Clinical effects of online cognitive behavioral group therapy for chronic pain patients and developing a therapeutic alliance: A pre-post pilot trial.

Background and Aims: Research suggests that various psychosocial factors influence chronic pain, with psychotherapies like cognitive behavioral therapy  proving effective. However, the limited availability and accessibility have prolonged suffering among patients with chronic pain. This challenge has led to a growing demand for accessible online interventions. We developed an online cognitive behavioral group therapy (CBGT) program, building upon our existing face-to-face CBGT program. We compared the scores obtained by patients during the treatment-as-usual (TAU) period with those collected at the beginning and at the end of the intervention. Methods: Patients with chronic pain (N = 22) agreed to participate in the online CBGT program, which was conducted once a week for 12 sessions. The sample size was decided based on the effect sizes of our past face-to-face CBGT. We assessed pain intensity [Visual Analogue Scale (VAS)], pain catastrophizing [pain catastrophizing scale (PCS)] and psychiatric assessment [Beck Depression Inventory-Second Edition (BDI)-II], State-Trait-Anxiety Inventory (STAI), and Short Form Health Survey (SF-36) at three points: entry, pretreatment, and posttreatment. We also evaluated the participants' therapeutic alliance with the treatment staff [short-form version of the Working Alliance Inventory (WAI-S)]. We utilized analyses of variance, Friedman test, paired t-tests, Wilcoxon signed-rank test, and Pearson correlation analysis for data evaluation. Results: Results indicated a significant posttreatment improvement in VAS, PCS, and BDI-II scores compared to the TAU period. Furthermore, posttreatment WAI-S scores increased significantly compared to pretreatment scores. Also, positive correlations were observed among pre- and posttreatment changes in WAI-S, pain intensity, and pain catastrophizing scores. Conclusion: There is a possibility that a therapeutic alliance can be established, and therapeutic effects achieved through an online CBGT intervention; however, additional research is required to substantiate this potential. We have registered this clinical trial in UMIN-CTR on 04/21/2021 with the number UMIN000043982.

The Serotonin-Mediated Anti-Allodynic Effect of Yokukansan on Paclitaxel-Induced Neuropathic Pain.

Refractory peripheral neuropathy can occur as a side effect in 60-70% of patients receiving Paclitaxel (PTX). Yokukansan (YKS) is a Japanese herbal medicine reported to have analgesic properties for entrapment nerve injuries. Therefore, we investigated the anti-allodynic effect of Yokukansan on Paclitaxel-induced neuropathic pain. All experiments used 6-week-old male Sprague Dawley rats. Mechanical allodynia was evaluated using a dynamic plantar aesthesiometer. A mobile touch-stimulator unit applied progressively increasing force to the mid-plantar region of the hind paw in a vertical direction until the animal withdrew its paw. This was carried out before the Paclitaxel administration and during the first, second, third, and fourth weeks. Using a rat model of PTX-induced neuropathic pain (PTX rat), we injected PTX (intraperitoneally, 2 mg/kg) five times every 2 days. Using the dynamic plantar test, we evaluated the anti-allodynic effect of YKS (orally administered, 1 g/kg). YKS administration on a daily basis significantly enhanced the withdrawal threshold in PTX rats and reduced the expression level of activated microglia immunostaining with Iba1, a specific marker for microglia. The intrathecal administration of WAY-100635 (5-hydroxytryptamine [5-HT]1A receptor antagonist) and Ketanserin (5-HT2A/2C receptor antagonist) inhibited the protective effects of YKS. YKS exhibited an anti-allodynic effect in a rodent model of PTX-induced neuropathic pain by reducing the sensitivity to pain stimuli. These results suggest that Yokukansan may activate 5-HT receptors in the spinal cord, mediating Paclitaxel-induced neuropathic pain.

Difficult intubation and postoperative aspiration pneumonia associated with Moebius syndrome: a case report.

