Site Block Research Articles

An injectable oleogel-based bupivacaine formulation for prolonged non-opioid post-operative analgesia.

Opioid-based medications remain the mainstay of post-operative pain management, even though they are associated with a plethora of adverse effects including addiction, nausea, constipation, cognitive impairment, respiratory depression, and accidental death due to overdose. Local anesthetics are effective at controlling the intense pain after surgery but their short duration of effect limits their clinical utility in post-operative pain management. In this manuscript, an optimized injectable oleogel-based formulation of bupivacaine for multi-day post-operative pain management was characterized on the benchtop and assessed in two clinically-relevant porcine post-operative pain models. Benchtop characterization verified the optimized oleogel-based bupivacaine formulation design, demonstrating a homogenous stable oleogel with sufficient injectability due to shear-thinning properties, high drug loading capacity and first-order drug release kinetics over 5days. In vivo assessment in two pig post-operative pain models demonstrated that the oleogel-based bupivacaine formulation can provide statistically significant multi-day analgesia in two routes of administration: local instillation directly into a surgical site and ultrasound-guided peripheral nerve block injection. Pharmacokinetic assessment of ALX005 found that Cmax values were not statistically different from the bupivacaine HCl control, with no clinical signs of local anesthetic systemic toxicity observed, when administering up to 2.7 and 8.1 times the control dose of bupivacaine HCl. This study demonstrates the pre-clinical safety and efficacy of an injectable oleogel-based bupivacaine formulation and explores its utility as a single-administration long-acting local anesthetic product for post-operative pain management that can be used in both local and regional anesthetic applications.

Treatment of 5th Metecarpal Neck Fractures with Titanium Elastic Nail Using Local Anesthesia and Hematoma Block

Objective:Surgical treatment of 5th metacarp neck fractures using titanium elastic nail (TEN) is performed under general anesthesia or axillary block. In this study, our aim is to present the clinical and radiological results of patients who underwent surgery under local anesthesia for the TEN entry site and hematoma block for fracture reduction. Methods: There were 14 patients who met the inclusion criteria in the study. Radiologically, metacarpal shortness and volar angulation angles at the time of admission, after reduction in the ER and after surgical intervention when the fusion had been achieved were evaluated. Clinically, rotational deformity, range of motion of the affected finger were evaluated according to Quick DASH scores. Results: The volar angulation before and after reduction in ER was found to be as a mean of 46.2° (33-60°) and 40.6° (30-48°) respectively. After surgical intervention a mean of 17.2° (10-22°) was achived at the final follow-up. The metecarpal shortness was determined to be mean 4.4 mm (1.8-7.3mm) on first presentation, 3 mm (2-5 mm) after reduction in ER, and 2 mm (1.2-3.3mm) at the final follow-up examination in surgically treated group compared to healthy side. Radiological bone union was observed in mean 35 days, there was no pain on palpation, and the TEN was removed. Finger flexion and extension were determined to be full at the end of the 3rd month and no rotational defomity was observed. The mean Quick DASH score of the patients was 1.5 (1.2-2). Conclusion:5. metacarpal fractures with TEN under hematoma blockage and local anesthesia and leaving the proximal end out of the skin is a safe method for the treatment of such fractures.

Knowledge, Application and Practice of "Stop and Mock Before You Block" among Anaesthetic Doctors in Hospital Kuala Lumpur

Introduction : Safe practice during regional anaesthesia is important to ensure avoidance of morbidity and mortality. The Stop and Mock Before You Block is a safety initiative that is developed to prevent wrong sided and site regional blocks. The study aims to identify the incidences of wrong side or site blocks and also identify the knowledge, application and practice of anaesthetic doctors in Hospital Kuala Lumpur. Method : This is a observational descriptive study, where a questionnaire in the format of Google Form is distributed among Anaesthetic doctors via Whatsapp. The data was then collected and analysed using SPSS to generate frequencies and mean of responses. It was also used to analyse the relationship between the variables and demographics. Results : A total of 143 anaesthetic doctors responded. The study found an incidence of 8 wrongly performed blocks. The study also found significant correlation between years of practice and doctor’s grade to the knowledge, application and practice components. Conclusion : The study has identified 8 occurrences of wrong side or site block that has occurred among the anaesthetic doctors in Hospital Kuala Lumpur. Based on the results of the study, majority of the anaesthetic doctors had moderate to poor knowledge, application and practice of the Stop and Mock Before You Block safety initiative.

