Will AI keep you out of trouble? An expert panel review of LLMs for hazardous regional anesthesia consults.

Experience-driven differences in acute ischemic stroke management: A nationwide study.

Large cutaneous defects of the trunk and extremities are frequently encountered in dermatologic surgery and often exceed the limits of primary closure. Local flaps remain a strong reconstructive option because of their robust perfusion, excellent skin match, and ability to be performed under local anesthesia in the office setting. This experience-based narrative overview outlines the authors' preferred local flap techniques for the reconstruction of large truncal and extremity defects. Each approach is illustrated with representative cases. In our experience, local flaps provide dependable coverage for large truncal and extremity wounds while maintaining natural contour and mobility. Depending on anatomic site and defect characteristics, preferred options include A-T advancement, single- and double-arm (O-Z) rotation flaps, rhombic flaps, keystone flaps, and peri-areolar mobilization techniques. Local flaps remain versatile options for closure of large truncal and extremity defects.

Haemangiomas are benign vascular neoplasms typically diagnosed in infants and rarely seen in adults. Their occurrence in the medial canthal region is particularly uncommon and may clinically mimic more frequent benign lesions such as dermoid cysts. This is a rare case of an adult-onset medial canthal capillary haemangioma that was initially misdiagnosed as a dermoid cyst, emphasising the diagnostic challenge posed by such presentations. A 46-year-old female presented with a 10-year history of a painless, slowly progressive swelling over the right medial canthus. The lesion was soft, mobile, non-tender, and measured approximately 0.5×0.5 cm, without associated visual disturbances or discharge. Based on clinical examination, a provisional diagnosis of dermoid cyst was made. The lesion was surgically excised under local anaesthesia, revealing a well-circumscribed, encapsulated soft mass. Histopathological analysis demonstrated proliferation of capillary-sized blood vessels lined by flattened endothelial cells within a fibrous stroma, confirming the diagnosis of capillary haemangioma. The postoperative period was uneventful, and no recurrence was noted at three months follow-up. Adult-onset periorbital haemangiomas are extremely rare, with few cases documented in the literature. Their clinical presentation frequently overlaps with dermoid cysts due to similar location, consistency, and benign nature. Misdiagnosis is therefore common, highlighting the need for a high index of suspicion. Unlike infantile haemangiomas, adult variants do not undergo spontaneous involution and often require surgical excision for definitive management. This case underlines the importance of considering vascular tumours in the differential diagnosis of long-standing periorbital swellings in adults. Accurate diagnosis through histopathological confirmation is essential to avoid mismanagement and contributes to the limited existing literature on this rare clinical entity

Peripheral nerve blocks are widely used for anaesthesia in upper and lower limb surgery, but the methods used to assess their success vary substantially. This scoping review examined contemporary research practises and the extent to which trials report on peripheral nerve block evaluation. A search was conducted on PubMed for randomised controlled trials published between 2014 and 2025 in anaesthesia journals, involving pre-operative peripheral nerve blocks in adults undergoing limb surgery. Two independent authors screened and extracted data for each trial. Outcomes included the proportion of trials that reported block testing, described test methods, defined successful blocks, and reported success rates. Of 284 trials included, 215 (76%, 95% CI 71%-81%) reported testing blocks, and 210 (74%, 95% CI 69%-79%) described the test methods. Of the 215 trials reporting testing, 204 used sensory assessments (95%, 95% CI 91%-97%) and 157 used motor assessments (73%, 95% CI 67%-79%). Success criteria were defined in 164/284 trials (58%, 95% CI 52%-63%), and the same number reported success rates. In the 164 trials reporting on peripheral nerve block success, the median success rate was 98% (IQR 92%-100%). This scoping review investigated contemporary practise in test methodology reporting in RCTs involving PNBs. We found that although most trials do report testing PNBs, about one in four did not. Furthermore, approximately two in five trials did not define what constituted a successful block or report PNB success rates. Lack of consistent and transparent test methodology poses challenges when comparing trials and performing meta-analyses, and in translating trial findings into clinical practise. This scoping review exposes a methodological blind spot in regional anaesthesia research. Despite widespread use of peripheral nerve blocks, a substantial proportion of randomised trials fail to report testing methods, success definitions, or handling of failed blocks. Such omissions undermine interpretability, comparability, and clinical translation, and strengthen the case for standardised reporting of regional anaesthesia assessment in future trials.

