 33 ultrasound-guided intraneural injections of 11 median nerves from unembalmed human cadavers were performed at proximal, mid and distal forearm. 1 mL of a mixture of local anesthetic and methylene blue was injected intraneurally at a rate of 10 mL/min. Following injections, specimens were dissected to assess spread location. Video recordings of the procedures including ultrasound images were blindly analyzed to evaluate nerve swelling and injection pressures.Results31 injections were considered for analysis (two were excluded due to uncertainty regarding needle tip position). >15 pound per square inch was reached in six injections (19%) following a median injected volume of 0.6 mL. Nerve swelling was evident in all 31 injections (100%) with a median injected volume of 0.4 mL. On dissection, spread location was confirmed intraneural in all injections.DiscussionUltrasound is a more sensitive and earlier indicator of the low-volume intraneural injection than injection pressure monitoring.

Resumen La artroplastia total de rodilla es una de las cirugias realizadas con mas frecuencia en ortopedia. No obstante, hasta un 20% de los pacientes mostraran persistencia del dolor despues del procedimiento. El dolor posquirurgico persistente puede ser una continuacion del dolor agudo tras la cirugia o aparecer despues de un periodo asintomatico durante mas de 3 meses. En la actualidad, se han caracterizado los factores de riesgo que se asocian a dolor posquirurgico persistente tras la artroplastia total de rodilla. Forman parte del contexto perioperatorio del paciente (preoperatorio, intraoperatorio y postoperatorio) y se pueden agrupar en diferentes dimensiones: geneticas, demograficas, clinicas, quirurgicas, analgesicas, inflamatorias y psicologicas. Su identificacion y prevencion, mediante un abordaje multimodal y biopsicosocial, es esencial en el contexto de la medicina perioperatoria y ha demostrado que puede prevenir o mejorar el dolor tras la cirugia.

Ru or Pt nanoparticles have been prepared following the organometallic approach and deposited onto the surface of mesoporous graphitic carbon nitride (mpg-CN). Three different Ru-based samples have also been compared to investigate the effect of 4-phenylpyridine as a stabilizing agent. The photocatalytic performance towards the hydrogen evolution reaction (HER) has been tested showing that all hybrid systems clearly outperform the photocatalytic activity of bare mpg-CN. In particular, Pt-decorated mpg-CN yields the largest H

Development of competent and cost-effective materials for hydrogen evolution reaction (HER) has been attracting great attention since hydrogen is hailed as a promising environmentally friendly energy source to reduce the greenhouse emissions. Herein, Ru(0) nanoparticles (RuNPs) have been stabilized onto the surface of four different conducting carbon nanomaterials (CNMs) from 0D to 3D, such as 0D carbon nanohorns (CNH), 1D single-walled carbon nanotubes (CNTs), 2D reduced graphene oxide (rGO) and 3D graphite (GP), for their use in the photocatalytic HER. For this aim, the resulting RuNP@CNMs where physically mixed with mesoporous graphitic carbon nitride (mpg-CN) in an optimum composition ratio to maximize the photocatalytic HER activity. Notably, the resulting four hybrid RuNPs@CNM/mpg-CN materials showed an outstanding increase in the hydrogen evolution reaction (HER) when compared with the pristine mesoporous graphitic carbon nitride without co-catalyst. A comparison on the photocatalytic activity of the four hybrid RuNPs@CNMs physically mixed with mpg-CN and a deep study on the fate of the nanohybrids after catalysis are presented.

BackgroundThere is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.MethodsWe conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.ResultsSixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.ConclusionsHarmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

The popliteal sciatic nerve block is routinely used for anesthesia and analgesia during foot and ankle surgery. This article reviews our current understanding of the anatomy of the sciatic nerve and discusses how fascial tissue layers associated with the nerve may affect block outcomes . The anatomy of the sciatic nerve is more complex than previously described. The tibial and common peroneal nerves within the sciatic nerve trunk appear to be centrally separated by the Compton-Cruveilhier septum and encompassed by their own paraneural sheaths. This unique internal architecture of the sciatic nerve appears to promote proximal spread of local anesthetic to the internal aspect of the sciatic nerve trunk after a subparaneural injection at or below the divergence of the tibial and common peroneal nerves.