Enzyme-free nucleic acid and luminescent material cascade amplifications enable urinary dual miRNAs assay for non-invasive bladder cancer diagnosis

We presented a facile biosensing strategy for the detection of dual microRNAs (miRNA-21 and miRNA-126) in urine samples from bladder cancer (BC) patients. The fluorescent homogeneous detection of miRNAs was achieved by elaborate parallel catalytic hairpin assembly (CHA) integrated with material cascade amplifications. The continuous release of G-quadruplex (G4) sequences and Hg2+ was attributed to the specific recognition between the miRNAs and the corresponding hairpin oligonucleotides. Assisted by the streptavidin-(T-Hg2+-T-biotin)4 structures, more Hg2+ emission was obtained, and the spatial site block effect was used to order its distribution, significantly improving the selective recognition performance of cadmium telluride quantum dots (CdTe QDs) (1.4–2.9 times). Furthermore, the peroxidase-like activity of G4-hemin was used to catalyze the oxidation of dopamine (DA) to fluorescence-enhanced polydopamine (PDA). The generated PDA signal and the Hg2+-quenched CdTe QDs signal completed the synchronous detection to achieve a high-sensitivity analysis of the dual miRNAs. The limit of detection (LOD) of both miRNAs was as low as the fM level. Eventually, 56 clinical urine samples were quantified. The results showed satisfying specificity (100%) and sensitivity (92%) with a strong clinical agreement, including computed tomography (CT) and pathology findings, indicating a rapid non-invasive solution for early diagnosis of BC.

Early rhythm-control therapy for atrial fibrillation in patients with a history of stroke: a subgroup analysis of the EAST-AFNET 4 trial

Patients with atrial fibrillation and a history of stroke are at high risk of recurrent stroke and cardiovascular complications. In the EAST-AFNET 4 trial we showed that a systematic strategy of early rhythm control was associated with a lower risk of cardiovascular outcomes than usual care in patients with atrial fibrillation diagnosed in the past 12 months. In this pre-specified subgroup analysis we aimed to assess whether a strategy of early rhythm control is safe and can prevent adverse cardiovascular outcomes compared with usual care in such patients. EAST-AFNET 4 was a randomised, open-label trial with blinded-outcome assessment done at 135 hospitals and secondary care practices in 11 European countries. Adults with early atrial fibrillation (ie, diagnosed ≤12 months before enrolment) were randomly assigned (1:1) to either early rhythm control or usual care, with stratification according to site and variable block lengths used for concealment. The first primary outcome was time to first occurrence of the composite of cardiovascular death, ischaemic or haemorrhagic stroke, or hospital admission with worsening of heart failure or acute coronary syndrome. The second primary outcome was the number of nights spent in hospital in 1 year. The primary safety outcome was the composite of any death, stroke, or serious adverse events related to rhythm-control therapy. Here we present the results of these outcomes in patients with a history of stroke. Analyses were done in the intention-to-treat population. EAST-AFNET 4 is registered with ClinicalTrials.gov (NCT01288352), EudraCT (2010-021258-20), and ISRCTN (ISRCTN04708680). Between July 28, 2011, and Dec 30, 2016, 2789 patients were randomly assigned in the EAST-AFNET 4 trial to either early rhythm control (n=1395) or usual care (n=1394). Of these patients, five had no information on history of stroke and were excluded from this subgroup analysis. 217 (8%) patients had a history of stroke, of whom 110 were assigned to early rhythm control and 107 to usual care. The median age of participants with a history of stroke was 72·0 years (IQR 66·0-76·0). 95 (44%) participants were female and 122 (56%) were male. During a median follow-up of 4·7 years (3·5-6·4) for patients with a history of stroke, a first primary outcome event occurred in 18 (16%) of 110 patients in the early rhythm-control group (3·7 per 100 person-years) and 33 (31%) of 107 in the usual care group (7·4 per 100 person-years; hazard ratio [HR] 0·52, 95% CI 0·29-0·93). The mean number of nights spent in hospital per year was 5·1 (SD 13·2) for patients with a history of stroke assigned to early rhythm control and 6·6 (10·1) for those assigned to usual care (incidence rate ratio 0·87, 95% CI 0·55-1·38). Among patients with a history of stroke, primary safety events occurred in 17 (15%) patients in the early rhythm-control group versus 30 (28%) in the usual care group. In this prespecified subgroup analysis in patients with recently diagnosed atrial fibrillation and a history of stroke, the effects of early rhythm control were consistent with the findings of the primary analysis. As the evidence from this subgroup analysis is considered supportive and exploratory, further research is needed to confirm the safety and efficacy of this approach in patients with a history of stroke. German Ministry of Education and Research, German Center for Cardiovascular Research (DZHK), Atrial Fibrillation Network (AFNET), European Heart Rhythm Association, St Jude Medical-Abbott, Sanofi, and the German Heart Foundation.