Motor-sparing regional anaesthesia for lower limb burns: A novel combination of peripheral nerve blocks

Prostate cancer (PCa) is a prevalent urological malignancy, with a rising incidence. The transperineal prostate biopsy (TPB) is a widely adopted diagnostic procedure for confirming PCa. While traditional pharmacological interventions for pain management during TPB are accessible, their potential to induce gastrointestinal side effects and impair liver and renal function can restrict their clinical application. As a result, there is an escalating demand to delve into innovative nonpharmacological interventions (NPIs) that could potentially improve the management of pain in TPB patients. Among these, virtual reality (VR) has shown significant promise in the alleviation of pain and is currently under investigation for its potential synergistic effects when combined with supportive care practices. This study aims to assess the efficacy of handholding combined with virtual reality (HHVR) in reducing pain and anxiety among TPB patients, in comparison to a single NPI. We hypothesize that this integrated approach could offer superior pain management, potentially enriching the overall healthcare experience for those undergoing TPB. This study, a single-center, open-label, three-arm randomized controlled clinical trial, plans to enroll 177 patients undergoing their first TPB at a tertiary hospital in Sichuan Province, China. Participants will be randomly allocated to one of three groups: usual care, VR, and HHVR. The primary outcome measure is pain level assessment, with secondary endpoints including anxiety levels and salivary cortisol levels, the latter serving as a biomarker for stress response. Hemodynamic parameters will also be assessed to evaluate the physiological impact of the interventions. The primary analysis will adhere to the intention-to-treat principle, utilizing one-way analysis of variance to compare visual analog scale pain scores. Additionally, the study will examine the correlation between changes in salivary cortisol and patients' self-reported pain levels, aiming to establish an objective metric for pain assessment. This randomized controlled trial evaluated the therapeutic efficacy of a combined intervention, HHVR, for alleviating pain in patients undergoing TPB. The study also investigated the impact of HHVR on salivary cortisol levels, which are acknowledged as a reliable biomarker of stress-induced pain. Affirmative results would indicate that HHVR is efficacious in not only reducing pain but also diminishing anxiety levels. ClinicalTrials.gov ChiCTR2400084616. Retrospectively registered on 21 May 2024, https://www.chictr.org.cn.

Duration of analgesia and factors associated with block failure in ultrasound-guided ankle and popliteal/saphenous nerve blocks in elective foot and ankle surgery: A prospective observational study.

Periurethral injection of Bulkamid® for neurogenic vs. nonneurogenic female patients with stress urinary incontinence.

To evaluate the safety, feasibility, and short-term reliability of transvaginal sonography-guided ovarian cyst aspiration in women with benign-appearing ovarian cysts and to explore its potential economic and environmental implications compared with minimally invasive surgical management. This retrospective cohort study included women with sonographically benign ovarian cysts treated with transvaginal sonography-guided aspiration at a tertiary-care hospital between January 2024 and October 2025. Patient characteristics, cyst morphology according to International Ovarian Tumor Analysis (IOTA) Simple Rules, procedural feasibility, complications, and recurrence rates were analyzed. In addition, targeted literature reviews were performed to contextualize reported health care costs and carbon footprints of laparoscopic gynecologic procedures. Twenty-two women were included. The median age was 58years (range 31-87), the median cyst diameter was 5.9cm (range 2.8-10.0), and the median aspirated volume was 55mL (range 9-600). All cysts fulfilled benign sonographic criteria, most commonly IOTA pattern B1 (77.3%), and were predominantly located in the Douglas space (77.3%). The procedure was technically feasible in 95% of cases and was performed under local anesthesia in all but one patient. No major intra or post-interventional complications occurred. One cyst recurrence (4.5%) was documented during follow-up, noting that most patients were assessed only via self-presentation. Literature data indicate substantially higher health care costs for laparoscopic and robotic gynecologic procedures compared with sonography-guided interventions. Published studies report a mean carbon footprint of approximately 42kg CO2e per laparoscopic procedure, while no data are currently available for sonography-guided cyst aspiration. Transvaginal sonography-guided ovarian cyst aspiration appears to be a safe and feasible treatment option for carefully selected benign ovarian cysts, with low short-term recurrence and minimal morbidity. Available evidence suggests potential economic advantages and a likely lower environmental impact compared with minimally invasive surgery. Given the small sample size, this approach should be considered a complementary or alternative option in selected patients rather than a first-line treatment and warrants further evaluation in larger prospective studies.