BACKGROUND: Moebius syndrome is a rare congenital disorder characterized by non-progressive palsy of the abducens (VI) and facial (VII) cranial nerves. Its common features include dysfunctions associated with other cranial nerves, orofacial abnormalities, skeletal muscle hypotonia, and other systemic disorders of differing severities. There are several concerns in the perioperative management of patients with Moebius syndrome. CASE PRESENTATION: We present a report on the management of general anesthesia of a 14-year-old male patient with Moebius syndrome who was scheduled for mandibular cystectomy. The patient was diagnosed with Moebius syndrome at the age of 7 years based on his clinical manifestations of nerve palsy since birth and cranial nerve palsy of the trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), and sublingual nerves (XII). The patient's oral morphological abnormalities made intubation difficult. He also experienced dysphagia and aspiration pneumonia on a daily basis. Oral secretions were frequently suctioned postoperatively. However, after discharge, the patient developed aspiration pneumonia and was readmitted to the hospital. CONCLUSIONS: The main problem arising when administering general anesthesia to patients with this syndrome is difficult airway management. The oral abnormalities in these patients, such as small jaw and extreme dental stenosis, make mask ventilation and intubation difficult. Furthermore, this syndrome often involves respiratory impairment and dysphagia due to cerebral nerve palsy, so there is a high risk of postoperative respiratory complications. Since multiple organs are affected in patients with Moebius syndrome, appropriate perioperative management strategies must be prepared for these patients.

Subacute postoperative myofascial pain diagnosed and treated successfully by ultrasound: a case after laparoscopic hepatectomy.

BACKGROUND: Myofascial pain syndrome is one of the causes of prolonged postoperative pain after abdominal surgery. However, diagnosis and treatment of myofascial pain syndrome, especially its myofascial trigger point (MTrP), have not been well established. CASE PRESENTATION: A 55-year-old man experienced severe subacute abdominal pain after laparoscopic hepatectomy despite aggressive postoperative pain management. He had a positive Carnett's sign, indicating abdominal wall pain, 2 weeks after the surgery. Ultrasonography showed a hyperechoic spot surrounded by a hypoechoic area in the inner abdominal oblique muscle under the palpable spot that fulfills the criteria of MTrP. The echogenic MTrP disappeared after repetitive ultrasound-guided trigger point injections (USG TPIs) with pain relief. CONCLUSIONS: Our present case indicates that diagnosing myofascial pain by visualizing the echogenic MTrPs in the abdominal muscles, and subsequent USG TPIs, might provide an accurate maneuver for diagnosis and treatment of subacute myofascial pain after abdominal surgery.

Novel technique for identification of the pulmonary intersegmental plane using manual jet ventilation during pulmonary segmentectomy.

INTRODUCTION: For successful pulmonary segmentectomy, the identification of boundaries between segments is important. Previous measures include tracing the intersegmental vessels by staining with a dye via the affected pulmonary artery or bronchus and inflating with oxygen via a high frequency ventilator. However, problems with these methods have been reported. AIM: We developed a novel method using a manual jet ventilator (MJV) and investigated its efficacy in identification of the pulmonary intersegmental plane. MATERIAL AND METHODS: Patients underwent MJV for pulmonary segmentectomy in the period from January 2013 to December 2017 at our institution. The patients' characteristics, resected segments, availability of clear resection planes, and complications associated with MJV from medical records were investigated. A questionnaire survey was conducted with the surgeons on the effectiveness of lung segment identification using MJV. RESULTS: Of 199 cases of planned pulmonary segmentectomy, 171 cases with descriptions of identified intersegmental planes were analyzed. Of these, 152 (89%) cases showed a clear boundary. There were 19 cases where the exact boundaries were not clearly identified, but segmentectomy was still performed. Furthermore, we found that identification of the right upper lobes was difficult (p = 0.0028). A subjective questionnaire was answered by the 12 surgeons who performed the procedures. All 12 responded that MJV was very effective or effective regarding clarity, safety, shorter identification time, and shorter resection time. CONCLUSIONS: MJV enabled surgeons to more easily and safely identify the pulmonary intersegmental plane, thereby suggesting that MJV has clinical significance during pulmonary segmentectomy.