Selective inhibitors of JAK1 targeting an isoform-restricted allosteric cysteine.

The Janus tyrosine kinase (JAK) family of non-receptor tyrosine kinases includes four isoforms (JAK1, JAK2, JAK3, and TYK2) and is responsible for signal transduction downstream of diverse cytokine receptors. JAK inhibitors have emerged as important therapies for immun(onc)ological disorders, but their use is limited by undesirable side effects presumed to arise from poor isoform selectivity, a common challenge for inhibitors targeting the ATP-binding pocket of kinases. Here we describe the chemical proteomic discovery of a druggable allosteric cysteine present in the non-catalytic pseudokinase domain of JAK1 (C817) and TYK2 (C838), but absent from JAK2 or JAK3. Electrophilic compounds selectively engaging this site block JAK1-dependent trans-phosphorylation and cytokine signaling, while appearing to act largely as 'silent' ligands for TYK2. Importantly, the allosteric JAK1 inhibitors do not impair JAK2-dependent cytokine signaling and are inactive in cells expressing a C817A JAK1 mutant. Our findings thus reveal an allosteric approach for inhibiting JAK1 with unprecedented isoform selectivity.

Fat Stores and Antioxidant Capacity Affect Stopover Decisions in Three of Four Species of Migratory Passerines With Different Migration Strategies: An Experimental Approach

During migratory stopovers, birds must make decisions about when and where to travel and these decisions are likely contingent on their fuel stores, food availability, and antioxidant capacity as well as seasonal changes in key environmental factors. We conducted a field experiment on an offshore stopover site (Block Island, Rhode Island, United States: 41°130N, 71°330W) during autumn migration to test the hypothesis that birds with greater fuel stores and non-enzymatic antioxidant capacity have shorter stopovers than lean birds with low antioxidant capacity, and to determine the extent to which this depends on migration strategy. We used a 2 × 2 factorial field experiment (two levels each of available food and dietary polyphenols) with four species of songbirds kept in captivity for 3–5 days to produce experimental groups with different fuel stores and antioxidant capacity. We attached digital VHF transmitters to assess stopover duration and departure direction using automated telemetry. Non-enzymatic antioxidant capacity increased during refueling for Red-eyed Vireos (Vireo olivaceus) and Blackpoll Warblers (Setophaga striata) fedad libdiets, and forad libfed Hermit Thrushes (Catharus guttatus) supplemented with polyphenols, but not for Yellow-rumped Warblers (Setophaga coronata coronata). Glutathione peroxidase (GPx) decreased during captivity and was influenced by dietary treatment only in Red-eyed Vireos. Oxidative damage decreased during captivity for all species except Yellow-rumped Warblers. Stopover duration was shorter for Vireos and Blackpolls fedad libas compared to those fed maintenance.Ad libfed Hermit Thrushes supplemented with polyphenols had shorter stopovers than those fedad lib, as did thrushes fed at maintenance and supplemented with polyphenols compared with those fed at maintenance alone. There was no influence of condition on stopover duration for Yellow-rumped Warblers. Departure direction was not strongly related to condition, and birds primarily reoriented north when departing Block Island. Thus, fat stores and oxidative status interacted to influence the time passerines spent on stopover, and condition-dependent departure decisions were related to a bird’s migration strategy. Therefore, seasonal variation in macro- and micro-nutrient resources available for refueling at stopover sites can affect body condition and antioxidant capacity and in turn influence the timing and success of migration.