Nighttime lights data are a measure of economic activity whose error is plausibly independent of the measurement errors of most conventional indicators. Therefore, we can use nighttime lights as an independent benchmark to assess existing measures of economic activity (Pinkovskiy and Sala-i-Martin (2016)). We employ this insight to generate three findings in the study of PPP-adjusted estimates of GDP around the world between 1992 and 2010. First, we find that while market exchange rates described poor economies better than did PPP-adjusted estimates in the late 1990s (Dowrick and Akmal 2008; Almas 2012), this pattern has disappeared by the 2010s. Second, we also find that estimates of PPPs have been steadily improving from one price survey round to the next, including during the controversial 2005 and 2011 rounds. Third, we leverage this fact to assess whether it is optimal to measure relative prices as close as possible to the year of interest or to use the latest available relative price data and discard the rest, and provide a theoretical framework in which the latter may be optimal. Using data from the Penn World Tables, we find that, indeed, it is optimal to only use the latest price data, and hence, to revise existing PPP-adjusted estimates whenever a new price survey is released.

Axillary plexus blockade is a common technique in clinical practice with a well-known pattern of structures around the brachial artery. Historically, the only proper response to radial nerve stimulation was considered to be extension of the hand and wrist. Twenty-five axillary blockades were assessed by ultrasound and neurostimulation; the principal objective was to correlate the needle position over the radial nerve with the anatomical and histological structure of that nerve. During the procedure, the needle was directed in two ways to reach the medial or lateral margin of the nerve: above the brachial artery or beneath it. Once the needle reached the nerve, the current was augmented gradually until a response was elicited. For the cadaveric anatomical study, eight axillae were dissected and histological samples were examined. The response of the triceps brachii muscle differed significantly between the two approaches to the radial nerve (P

We propose a new approach to local anesthetic injection for the supraclavicular brachial plexus block: an intertruncal approach by which local anesthetic is deposited in the two adipose tissue planes between the upper and middle and the middle and lower trunks. We present sonographic and microscopic images to illustrate the relevant anatomy. This approach offers potential advantages over the ‘corner pocket’ technique in that it results in consistent local anesthetic spread to the three plexus trunks and the needle endpoint lies farther away from the pleural surface which is important for the prevention of pneumothorax. It also offers an advantage over the ‘intracluster’ approach as it purposefully avoids intraneural injection respecting the integrity of the epineurium of individual trunks. Comparative studies are required to confirm that these anatomic and technical advantages result in improved outcomes.

Background and objectivesCircumferential (C) spread of local anesthetic around the nerve is recommended for a successful nerve block. We tested the hypothesis that C spread produces a more complete block than non-circumferential (NC) spread.MethodsWe randomized 124 patients undergoing open carpal tunnel syndrome surgery to receive C or NC spread ultrasound-guided median and ulnar nerve blocks. The primary outcome was the proportion of patients who developed complete sensory block measured at 5, 15 and 30 min. The loss of cold sensation was graded as: 0 (complete block), 1 (incomplete block), or 2 (no block). Secondary outcomes included motor block, nerve swelling and adverse events.ResultsIn group C, complete sensory block at 5 min was 2.4 (95% CI 1.0 to 5.7; p=0.04) times more frequent in the median nerve and 3.0 (95% CI 1.2 to 7.2; p=0.01) times more frequent in the ulnar nerve compared with group C. However, at 15 and 30 min, it was similar between groups. Complete motor block was more frequent in group C than in group NC for both the median nerve: 1.5 (95% CI 1.1 to 2.2; pConclusionsC spread around the median and ulnar nerves at the level of the antecubital fossa generates more complete sensory and motor blocks compared with NC spread.Trial registration numberEudraCT 2011-002608-34 and NCT01603680

Perioperative pulmonary aspiration of gastric content is a serious complication. Fasting guidelines try to ensure an empty stomach before intervention. Certain medications or pathologies may cause delayed gastric emptying. Bedside ultrasonography is a useful tool when gastric content status is unclear or in emergency situations where fasting is not feasible. The aim of this prospective case–control observational study was to assess differences in gastric fluid volume between fasted patients with or without predisposing factors for delayed gastric emptying. Patients were preoperatively scanned. Antral cross-sectional area was measured by two tracing methods and total gastric clear fluid volumes were calculated. Data was recorded from September 2018 to March 2019 in a university hospital setting in Barcelona, Spain. Fifty-three patients were enrolled, 23 with delayed gastric emptying predisposing factors (DGEF) and 30 without non-DGEF. Ultrasound-estimated gastric clear fluid volume was 35.21 ± 32.69 mL in the DGEF versus 53.50 ± 30.72 mL in the non-DGEF group (p = 0.08). Average volume per unit of weight was 0.61 ± 0.46 mL/kg. Only 1 patient in the DGEF group had a volume that posed a higher risk of aspiration (1.57 mL/kg). Perfect correlation (R = 0.91; p

