Ottawa Hospital

Hip arthroscopy is an increasingly common outpatient surgical procedure where postoperative pain can be severe. Peripheral nerve blocks have been evaluated for analgesia following hip arthroscopy; however, there is no consensus on an optimal technique that provides effective local anesthetic-based postoperative analgesia without motor blockade. We hypothesized that the pericapsular nerve group (PENG) block would provide effective motor-sparing analgesia following ambulatory hip arthroscopy. We conducted a randomized placebo-controlled double-blind trial comparing an ultrasound-guided PENG block with 20 mL of 0.5% ropivacaine to a control with a sham injection. Our primary outcomes were cumulative opioid consumption (oral morphine equivalent) and quality of recovery (QoR-15) scores at 24 hours postoperatively. Secondary outcomes included pain, postoperative opioid consumption, time to first analgesic request, postanesthesia care unit (PACU) length of stay, and opioid and block-related side effects. 94 patients were included (47 per group). QoR was similar between groups at 24 hours as measured by the QoR-15 (range 0-150, higher scores indicate better recovery): mean SD 96.8±20.9 in the PENG group versus 101.0±20.9 in the control group (mean difference -4.2; adjusted p=0.414). Opioid consumption at 24 hours was also similar between groups. In adjusted analyses, the PENG group required less opioid analgesia in the PACU (mean difference -9.5 MME; p=0.039) and had a shorter PACU stay (mean difference -20.5 min; p=0.027). Pain scores at rest and on movement decreased over time in both groups, with no consistent differences in overall pain trajectories. Opioid consumption at 48 hours, opioid-related adverse effects and block-related complications were similar between groups. When administered preoperatively, the PENG block provides only modest early perioperative benefits without improving overall postoperative analgesia or QoR in patients undergoing ambulatory hip arthroscopy. Based on these findings, routine preoperative use of the PENG block for ambulatory hip arthroscopy cannot be recommended beyond standard multimodal analgesia, although it may be considered selectively to facilitate early PACU recovery in carefully chosen patients. The potential role of postoperative PENG block as a rescue intervention warrants further investigation. NCT03449680; https://clinicaltrials.gov/study/NCT03449680.

Antiphospholipid antibodies (aPL) are directed against phospholipids and phospholipid-binding proteins. Laboratory assays used to detect aPL include serological tests for aPL against β2-glycoprotein 1, cardiolipin and other molecules, as well as functional assays for lupus anticoagulant. The presence of aPL can lead to endothelial dysfunction or a hypercoagulable state through prothrombotic and antifibrinolytic mechanisms. These processes, often in conjunction with a 'second hit', such as trauma, surgery, or other causes of hypercoagulability or stasis, can lead to venous or arterial thrombosis. The thrombotic risk associated with aPL is best recognized in thrombotic antiphospholipid syndrome, characterized by a persistently positive test for lupus anticoagulant or seropositivity for aPL associated with venous, arterial or microvascular thrombosis. However, aPL seropositivity and its clinical effect on thrombotic events have been increasingly recognized in a broader group of individuals who do not meet traditional research criteria for thrombotic antiphospholipid syndrome. In this Review, we provide an overview of the evidence related to aPL seropositivity in individuals with or without previous thrombosis and the clinical relevance of aPL seropositivity in predicting the risk of thrombotic cardiovascular events. We discuss potential management strategies and identify key knowledge gaps that warrant further research.

The general recommendation for hypoglycemia treatment is 15 grams (g) of simple carbohydrates, with re-check in 15 minutes. This oral hypoglycemia treatment is universally applied without consideration of the type of diabetes or the cause of hypoglycemia. These recommendations were only based on two small-sized studies of intravenous insulin-induced hypoglycemia in adults living with type 1 diabetes mellitus (T1D). We aimed to determine, in people living with T1D, which oral carbohydrate treatments attain >50% non-severe hypoglycemia (glucose 3.0 to 3.9 mmol/L) resolution at time of first glucose re-check. Medline, Embase, Scopus, and Cochrane Central Register of Controlled Trials were searched for full-text studies of oral treatment for non-severe hypoglycemia in T1D. Two authors screened the results and extracted data. Amongst the four studies of multiple daily insulin injections or non-closed-loop insulin pumps, >50% hypoglycemia resolution at first re-check was only observed in two studies: exercise-induced hypoglycemia study with 20 grams of glucose treatment attaining 60% hypoglycemia resolution at 15 minutes; real-life patient recorded study with 0.2 grams per kilogram body weight (g/kg) or 0.3 g/kg or 15 g glucose tablet treatment attaining 61%, 71%, and 63% hypoglycemia resolution at 10 minutes, respectively. Two of the three studies of closed-loop insulin pumps achieved >50% hypoglycemia resolution at first re-check: 16 grams of glucose tablets at 20 minutes attained 58% hypoglycemia resolution; 10 to 30 g of sucrose attained 79 to 100% hypoglycemia resolution at 15 minutes. The optimal quantity of oral carbohydrate treatments for T1D required to attain hypoglycemia resolution at first glucose re-check varies based on cause of hypoglycemia and type of insulin management.Systematic Review Registration: Prospero registration number: CRD420251033695; no amendments. Study protocol and literature search strategies are available from the authors upon request.

Introduction: Functional pituitary tumors (FPT) are hormone-producing adenomas that present distinct surgical difficulties, primarily because they are often microadenomas and require total removal to restore normal hormone levels. Distinguishing these tumors from healthy pituitary tissue during endoscopic transsphenoidal surgery can be challenging. Indocyanine green (ICG) fluorescence has shown promise as a technique to enhance visualization during surgery; however, its use in FPTs remains poorly defined. This literature review aims to evaluate the use of ICG in endoscopic transsphenoidal surgery for adult functional pituitary tumors. The primary focus is on assessing complete tumor resection, biochemical remission, and tumor differentiation from normal tissue after ICG use. Secondary goals include reviewing different ICG administration methods. Methods: We developed a search strategy to perform a systematic literature search across multiple databases with a set of MeSH terms and keywords on the OVID platform. In addition, we conducted a manual literature search by reviewing the reference lists of the studies included. After this, the relevant search results were uploaded to COVIDENCE for systematic management of the screening process by two reviewers. Articles that met our inclusion criteria were then selected for data extraction. Results: The initial search results gave 319 studies, of which 10 met the inclusion criteria after going through various screening phases. These were then included in the final analysis, consisting of 55 adult FPT cases. The majority of studies reported successful differentiation between tumor and normal pituitary tissue, with ICG fluorescence facilitating complete tumor resection and subsequent biochemical remission. Our review also identified two primary ICG administration techniques: low-dose intraoperative injection and high-dose preoperative administration. Conclusion: Findings from our study indicate that ICG fluorescence is a clinically effective tool for enhancing tumor visualization during endoscopic transsphenoidal surgery in adult FPT patients. Both low-dose intraoperative and high-dose preoperative ICG administration techniques showed promising outcomes in improving surgical precision. Having said that, further research, with larger comparative studies and the development of a standardized protocol, is required to optimize ICG use in FPTs as well as to address the variability in fluorescence intensity observed among different FPT subtypes.