Randomized Trial of Poloxamer 407-Based Ropivacaine Hydrogel After Thoracoscopic Pulmonary Resection

BackgroundWe conducted a comparative study to evaluate the efficacy of poloxamer 407-based ropivacaine hydrogel at the wound site (Gel) and continuous thoracic paravertebral block using On-Q PainBuster (On-Q; B. Braun Medical) for postoperative pain after thoracoscopic pulmonary resection. MethodsThis prospective, randomized, noninferiority study included 89 patients randomized to the Gel group (poloxamer 407-based 0.75% ropivacaine, 22.5 mg) or the On-Q group (0.2% ropivacaine, 4 mg/h for 48 hours). The primary outcome measure was total fentanyl consumption, and secondary outcome measures were the need for rescue analgesia and pain intensity using the numeric rating scale (NRS). ResultsThere was no significant difference in total fentanyl consumption between the Gel group and the On-Q group (1504.29 ± 315.72 μg vs 1560.32 ± 274.81 μg, P = .374). Pain intensity using the NRS between the Gel group and the On-Q group demonstrated no statistical differences at 6 hours (3.56 vs 3.55, P = .958), 24 hours (3.21 vs 3.00, P = .25), 48 hours (2.75 vs 2.49, P = .233), and 72 hours (2.39 vs 2.33, P = .811), and there was no significant difference in the frequency of analgesic rescue medication use (3.70 vs 3.33, P = .417). ConclusionsWe confirm the noninferiority of Gel compared with On-Q for acute postoperative pain after thoracoscopic pulmonary resection. Considering a technical simplicity and low systemic toxicity of the local injection of Gel, this analgesic modality may be worthy of further research and is thus considered to have potential as a viable alternative to On-Q for regional analgesia.

Selective scalp block decreases short term post-operative pain scores and opioid use after craniotomy: A case series

There is no consensus on the management of post-craniotomy pain. Several randomized controlled trials have examined the use of a regional scalp block for post-craniotomy pain. We aim to investigate whether scalp block affected short or long-term pain levels and opioid use after craniotomy. This study prospectively administered selective scalp blocks (lesser occipital, preauricular nerve block + pin site block) in 20 consecutive patients undergoing craniotomy for semicircular canal dehiscence. Anesthesia, pain, and opioid outcomes in these patients were compared to 40 consecutive historic controls. There was no significant difference in patient demographics between the two groups and no complications related to selective scalp block. The time between the end of procedure and end of anesthesia decreased in the scalp block group (16 vs 21 min, P = 0.047). Pain scores were significantly less in the scalp block group for the first 4 h, after which there was no statistically significant difference. Time to opioid rescue was longer in the scalp block group (3.6 vs 1.8 h, HR 0.487, P = 0.0361) and opioid use in the first 7 h was significantly less in the scalp block group. Total opioid use, outpatient opioid use, and length of stay did not differ. Selective scalp block is a safe and effective tool for short-term management of postoperative pain after craniotomy and decreases the medication requirement during emergence and recovery. Selective scalp block can speed up OR turnover but is not efficacious in the treatment of postoperative pain beyond this point.