[Use of i-gel supraglottic airway for emergency airway management by novice personnel in comparison with laryngeal mask airway and tracheal intubation in manikin models].

BACKGROUND: Tracheal intubation (TI) is a difficult skill to acquire and its proficiency deteriorates over time if not regularly practiced. However, inexperienced personnel may be required to perform airway management in emergency situations. We compared a novel supraglottic device, i-gel, with laryngeal mask airway classic (cLMA) and TI devices in regard to total success count, time required for placement, and difficulties encountered by novice personnel using a manikin model. METHODS: Following a brief training, 24 residents were asked to insert each of i-gel, cLMA, and TI in a randomize fasion using a manikin. Success counts for placement and time required to chest rise were recorded. After completing the tests, the participants scored the difficulty of each device using a visual ana-log scale (0-100 mm, very easy to very difficult). RESULTS: The total success count with i-gel (46 times) was significantly higher than those of both cLMA (32 times) and TI (38 times), and the time to chest rise with i-gel (14 +/- 6 seconds) was significantly shorter than with cLMA (38 +/- 26 seconds). The difficulty score for i-gel (12 [0-51] mm) was significantly lower than those for both cLMA (51 [0-94] mm) and TI (25 [0-73] mm). CONCLUSIONS: An i-gel may be useful for emergency airway management by inexperienced personnel. Further studies in a clinical setting are necessary to confirm these findings.

Continuous intravenous infusion of ketamine and lidocaine as adjuvant analgesics in a 5-year-old patient with neuropathic cancer pain.

For difficult to treat neuropathic pain from cancer, adjuvant analgesics are often used with opioids. We present the case of a 5-year-old girl who was diagnosed with meningitis caused by malignant T-cell lymphoma. She had severe neuropathic pain not relieved by increasing doses of a fentanyl infusion. Intravenous administration of ketamine and lidocaine in combination with fentanyl provided excellent analgesia without significant side effects. Ketamine and lidocaine can be safely infused together with concomitant opioids for the treatment of refractory neuropathic pain caused by cancer.

[Adverse events during transcranial muscle evoked potential monitoring].

BACKGROUND: Transcranial muscle evoked potential (TC-MsEP) monitoring is available to assess spinal cord motor tract function for preventing paralysis in spine surgery. Recently, the quality of monitoring has improved. However, adverse events such as torn tracheal tube, bitten tongue, and mandibular fracture are reported. METHODS: We reviewed retrospectively adverse events with TC-MsEP monitoring by Multipulse D-185 (Digitimer Ltd., the U.K.) during spine surgery in our hospital. In addition, we compared the number of cases with transformed tracheal tubes in cases using Multipulse D-185 and in cases using the other stimulation device. RESULTS: Since June 2007, Multipulse D-185 is applied as a stimulating device of TC-MsEP, and we experienced two adverse events of lasceration of tongue and teeth dislocation. There was a significant difference (P=0.02) in the number of transformed tracheal tube between Multipulse D-185 (11 of 20) and the other stimulation device (2 of 19). CONCLUSIONS: It seems that two adverse events were due to excessive masseter muscles contraction with TC-MsEP monitoring. Prevention for bite injury and ventilation strategy for tube occlusion or stenosis using Multipulse D-185 for TC-MsEP are necessary.

[Anesthetic management of a patient with erythropoietic protoporphyria for laparoscopic appendectomy].