Ultrasonography is useful for detecting intraneural injections. However, the reliability of the sonographic findings of intraneural and subparaneural injections in terms of true spread location and their association with intrafascicular deposits has not been systematically evaluated.Our objectives were: 1) to explore the reliability of sonographic findings of intraneural and subparaneural injections when validated with tests of true spread such as histology, dissection, or imaging; and 2) to evaluate their association with intrafascicular deposits. A scoping review was conducted according to Joanna Briggs guidelines. Cinahl, PubMed, ProQuest, ScienceDirect, Scopus and Cochrane databases were searched for studies on adults, cadavers, and animal models. Pediatric studies were excluded.The search strategy found 598 citations. Following screening, 19 studies were selected. Intraneural injections occurred in the brachial plexus, sciatic, femoral, and median nerves. Subparaneural injections in popliteal, supraclavicular and interscalene blocks. Sixteen different ultrasound findings were used to label injection location. Subepineural deposits within individual nerves occurred occasionally following subparaneural injections, regardless of nerve expansion. Overall, five studies reported intrafascicular deposits, two of which frequently, following intraneural and subparaneural injections. None of the currently used ultrasound findings was predictive of intrafascicular deposits.Our results suggest that sonographic parameters of intraneural and subparaneural injections are reliable in terms of detecting spread location. Intrafascicular injectate deposition may occur, albeit infrequently, particularly in the proximal brachial plexus. Our findings support the judicious interrogation of sonographic parameters suggestive of incipient intraneural injection.

The cervical plexus and its branches are situated in the lateral aspect of the neck between the sternocleidomastoid and trapezius muscles. The following images depict a step-by-step dissection of the cervical plexus and its branches.

Altres ajuts: acords transformatius de la UAB A cobalt complex bearing a κ-NP ligand is presented (1 or Co(L), where L is (1E,1'E)-1,1'-(pyridine-2,6-diyl)bis(N-(3-(diphenylphosphanyl)propyl)ethan-1-imine). Complex 1 is stable under air at oxidation state Co thanks to the π-acceptor character of the phosphine groups. Electrochemical behavior of 1 reveals a two-electron Co/Co oxidation process and an additional one-electron reduction, which leads to an enhancement in the current due to hydrogen evolution reaction (HER) at E=−1.6 V vs Fc/Fc. In the presence of 1 equiv of bis(trifluoromethane)sulfonimide, 1 forms the cobalt hydride derivative Co(L)-H (2), which has been fully characterized. Further addition of 1 equiv of CoCp* (Cp* is pentamethylcyclopentadienyl) affords the reduced Co(L)-H (2) species, which rapidly forms hydrogen and regenerates the initial Co(L) (1). The spectroscopic characterization of catalytic intermediates together with DFT calculations support an unusual bimolecular homolytic mechanism in the catalytic HER with 1.

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice., info:eu-repo/semantics/published

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.Der erste Teil der Leitlinien und Empfehlungen für den muskuloskelettalen Ultraschall, die unter der Schirmherrschaft der European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) erstellt wurden, enthält Informationen über den Einsatz des muskuloskelettalen Ultraschalls zur Beurteilung von extraartikulären Strukturen (Muskeln, Sehnen, Gelenke, Bänder, Knochen, Schleimbeutel, Faszien, Nerven, Haut, subkutanes Gewebe und Nägel) und deren Pathologien. Für jede Struktur werden die klinische Anwendung, praktische Punkte, Einschränkungen und Artefakte beschrieben und diskutiert. Nach einer ausführlichen Literaturrecherche wurden die Empfehlungen gemäß den Kriterien des Oxford Centre for Evidence-based Medicine und den GRADE-Kriterien entwickelt, und der Konsensgrad wurde durch die Delphi-Methode ermittelt. Das Dokument ist als Leitfaden für klinische Anwender in der täglichen Praxis gedacht.