주거단지계획요소와 일조 만족률의 상관관계 분석

This study aims to research on investigation and analysis of sunshine environment which is the most important factor of a unit residence among various indicators that determine the quality of residential environment. In Korea, the sunshine environment is stipulated in ‘Limits on Heights of Buildings for Securing Sunshine, etc.’, Article 61 of Building Act and Article 86 of Enforcement Decree of the Building Act and is enforced in deference to the precedent set by the Supreme Court on May 18, 2000. Other related laws do not have special regulations for the sunshine environment. Therefore, a research on this study would select the case-sites by conducting the following investigations and analyses. Firstly, it was analyzed whether all units in the sites secure the sunshine for at least two hours on the day of the winter solstice in applying the ‘limits on heights of buildings for securing sunshine etc.’ Secondly, a satisfaction rate of sunshine to improve it in the sites was investigated and analyzed for each complex, block and unit according to site planning factors that can affect the right to sunshine when planning a site. Thirdly, the analysis was conducted on the influences of the construction-scale elements among site planning factors (such as site area, site area per unit, coverage ratio, floor area ratio, number of floors, number of unit), outdoor space elements (such as street ratio, green space ratio, outdoor living space ratio, outdoor space area) and elevation blockage ratio and facade area ratio which are used in index-based standards in order to determine the correlation between sunshine environment and site planning factors. For a quantitative analysis of the collected data on this study, adopted by the site block planning and computer simulation techniques using AutoCAD 2008 and Photoshop CS2 and the Sunshine analysis was conducted using by Sun Sketch in particular parts.

Further reducing the risk of wrong site block.

Further reducing the risk of wrong site block.

Two-Sided Simultaneous Block of a F- Channel (FLUC)

The recently discovered family of F- channels, the Flucs, are highly selective for F- and function to rescue microorganisms from F- toxicity in acidic environments. Structurally, Fluc is a four pass transmembrane protein that assembles as a dual-topology homodimer. This architecture, where two Fluc subunits orient antiparallel with respect to each other, is unique among ion channels and requires a two-fold symmetry axis parallel to the membrane plane. The symmetry axis further suggests that Fluc may present identical interfaces on both sides of a membrane.In fact, using fibronectin III domain “monobody” blockers specifically selected from a phage display library for nano-molar binding affinity, it was shown that a single Fluc channel is blocked on both sides of a planar lipid bilayer [Stockbridge et. al. Nature Comm., in press]. This leaves open the question of whether the sites of block on either side of the channel can be occupied simultaneously. We approach this question by experimentally testing a two site block model O B1 B2 by analysis of monobody dependent block times in single channel electrophysiology recordings. In the case of symmetric block, this scheme postulates that the dwell times of the B1 and B2 composite blocked state should exhibit monobody concentration dependence. In addition, information about cooperativity, whether negative or positive, between the two blocking sites can be quantitatively determined.

안드로이드 플랫폼 기반 악성사이트 차단 방법

ABSTRACT According to the increasing use of smart devices such as smart phones and tablets, the service that targets mobile office, finance and e-government for convenience of usage and productiv ity has emerged significantly. As a result, important information is treated with the smart devices and also, the malicious activity that targets smart devices is increasing steadily. In particular, the damage case by harmful sites, malware distribution sites an d phishing sites that targets smart devices has occurred steadi ly and it has emerged as a social issue. In the case of smart devi ces, the Android platform is occupied the 90% in Korea, 2013 therefore the method of device block level is required to resol ve the social issues of smart devices. In this paper, we propos e a method that can be effectively blocked when you try to access an illegal site to Web browser on the Android platform and develop the application and also analyze the wrong site block f unction. Keywords: Android, Malicious websites, Phishing, Smishing접수일(2013년 10월 24일), 수정일(2014년 3월 7일), 게재확정일(2014년 5월 14일)* 본 연구는 미래부가 지원한 2014년 정보통신·방송(ICT) 연구개발사업의 연구결과로 수행되었음. 또한, 본 연구는 미래창조과학부 및 정보통신산업진흥원의 대학 ICT연구센터육성지원사업의 연구결과로 수행되었음 (NIPA-2014 -H0301-14-1010)