Porphyria is a hereditary disorder due to reduction in enzyme activity of heme synthesis system, resulting in accumulation of heme precursors. Erythropoietic protoporphyria (EPP) is a type of porphyria. There are varieties of clinical expressions of EPP such as hepatic damage and photosensitivity, caused by the accumulation of protoporphyrin in the liver and the skin. Therefore it is important to prevent development of these clinical expressions. A 36-year-old woman with EPP was scheduled for a laparoscopic appendectomy. Anesthesia was induced with remifentanil, sevoflurane and rocuronium, and maintained with remifentanil, fentanyl and sevoflurane. She had performed normal daily activities without taking countermeasures against photosensitivity, so we did not change the light in the operating room, and allowed using endoscopy. The surgery was performed without any complications. No skin symptom was observed perioperatively. The level of aminotransferase was elevated temporally after the operation, while the level of protoporphyrin was unchanged. Therefore, we considered there was no manifestation of EPP perioperatively. In general, patients with EPP do not develop acute attacks induced by drugs like barbiturates. Since there was a case report of severe liver dysfunction of EPP, we did not use any contraindicated drugs in patients with acute intermittent porphyria in this patient. Considering a possibility of motor nerve damage in severe EPP, we carried out anesthetic management without epidural anesthesia.

[Survey of skills needed to assist tracheal intubation: nurse assistants lack accurate knowledge of BURP and cricoid pressure maneuvers].

BACKGROUND: The backward, upward and rightward pressure (BURP) maneuver and cricoid pressure (CP) are easily confused because of their similarities. We surveyed nurses to determine their knowledge and skills regarding these maneuvers. METHODS: Forty nurses (OR, n=20; ER, n=20) answered questionnaires regarding BURP and CP, and were then asked to apply CP to a laryngopharynx model equipped with a digital scale to measure compression force. RESULTS: As for the BURP maneuver, 26 nurses (OR 20, ER 6) noted previous experience, while only 13 (OR 3, ER 10) and 1 (OR) nurses answered correctly regarding the compression point and correct direction, respectively. As for CP, 16 nurses (OR 14, ER 2) noted previous experience, but only 3 (all ER) answered correctly. Twenty-six nurses (OR 16, ER 10) incorrectly compressed the thyroid cartilage on the laryngopharynx model, and 24 (OR 18, ER 6) incorrectly applied backward and upward pressure, which was significantly frequent among the OR nurses. The measured forces of CP were 2.11 +/- 1.3 kg (mean +/- SD) and 2.5 +/- 2.1 kg for the OR and ER nurses, respectively, which were not significantly different. CONCLUSIONS: We found that the nurses are confused with the BURP and CP maneuvers. Unless applied correctly, these maneuvers may interfere with tracheal intubation. Constant education and training are essential for effective and safe implementation of these maneuvers.

Successful management of a patient with Marfan syndrome complicated with acute aortic dissection using landiolol during Cesarean section.

Aortic dissection is a lethal complication in pregnant women with Marfan syndrome. To decrease arterial wall stress, beta-blockers have been used as standard treatment, although uterine contractions caused by beta-2-adrenergic receptor antagonism may result. Herein, we report a patient with Marfan syndrome who was given landiolol, a selective beta-1-adrenergic receptor antagonist with a short half-life, for management during a Cesarean section procedure following development of acute aortic dissection. A 30-year-old pregnant woman with Marfan syndrome in the 38th week of gestation was referred to our department for an emergency Cesarean section because of development of acute aortic dissection. Blood pressure (BP) decreased from 157/70 to 128/64 mmHg after giving nicardipine and nitroglycerin. However, heartrate (HR) increased from 112 to 145 bpm, which was reduced to 105 bpm with landiolol, while BP was maintained. A Cesarean section was performed without complications under combined spinal-epidural anesthesia. Hemodynamic state, uterine contraction, and the extent of aortic dissection remained stable. The postoperative course was uneventful, and the patient and her baby were discharged safely. Landiolol was useful for reduction of HR without affecting BP or uterine contractions during a Cesarean section procedure in our patient with aortic dissection.

[Difficult tracheal intubation using airway scope in a pediatric patient with Hunter syndrome].