We hypothesize that the sciatic nerve in the subgluteal space has a specific behavior during internal and external coxofemoral rotation and during isometric contraction of the internal and external rotator muscles of the hip. In 58 healthy volunteers, sciatic nerve behavior was studied by ultrasound during passive internal and external hip rotation movements and during isometric contraction of internal and external rotators. Using MATLAB software, changes in nerve curvature at the beginning and end of each exercise were evaluated for longitudinal catches and axial movement for transverse catches. In the long axis, it was observed that during the passive internal rotation and during the isometric contraction of external rotators, the shape of the curve increased significantly while during the passive external rotation and the isometric contraction of the internal rotators the curvature flattened out. During passive movements in internal rotation, on the short axis, the nerve tended to move laterally and forward, while during external rotation the tendency of the nerve was to move toward a medial and backward position. During the isometric exercises, this displacement was less in the passive movements. Passive movements of hip rotation and isometric contraction of the muscles affect the sciatic nerve in the subgluteal space. Retrotrochanteric pain may be related to both the shear effect of the subgluteus muscles and the endoneural and mechanosensitive aggression to which the sciatic nerve is subjected.

Background and objectivesWe assume that intrafascicular spread of a solution can only occur if a large enough portion of the distal needle orifice is placed inside the fascicle. Our aim is to present and evaluate a mathematical model that can calculate the theoretical vulnerability of fascicles, analyzing the degree of occupancy of the needle orifice in fascicular tissue by performing simulations of multiple positions that a needle orifice can take inside a cross-sectional nerve area.MethodsWe superimposed microscopic images of two routinely used nerve block needles (22-gauge, 15° needle and 22-gauge, 30° needle) over the microscopic images of cross-sections of four nerve types photographed at the same magnification. Fascicular tissue that was overlapped between 80% and 100% by a needle orifice was considered at risk to possible intrafascicular injection. The effect of three angular approaches was evaluated.ResultsThere were statistical differences between the vulnerability of fascicular tissue depending on nerve type, the bevel angle of the needle and the angle approach. Fascicular vulnerability was greater in nerve roots of the brachial plexus after using a 22-gauge 30° needle, as was choosing a 45° angle approach to the longitudinal axis of the nerve.ConclusionsOur results suggest that clinicians may want to consider needle insertion angle and bevel type as they perform peripheral nerve blocks. Furthermore, researchers may want to consider this mathematical model when estimating vulnerabilities of various nerves, needle types and angles of approach of needles to nerves.

Photoelectrochemical cells that utilize water as a source of electrons are one of the most attractive solutions for the replacement of fossil fuels by clean and sustainable solar fuels. To achieve this, heterogeneous water oxidation catalysis needs to be mastered and properly understood. The search continues for a catalyst that is stable at the surface of electro(photo)anodes and can efficiently perform this reaction at the desired neutral pH. Here, we show how oligomeric Ru complexes can be anchored on the surfaces of graphitic materials through CH–π interactions between the auxiliary ligands bonded to Ru and the hexagonal rings of the graphitic surfaces, providing control of their molecular coverage. These hybrid molecular materials behave as molecular electroanodes that catalyse water oxidation to dioxygen at pH 7 with high current densities. This strategy for the anchoring of molecular catalysts on graphitic surfaces can potentially be extended to other transition metals and other catalytic reactions. Efficient and stable water oxidation catalysts are important if photoelectrochemical cells are to be used to provide clean and sustainable solar fuels. A water oxidation catalyst that operates at neutral pH has now been developed that features ruthenium coordination oligomers anchored onto the surfaces of graphitic materials through CH–π interactions.

International audience; The performance of OER anodes based on supported nanocatalysts is highly dependent on the interactions taking place at the interface between the nanocatalyst and the employed conductive support. Herein, the versatility offered by the organometallic approach for the synthesis of metal-based nanostructures allowed preparing electrodes of tailored nanocatalyst–support interactions. A set of OER working electrodes based on Co(OH)2 nanoparticles (NPs) and carbon microfibers (CFs) were prepared. The so-obtained systems differ in either the stabilizer present at the surface of the NPs (THF or 1-heptanol), the surface functionalization of the used CFs (bare CFs or oxidized-CFs) or the growth of the NPs in the presence (in situ) or the absence (ex situ) of the carbonaceous support. Correlation of a detailed structural and compositional analysis with the electroactivity of the tested nanomaterials allows extracting valuable insights about the influence of the metal–support interface on the OER performance of the studied anodes.