The Typologies of Block and Unit Plan in Malaysian Apartments- Focused on Middle Cost Houses Supplied by the Private Sector -

Most Southeast Asian countries, including Malaysia, have experienced rapid industrialization, after which their people started to acquire high standards of living and began to pay attention to the quality of housing. Apartments are a housing typology imported from Western culture, and this housing type has had a strong impact on the people who were very familiar with the landed properties such as terrace houses, detached houses and semi-detached houses. This type has also affected their urban lifestyle. In Malaysia, apartments are supplied by the public and private sectors. Apartment planning supplied by the public sector is very simple and uniform. However, apartment planning supplied by the private sector has demonstrated an improvement in residents′ living conditions and better response to their housing needs and requirements. For these reasons, this study focuses on the apartments supplied by the private sector. The authors selected 34 housing precincts in Kuala Lumpur for this study, and analyzed their site plans, block plans, and unit plans in order to extract their representative typologies.As a result, the authors could understand the unique characteristics of apartment planning in Malaysia, and ultimately, were able to grasp its essential housing needs and the regional characteristics of Malaysian apartment planning.

Single Shot Epidural Injection for Cervical and Lumbosaccral Radiculopathies: A Preliminary Study

BackgroundEpidural steroid injection is an established treatment modality for intervertebral disc prolapse leading to radiculopathy. In cases where two levels of radiculopathy are present, two separate injections are warranted. Herein, we present our experience of management of such cases with a single epidural injection of local anaesthetic, tramadol and methylprednisolone, and table tilt for management of both radiculopathies.Methods50 patients of either sex aged between 35-65 years presenting with features of cervical and lumbar radiculopathic pain were included and were subjected to single lumbar epidural injection of local anaesthetic, tramadol and methylprednisolone, in the lateral position. The table was then tilted in the trendelberg position with a tilt of 25 degrees, and patients were maintained for 10 minutes before being turned supine. All patients were administered 3 such injections with an interval of 2 weeks between subsequent injections, and pain relief was assessed with a visual analogue scale. Immediate complications after the block were assessed.ResultsImmediate and post procedural complications observed were nausea and vomiting (20%), painful injection site (4%), hypotension (10%) and high block (4%). Pain relief was assessed after the three injections by three grades: 37 (74%) had complete resolution of symptoms; 18% had partial relief and 8% did not benefit from the procedure.ConclusionsThis technique may be used as an alternative technique for pain relief in patients with unilateral cervical and lumbar radiculopathies.

Ets-1 and Ets-2 Regulate the Expression of MicroRNA-126 in Endothelial Cells

MicroRNA plays important roles in vascular biology, but the regulation of endothelial-specific microRNA is not well characterized. MicroRNA-126 (miR-126) is highly expressed in endothelial cells, and it regulates angiogenesis and vascular inflammation. Here we show that the transcription factors Ets-1 and Ets-2 regulate miR-126 expression. A genomic region between -71 and -100 bp upstream of the miR-126 transcriptional start site is critical for transactivation of the gene containing miR-126. This genomic region contains a potential Ets binding site. Mutations within the Ets binding site block transactivation, and Ets-1 and Ets-2 interact with this critical genomic region. Knockdown of endogenous Ets-1 and Ets-2 decreases miR-126 expression. Finally, knockdown of miR-126 alters regulation of an Ets-1 target gene. Taken together, these data show that the transcription factors Ets-1 and Ets-2 play a key role in controlling the expression of miR-126 and suggest that miR-126 may mediate some of their vascular effects.