Local anesthetic systemic toxicity is a rare but potentially life-threatening complication of regional anesthesia that can occur when high doses of local anesthetics are administered. This study aimed to evaluate the frequency of local anesthetic doses exceeding safe thresholds in axillary brachial plexus blocks using four different calculation methods. This retrospective study analyzed 2395 patients who underwent axillary brachial plexus block between 2017 and 2021 at Geneva University Hospitals. Four progressively more conservative sets of dosing rules were systematically applied. These included standard package insert recommendations, weight-based limits using actual weight, weight-based limits using ideal body weight, and consensus-based rules adapted to patients' comorbidities and treatments. For local anesthetic mixtures, proportional calculations were applied to determine cumulative maximum safe doses. Using the most conservative calculation method, local anesthetic doses exceeded maximum safe thresholds in 64.8% of cases, compared to 29.5% using package insert recommendations. Potentially unsafe doses were consistently more frequent with local anesthetic mixtures (85.4%) compared to single agents (32.4%) across all calculation methods. Symptoms compatible with local anesthetic systemic toxicity occurred in 19 patients (0.79%), with severe manifestations in 9 cases (0.38%). No significant relationship was found between these symptoms and potentially unsafe doses, regardless of the calculation method used. This study reveals substantial variation in local anesthetic dosing practices for axillary brachial plexus blocks. Rates of potentially unsafe doses varied significantly depending on the criteria applied. The consistent pattern of higher rates of potentially unsafe doses with mixture use highlights opportunities for practice standardization and improved safety protocols in regional anesthesia. The multiple calculation approaches allow clinicians to compare findings with their own institutional practices.

Survival of indirect pulp capping in deeply carious primary molars under local versus general anesthesia: a retrospective cohort study using propensity score matching.

Most transforaminal endoscopic lumbar discectomy (TELD) surgeries performed under local anesthesia involve intricate procedures, require multiple fluoroscopy sessions, and have a steep learning curve. This study introduces a modified technique aimed at optimizing TELD for lumbar disc herniation. A total of 76 patients (42 men and 34 women, mean age 53.8 years) underwent TELD using a "Guiding Rod" for simplified positioning and visual trephine for foraminoplasty. Parameters, including the fluoroscopy frequency, positioning time, foraminoplasty time, operation time, and intraoperative blood loss, were meticulously recorded and retrospectively analyzed. The Visual Analog Scale pain score, Japanese Orthopedic Association, and Oswestry Disability Index score were evaluated preoperatively and at 3 days, 3 months, and 6 months postoperatively. Implementing our modified technique resulted in a mean fluoroscopy frequency of 3.93 ± 0.97 times and a mean positioning time of 3.60 ± 1.10 minutes. The mean foraminoplasty time was 3.88 ± 1.82 minutes, and the mean operation time was 48.38 ± 10.85 minutes. Intraoperative blood loss remained consistently below 15 mL, with no reported complications. All clinical scores (visual analog scale, Japanese Orthopedic Association, and Oswestry Disability Index) improved significantly compared with preoperative values. The use of the "Guiding Rod" for simplified positioning alongside visual trephine application in TELD for lumbar disc herniation demonstrates ease of operation and safety and minimizes radiation exposure, thereby optimizing TELD technology. This study highlights advanced techniques in transforaminal endoscopic discectomy.

Weightbearing radiographs accurately predict deep deltoid ligament injury in Weber B ankle fractures - a minimally invasive arthroscopic evaluation.

Efficacy and safety of sacral erector spinae plane (S-ESP) block in adult and pediatric patients during surgical procedures: A comprehensive systematic review and meta-analysis.