Purpose: High doses of local anesthetic administered intra-articularly and peri-articularly during local infiltration analgesia (LIA) for total knee arthroplasty (TKA) may have potential effects on patient hemodynamics. The aim of this study was to know if hemodynamic changes are associated with LIA in patients undergoing TKA. Methods: In a prospective observational design, elective patients undergoing orthopedic surgery for TKA and treated with LIA consisting of a mixture of ropivacaine (300 mg) and epinephrine (1 mg) were investigated for changes in selected hemodynamic parameters: heart rate (HR), non-invasively registered mean arterial blood pressure (MAP), and incidence of arrhythmias during the perioperative course, consisting of the following periods: period 1. from establishment of spinal anesthesia to prior to LIA administration, period 2. from administration of LIA to before release of ischemia tourniquet, period 3. from release ischemia tourniquet to end of surgery, and period 4. from transfer to the post anesthesia care unit to the ward. Statistical analysis was done with ANOVA-RM for the difference in means in repeated measurements, and with the Tukey Test between pairs. Data are presented as mean ± standard deviation. A P value 0.50), and from period 2 to period 4 (89 ± 13 to 91 ± 11 mmHg, P > 0.50). No arrhythmias were detected during follow-up. Conclusions: A mixture of ropivacaine and epinephrine for LIA, despite the high doses administered, does not have a negative impact on hemodynamics.

Introduction Thoracic erector spinae plane block is now performed in many different surgical procedures, including lumbar spinal fusion. We evaluated the analgesic effect of lumbar ESP performed at L4 after lumbar spinal fusion surgery. Methods and case series Eight patients scheduled for lumbar spinal fusion were included in the case series. Erector spinae plane block was performed at L4 preoperatively, administering 20 ml of 0.2% ropivacaine on each side. We recorded patient-reported pain intensity during the first 48 postoperative hours using a visual analogue scale (VAS) and rescue analgesia requirements. Pain at rest was controlled in all patients (VAS 0–3), although pain on movement ranged from mild to severe (VAS 0–8). Rescue analgesia consumption ranged from 1 to 22 mg morphine. Conclusions Lumbar ESP appears to contribute to pain control during the first 48 h after lumbar spinal fusion.

Resumen Introduccion El bloqueo en el plano del erector espinal (erector spinae plane [ESP]) a nivel toracico se ha desarrollado en los ultimos anos en multitud de procedimientos quirurgicos, incluido los pacientes tratados mediante artrodesis lumbar. Nos propusimos evaluar el efecto analgesico del ESP realizado a nivel lumbar L4 en el postoperatorio inmediato en pacientes intervenidos por artrodesis lumbar. Metodos y casos clinicos Descripcion de una serie de 8 casos clinicos intervenidos por artrodesis lumbar a quienes se les realizo un bloqueo del ESP lumbar bilateral en L4 con 20 ml de ropivacaina al 0,2% por lado. Se describio la intensidad del dolor durante las primeras 48 h del postoperatorio mediante escala visual analogica y la analgesia de rescate empleada. El dolor postoperatorio en reposo fue controlado en todos los pacientes (entre 0 y 3), si bien el dolor en movimiento fue considerado entre leve y severo segun los pacientes (entre 0 y 8). El consumo de rescate fue entre 1 y 22 mg de morfina. Conclusiones El ESP lumbar parece contribuir al control del dolor postoperatorio inmediato durante las primeras 48 h en pacientes intervenidos por artrodesis lumbar.

Resumen Introduccion El bloqueo en el plano del erector espinal (erector spinae plane [ESP]) a nivel toracico se ha introducido como metodo analgesico postoperatorio. Sin embargo, a pesar de que su empleo a nivel lumbar ha sido publicada, su distribucion y su mecanismo de accion no han sido esclarecidos. Nos propusimos describir la tecnica de puncion del bloqueo ESP a nivel lumbar y evaluar la distribucion de 20 ml administrados a nivel de la transversa de L4 en un modelo cadaverico. Metodos Estudio observacional tras 12 bloqueos del ESP lumbar en L4, sobre un modelo de cadaver fresco (6 bilaterales). Se valoro la distribucion de 20 ml de solucion inyectada contrastada mediante tomografia computarizada en las 6 muestras. Fueron evaluados mediante estudio anatomico 4 de las muestras, 2 mediante diseccion por planos y otros 2 fueron congelados y seccionados con cortes axiales de 2-2,5 cm de grosor. Resultados La distribucion de la solucion inyectada se distribuyo en el interior de la musculatura erectora espinal craneo-caudal desde L2 a L5, con limite medial en la articulares interapofisarias y lateral en la fascia toracolumbar. El paso anterior a la transversa no se observo en el 33% de los casos, fue minimo y sin afectacion de los nervios espinales correspondientes en el 51%, siendo extenso en 2 muestras (16%) y con afectacion del nervio espinal correspondiente. Conclusiones El ESP lumbar a nivel de L4 tiene una accion constante sobre los ramos posteriores de los nervios espinales, siendo infrecuente su paso al espacio paravertebral y bloquear el nervio espinal.