Finding traps in nonlinear spin arrays

Precise knowledge of the Hamiltonian of a system is a key to many of its applications. Tasks such state transfer or quantum computation have been well studied with a linear chain, but hardly with systems, which do not possess a linear structure. While this difference does not disturb the end-to-end dynamics of a single excitation, the evolution is significantly changed in other subspaces. Here we quantify the difference between a linear chain and a pseudo-chain, which have more than one spin at some site (block). We show how to estimate a number of all spins in the system and the intra-block coupling constants. We also suggest how it is possible to eliminate excitations trapped in such blocks, which may disturb the state transfer. Importantly, one uses only at-ends data and needs to be able to put the system to either the maximally magnetized or the maximally mixed state. This can obtained by controlling a global decoherence parameter, such as temperature.

English

In 1929, the Block P Mill and Tailings Site (Block P) near Monarch, MT was the largest lead producer in Montana. When the mill finally closed in 1943 the site left behind a legacy of barren, phytotoxic soil and an ongoing transport of hazardous trace elements into nearby streams. Problems included areas of soil acidity as low as 1.8 pH, and zones with highly elevated concentrations of arsenic, cadmium, copper, lead, zinc and manganese in both soils and tailings materials. As a result, much of Block P, which would have been fully covered with vegetation if undisturbed, was nearly devoid of plant life. In 2001, however, it was decided to clean up and restore Block P to a functional site with natural vegetation. In 2004 and 2005, waste materials were consolidated to a centralized repository. Then, soil amendments (compost, slow-release fertilizer and lime) were added to areas from which tailings were removed, leave-area soils and imported fill materials. In 2005 and 2006, the project site was replanted with native grass and forb seeds, as well as containerized woody plant species that had been propagated from local stock. In July 2008, scientists from ESG monitored the status of revegetation at Block P. Monitoring included assessments of containerized woody plant survival, herbaceous cover, and overall cover on the nine revegetation units at the site. The monitoring results show a continued trend toward successful revegetation. The average containerized woody plant survival, weighted for unit size, was 74 percent, which exceeds the 70 percent project goal. Average herbaceous canopy cover and average total canopy cover of all plants across the entire project site are respectively 46 and 49 percent. The canopy cover of native species far exceeds non-native canopy cover, the cover of weedy exotic species is minimal, and hundreds of woody volunteer plants are appearing. The improvements in vegetation, environmental, and aesthetic values of the Block P Mill and Tailings site are clear and palpable, and demonstrate the efficacy of using appropriate soil amendments and site-adapted native plant species to restore even the most challenging of disturbed sites.

A New Approach to Preanesthetic Site Verification After 2 Cases of Wrong Site Peripheral Nerve Blocks

We discuss the importance of a "preanesthetic site verification" and highlight 2 significant modifications to a policy developed at our institution in 2003. The report describes 2 cases of wrong site peripheral nerve blocks that initiated protocol amendments to address shortcomings of the original policy. Two specific limitations were identified to improve upon. First, the practitioner must not overlook the site verification as it is essential prior to every block. Second, time delays between the verification and block performance should be minimized. The "preanesthetic site verification" is an integral part of preventing wrong site block and surgery. To ensure that it is carried out before every peripheral nerve block, a unique multidisciplinary approach was adopted in which the block needles were removed from anesthesia carts and transferred to a separate container in the area of the circulating nurse. The anesthesiologist must now request a block needle from the circulating nurse immediately prior to block performance and confirm the site at that time. This safety process emulates the presurgical site verification that takes place before a scalpel is passed to a surgeon. Furthermore, the circulating nurse must remain at the bedside until block initiation to make sure that delays between site verification and block performance do not impinge on correct site placement.

Pneumocephalus in Patients With Orthostatic Headache

Cerebrospinal fluid (CSF) leak or shunt overdrainage is a well-known cause of orthostatic headaches and low CSF pressures. We report two cases of orthostatic headache with pneumocephalus on brain imaging. The orthostatic headache developed after drainage of spinal operation site and epidural block. Brain MRI revealed characteristic findings of CSF hypovolemia including pachymeningeal enhancement and mild subdural fluid collections. Air was also observed in the ventricular or subarachnoid space in both patients, which might enter the subarachnoid or ventricular space during a procedure via the pressure gradient or an injection.