Hunter syndrome, manifested by mucopolysaccharidosis II (MPS II), is a hereditary disorder caused by accumulation of glycosaminoglycans. An important issue in regard to anesthesia in affected individuals is airway management, because of gargoylism. An 8-year-old boy with MPS II was scheduled for adenotonsillectomy. We performed slow induction with sevoflurane, then utilized an Airway Scope (AWS; HOYA Corporation Tokyo, Japan), which enables operators to observe tube passage through the vocal cords with an LCD monitor, for tracheal intubation, because intubation guided by a fiberoptic bronchoscopy (FOB) was considered to be risky for glottic damage. Attempted tracheal intubations with the AWS alone and in combination with an FOB inserted through the tracheal tube failed, even though a clear image of the glottis was obtained. Finally, we inserted a stylet into the tracheal tube attached to the blade of the AWS and successful tracheal intubation was accomplished. The operation was completed uneventfully and the patient entered the ICU with his trachea intubated, because of pharyngeal and laryngeal edema. Although useful for difficult airway management, tracheal intubation with the AWS may be difficult when used in patients with a narrow oral cavity or small tracheal tube.

[Anesthesia for anticoagulated patients].

BACKGROUND: Anticoagulated patients who undergo surgry have been increasing in number. They may develop thrombo-embolic and/or bleeding complications. METHODS: We studied 79 patients retrospectively who had undergone elective surgery from April 2002 through December 2003. We studied their basal diseases, types of anticoagulants, stopping or continuing anticoagulants during their surgical period, thrombo-embolic and/or bleeding complications and changing of the anesthetic method. RESULTS: Thrombo-embolic complications occurred in 2 patients (2.5%) who developed brain emboli. Both of them had arythmia. Bleeding complications occurred in 4 patients (5.1%), of whom 3 patients developed bleeding during spinal or epidural anesthesia and one of them had hematoma from the surgical wound. There was no mortality, and 28.8% of patients underwent change of anesthetic method where only general anesthesia was used. CONCLUSIONS: It is recommended that patients at high risk of thrombo-embolism should continue to receive anticoagulant or heparin during surgical period.

[Anesthetic management of renal transplantation for a 15-year-old girl with cerebral palsy].

A 15-year-old girl with severe cerebral palsy underwent renal transplantation. It was difficult to anastomose blood vessels because her inferior limbs were contracted. The clamp time was 67 minites. After unclamping, blood pressure fell down from 120/60 to 80/50 mmHg, and CVP fell down from 6 to 3 mmHg. First flow of urine from the donor kidney was noticed 9 hours after unclamping. We regarded difficulty of the operation for cerebral palsy and insufficient infusion as the cause of the late first flow of urine. Two weeks later, there was enough urine flow, and renal function became better. Recently, it is thougt optimal to perform renal transplantations of children who have chronic renal insufficiency and end-stage renal disease. However, there are few reports of renal transplantations for children with cerebral palsy, and there is no guideline for them. Therefore, we anesthesiologists, also have to further examine anesthetic management for each case.

[Epidemiological study of hepatitis B and C in 34,336 patients operated at Hiroshima Prefectural Hospital during the period from 1993 to 2000].

BACKGROUND: We have many chances to deal with blood transfusion in the operation room, and it is important for us to pay more attention to prevent hospital infection. METHODS: We surveyed epidemiologically the prevalence of hepatitis B virus surface antigen (HBV) and hepatitis C virus antibody (HCV) in 34,336 patients operated at Hiroshima Prefectural Hospital from April 1993 through March 2001. RESULTS: The prevalence of HBV seropositivity was 1.8% in total, 1.6% in scheduled, and 2.5% in emergent cases. The prevalence of HCV seropositivity was 7.1% in total, 6.8% in scheduled, and 8.0% in emergent cases. Prevalences of both of them in emergent cases were higher than scheduled. The prevalence of HBV was highest (3.4%) in patients with age of 40's, and the prevalence of HCV increased with age. The prevalences of HBV and HCV were highest (4.5% and 19.0%) in the division of surgery and dialysis-kidney disease center. CONCLUSIONS: It is important to carry out standard precautions for all patients to prevent hospital infection. Furthermore, we should pay attention to emergent operative cases and operative cases in dialyzed patients.