Introduction Thoracic erector spinae plane (ESP) block is now used for postoperative analgesia. However, although reports of lumbar ESP have been published, the anesthetic spread and mechanism of action of this technique remains unclear. We describe the lumbar ESP block technique and evaluate the spread of 20 ml of solution administered at the level of the transverse process of L4 in a cadaver model. Methods Observational study after 12 lumbar ESP blocks at L4 on a fresh cadaver model (6 bilaterally). The spread of 20 ml of injected contrast solution was assessed by computed tomography in all 6 samples. Four of the samples were evaluated by anatomical study, 2 by plane dissection, and 2 others were frozen and cut into 2–2.5 cm axial slices. Results The injected solution spread from L2 to L5 in a cranio-caudal direction in the erector spinae muscle, reaching the facet joints medially and the thoracolumbar fascia laterally. In 33% of cases the solution did not spread anterior to the transverse process; in 51%, spread was minimal and did not affect the corresponding spinal nerves, and in 2 samples (16%), spread was extensive and reached the corresponding spinal nerves. Conclusions Lumbar ESP at L4 always acts on the posterior branches of the spinal nerves, but seldom spreads to the paravertebral space to block the spinal nerve.

Purpose of review Summarize the current thinking concerning the clinically relevant aspects of nerve anatomy and best injection sites for nerve blocks. Recent findings The widespread use of ultrasound in regional anesthesia has changed the practice of regional anesthesia and created new possibilities. Among them is the ability to identify fascial planes, and this has become the basis for a new group of blocks, the fascial plane blocks. In this kind of blocks, the target for injection is the plane itself and not a nerve in particular. transversus abdominis plane, pectoralis muscles, erector spinae plane blocks are some examples of fascial blocks. Because injecting into a fascial plane is not controversial, these blocks are not included in our discussion of optimal placement of the needle.To determine optimal needle placement, it is important to have a clear definition of what constitutes intraneural. Although, there is almost universal agreement that the violation of the epineurium defines the intraneural concept, the literature include several studies where this assessment is erroneous.Although intentional intraneural injection is still considered objectionable, some literature suggests that injecting intraneurally, especially if extrafascicular, may be benign. This evidence is limited and anecdotal. Summary It is necessary to have a better understanding of what intraneural injection is when dealing with any type of nerve blocks, be that single nerve, plexuses, or the sciatic nerve. Perineural injections provide successful anesthesia without putting the nerve integrity at risk. That practice is supported by years of experience and common sense. Currently, there is no evidence to support any kind of intraneural injections, intrafascicular or extrafascicular.

Introduction To recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage. However, signs of intraneural injection are not clearly established. The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1 ml of solution. Material and methods Ultrasound guided median nerve blocks were performed in the forearm of 10 fresh cadavers on 60 occasions (3 per forearm). They were randomised into the intraneural (n = 30) or perineural (n = 30) location of the needle tip, after the consensus of location by 7 specialists. After 1 ml of solution was injected an evaluation was made of the changes in the cross-sectional area of the nerve, as well as the displacement along the nerve. Results The cross-sectional area of the median nerve was increased in both groups, however, the increase was significantly higher in the Intraneural group (perineural 0.007 ± 0.013 cm2 vs. intraneural 0.032 ± 0.021 cm2, p Conclusions Based on this experimental study, it is concluded that the injection of a small volume (1 ml) allows to discriminate the disposition of the intraneural vs perineural needle in a high percentage of cases. Therefore, it is suggested that this “dose test” should be considered in the safety algorithms if it is required to reduce the incidence of intraneural injection.