General anesthesia (GA) has long been the preferred modality of anesthesia for spine surgery, including transforaminal lumbar interbody fusions (TLIFs). However, recent advances in regional anesthesia, including spinal (awake) anesthesia and regional blocks, have demonstrated potential improvements in both surgical outputs and recovery times compared with GA. This study aims to describe the associations between regional anesthesia, clinical outcomes, and opioid utilization among patients undergoing TLIF. The electronic medical records of a single fellowship-trained spine surgeon were analyzed retrospectively, and patients undergoing a single-level TLIF between 2018 and 2024 were included. Pre- and postoperative clinical measures (eg, length of stay, operating time, and readmission rates) and both intra- and postoperative opioid use were collected. All data were analyzed using a multivariable regression model. Compared with GA, awake anesthesia was associated with reduced intraoperative opioid utilization (P = 0.007) across all TLIF groups, while the use of an erector spinae plane (ESP) block was associated with a reduced length of stay (P = 0.044) and lower postoperative opioid utilization (P < 0.001). The use of spinal anesthesia combined with the use of an ESP block was associated with significantly lower length of stay and lower postoperative morphine equivalent daily dose (P = 0.030 and P = 0.002, respectively). Awake TLIF surgery under spinal anesthesia and the use of an ESP block were independently associated with reduced opioid usage, while the combined use of these techniques was associated with decreased length of stay and reduced postoperative opioid usage. Additional investigation and prospective studies are needed to further elucidate these complex relationships. The relationship between regional anesthesia and patient outcomes has not been comprehensively characterized in the TLIF patient population despite the growing utilization of these techniques in spine surgery. Once established, these findings have potential implications for the integration of regional anesthesia into TLIF procedures as a new standard of care. Preliminary evidence suggests that regional anesthesia offers multiple benefits over GA, including health and mortality outcomes, time to ambulation and recovery, and incidence of postoperative complications. However, little is known about the applicability of these findings to patients undergoing TLIF.

The Plan A blocks framework was proposed in 2019 with the aim of promoting a small number of versatile, high-value regional anaesthetic techniques to build core competencies among all anaesthetists. Clinical practice, educational curricula and academic understanding have evolved since then. We aimed to provide a pragmatic and clinically focused narrative review on the current understanding of Plan A blocks and to explore their implementation and signpost future directions. We conducted a focused literature search for articles of relevance to Plan A blocks. We also searched online resources, including websites of societies and institutions, for evidence relevant to our primary area of interest. Plan A blocks have influenced the Royal College of Anaesthetists' curriculum and inspired several international consensus projects defining core blocks for adult and paediatric practice. Delphi studies have supported the inclusion of interscalene brachial plexus, axillary brachial plexus, femoral and sciatic nerve blocks as key techniques. Despite wide dissemination, challenges hindering clinical practice change persist, including resource limitations; lack of confidence; and variable access to structured training. Emerging educational technologies such as simulation, artificial intelligence-assisted ultrasound interpretation and augmented reality offer promise, but remain limited by cost and fidelity. The Plan A blocks framework has become an established concept and is accepted widely as a pragmatic, scalable strategy. Although barriers remain to clinical practice change, ensuring widespread competence in Plan A blocks and implementation into clinical pathways should improve patient access to regional anaesthesia globally.

Metronome Rhythm Based Auditory Stimulation Modulates Pain and Anxiety During Transperineal Prostate Biopsy: A Prospective Clinical Study.

This study aims to structure knowledge on the problem of regional anesthesia complications: its etiopathogenesis, symptoms, diagnostic methods, and approaches to prevention are examined. Regional anesthesia is a crucial component of modern perioperative protocols, providing effective analgesia, reducing opioid use, and accelerating recovery. However, this technique is associated with certain risks, ranging from mild and temporary to severe and persistent complications. Their occurrence is often associated with noncompliance with clinical guidelines and standards. The most common early complications include block failure, toxic effects of local anesthetics on the central nervous and cardiovascular systems, and unintentional puncture of adjacent structures. Total spinal anesthesia with epidural technique poses a serious but rare risk. Among neurological complications, transient neuropathies predominate, usually associated with surgical trauma, tension, or ischemia. Post-dural puncture headache after spinal anesthesia is a separate category. Infections (abscess, meningitis) and hematomas in the spinal canal are rare but carry the risk of irreversible spinal cord damage. The risk of complications is increased by technical difficulties, anatomical abnormalities, coagulopathy, and the patient's comorbidities. Strict aseptic technique, the use of instrumental guidance for precision, and controlled dosage of local anesthetics play a key role in prevention.

Traditionally, regional anesthesia has been considered a local analgesic technique with benefits limited to the site of blockade. However, emerging preclinical and clinical evidence indicates that it may produce systemic effects by modulating the gut-brain axis. The gut-brain axis is a bidirectional regulatory system that integrates neural, immune, endocrine, and microbial signaling and is crucial for managing perioperative stress, inflammation, and physiological balance. This perspective article examines how regional anesthesia influences the gut-brain axis through several interconnected pathways, including neural modulation, immune regulation, endocrine effects, and indirect alterations in gut microbiota. We argue for reconceptualizing regional anesthesia as a systemic modulator and discuss its potential applications in perioperative recovery and chronic disease management. We conclude by calling for interdisciplinary research and mechanism-focused clinical trials to integrate this perspective into a more holistic model of perioperative medicine.