Resumen Introduccion Conocer la relacion entre la aguja y el nervio durante el bloqueo de nervio periferico es de interes para evitar el dano neural; sin embargo, los signos de inyeccion intraneural no se hallan claramente establecidos. Nos propusimos determinar los cambios observados en el nervio periferico tras inyectar 1 ml de solucion en disposicion intraneural o perineural de la aguja. Material y metodos Se utilizaron 10 cadaveres frescos, a los cuales se les realizo bloqueo de nervio mediano ecoguiado en plano en 60 ocasiones (3 por brazo), realizando una puncion intraneural (n = 30) o perineural (n = 30) segun aleatorizacion previa. Tras el consenso de localizacion por 7 especialistas, se inyecto 1 ml de solucion y se evaluo el cambio en el area de seccion del nervio y el desplazamiento a lo largo del mismo. Resultados El area de seccion del nervio mediano se aumento en ambos grupos, sin embargo, el incremento fue significativamente mayor en el grupo intraneural (perineural 0,007 ± 0,013 vs. intraneural 0,032 ± 0,021 cm2, p Conclusiones En base a nuestro estudio experimental concluimos que la inyeccion de un pequeno volumen (1 ml) permite discriminar la disposicion de la aguja intraneural vs. perineural en un porcentaje elevado de casos. Por ello, sugerimos que esta «dosis test» debe de considerarse en los algoritmos de seguridad si queremos reducir la incidencia de inyeccion intraneural.

Molecular water oxidation catalysis is a field that has experienced an impressive development over the past decade mainly fueled by the promise of generation of a sustainable carbon neutral fuel society, based on water splitting. Most of these advancements have been possible thanks to the detailed understanding of the reactions and intermediates involved in the catalytic cycles. Today's best molecular water oxidation catalysts reach turnover frequencies that are orders of magnitude higher than that of the natural oxygen evolving center in photosystem II. These catalysts are based on Ru complexes where at some stage, the first coordination sphere of the metal center becomes seven coordinated. The key for this achievement is largely based on the use of adaptative ligands that adjust their coordination mode depending on the structural and electronic demands of the metal center at different oxidation states accessed within the catalytic cycle. This Review covers the latest and most significant developments on Ru complexes that behave as powerful water oxidation catalysts and where at some stage the Ru metal attains coordination number 7. Further it provides a comprehensive and rational understanding of the different structural and electronic factors that govern the behavior of these catalysts.

BACKGROUND Standard analgesic strategies for total knee arthroplasty employ local infiltration analgesia. Blockade and radiofrequency ablation of the genicular nerves are effective treatments for patients with chronic pain because of knee osteoarthritis. OBJECTIVE To test the noninferiority of the analgesic effect of genicular nerves block in comparison with local infiltration analgesia after 24 h of total knee arthroplasty. DESIGN Prospective cohort study. SETTING Perioperative setting. PATIENTS Thirty-five patients scheduled for total knee arthroplasty were prospectively included in the study and compared with 35 patients in a retrospective cohort. INTERVENTION Genicular nerve blocks in the prospective cohort were compared with local infiltration analgesia in the retrospective cohort. MAIN OUTCOME MEASURES The pain numeric rating scale and the cumulative opioid consumption in oral morphine equivalents during the first 24 h. RESULTS We conducted propensity score-matched analyses of patients using acute postoperative pain-related risk covariates. After one-to-one propensity score matching, 21 patients were included in the local infiltration analgesia group and 21 in the genicular nerve block group. The median difference in numeric rating score at rest at 24 h was -0.99 [95% confidence interval (CI), -1.99 to 0.5, P = 0.012] on the unmatched cohort and -1.9 (95% CI, -2 to 0, P = 0.002) on the matched cohort (meeting the noninferiority criteria, Δ=1). The median difference in cumulative opioid consumption was 2.5 mg (95% CI, -13.5 to 2.5, P

A family of Cu-based complexes bearing dianionic bpy-amidate ligands have been prepared and characterized by spectroscopic and electrochemical techniques. The new complexes are capable to perform water oxidation catalysis at overpotentials between 557- 830 mV pH 11.6. A detailed electrocatalytic study in combination with computational calculations revealed the all ligand-based nature of the electron transfer processes involved in the catalytic cycle.

To the Editor We would like to thank Soel and Tsui[1][1] for their interest in our recently published study.[2][2] Though we agree with most of their comments, we would like to dig a little deeper on the subject. First of all, it is imperative to differentiate between intraneural injection and