Ultrasound-guided versus palpation-guided corticosteroid injections for tendinosis of the long head of the biceps: A randomized comparative study.

PURPOSE: To compare accuracy, patient discomfort, and clinical outcome of ultrasound-guided versus palpation-guided corticosteroid injections to the bicipital groove in patients with long head of biceps (LHB) tendinosis. MATERIALS AND METHODS: Forty-four patients with primary LHB tendinosis were randomized into two groups (group A, n = 22; group B, n = 22). All patients underwent treatment with a single corticosteroid injection to the bicipital groove. Injections in group A were performed under ultrasound-guidance, while in group B using a palpation-guided technique. The duration of each procedure was recorded. To assess accuracy, ultrasound examination was performed in both groups after injection. Patient discomfort was evaluated with visual analogue scale (VAS) for pain. The clinical outcome was assessed comparing the VAS, the Single Assessment Numeric Evaluation (SANE) score and the QuickDASH score before treatment and after 4 weeks and 6 months. RESULTS: The mean duration of the procedure was 64 ± 6.87 s in group A and 81.91 ± 8.42 s in group B (p < 0.001). Injection accuracy in group A was 100% and in group B 68.18%. Discomfort was lower in group A, as compared to group B (22.10 vs. 35.50; p < 0.001). Symptoms, as measured by VAS, SANE and QuickDASH scores, improved in both groups at 4 weeks and 6 months (p < 0.05). Superior clinical improvement was recorded in group A in both time points (p < 0.05). CONCLUSIONS: Corticosteroid injections are an effective treatment for primary LHB tendinosis. Under ultrasound guidance, injections to the bicipital groove are faster and produce lower discomfort. Superior accuracy and clinical outcomes can be achieved using the ultrasound-guided technique. LEVEL OF EVIDENCE: Level II; Prospective Randomized Comparative Study.

Oral Diclofenac Potassium Versus Intravenous Acetaminophen in Acute, Isolated, Closed-Limb Trauma.

Pain control is an important concern in limb trauma. The most ideal agent for this purpose varies among different hospitals. The objective of this study was to compare the analgesic effect of oral diclofenac potassium versus intravenous acetaminophen in patients with limb trauma. This was a double-blind randomized clinical trial conducted on 60 adult patients. Oral diclofenac potassium (50 mg) was given in Group D, and intravenous acetaminophen (1 g in 500 ml normal saline over 20 min) was administered in Group A. Patients' pain scores (visual analogue scale) were recorded and compared at baseline, 5, 15, 30, 60 min, and 4 hr after drug administration. The mean age was 42.62 ± 15.42 and 38.04 ± 17.48 years in Group A and Group D, respectively. No significant change was observed between the 2 groups (p = 0.11). In this study, both drugs could decrease the pain score effectively and safely in isolated limb trauma.

Severe Streptococcal Infection Following Cat Scratch.

INTRODUCTION: Cats can transmit bacterial infections to humans through biting and scratching. Streptococcal infections in wounds caused by cat bites or scratches rarely have been reported in the literature. CASE REPORT: The case of severe streptococcal skin infection after a 2-day-old cat scratch of the right arm, elbow, and forearm in a 68-year-old woman is presented herein. Group A ß-hemolytic streptococci (GABHS) was isolated from the wound of the patient as well as the oral cavity and claws of the cat; likewise, Escherichia coli also was isolated from the oral cavity and claws of the cat. She was successfully treated with intravenous tigecycline for 2 weeks at a starting dosage of 100 mg daily. Tetanus prophylaxis was performed. Complete remission was observed 3 weeks after beginning treatment. Follow-up visit at 32 months was negative for clinical manifestations. CONCLUSIONS: For the first time documented in the literature, GABHS were isolated from the wound of the patient and from the cat's oral cavity and claws.

The effect of probiotic treatment on elderly patients with distal radius fracture: a prospective double-blind, placebo-controlled randomised clinical trial.

Probiotic treatment has been shown to improve bone formation, increase bone mass density and prevent bone loss. We aimed to assess the effect of probiotic treatment on functional recovery in elderly patients with a distal radius fracture. A total of 417 elderly patients with an acute distal radius fracture were enrolled in this double-blind placebo-controlled clinical trial. They were randomised to receive skimmed milk containing either a commercial probiotic (Lactobacillus casei Shirota) or placebo daily for a period of 6 months after the fracture. Treatment outcomes were the DASH (disabilities of the arm, shoulder and hand) score, pain, complex regional pain syndrome (CRPS) score, active range of motion and grip strength, all of which were measured on a monthly basis. Throughout the duration of the study, DASH score, pain, CRPS score, wrist flexion and grip strength of patients receiving probiotics exhibited a significantly faster pace of improvement than those on placebo, with treatment outcomes of patients receiving Lactobacillus casei Shirota at month 4 at comparable levels with those of patients receiving placebo at month 6. In elderly patients with a fracture of the distal radius, administration of the probiotic could greatly accelerating the healing process.

[PECULIARITIES OF THE TREATMENT TACTICS IN CLOSURE OF DEFECTS OF COVERING TISSUES OF TRUNK AND EXTREMITIES OF MECHANICAL ORIGIN].

Results of treatment of 242 patients, to whom 697 оperative interventions were done, including 492 (70.6%) ­with restoration of the injured soft tissues and other trunk and extremities structures ­were analyzed. Choice of the correcting intervention method and closure of the covering tissues defect have depended on the wound dimensions and depth, peculiarities of hemodynamics in the area injured. Application of Lacert preparation for the traumatic injury consequences made spectrum of treatment options in patients, suffering covering tissues defect,broader. Differential approach to choice of procedure for the wound surface closure have permitted to achieve satisfactory results in 98.75% of patients.

Nebulized fentanyl vs intravenous morphine for ED patients with acute limb pain: a randomized clinical trial.

OBJECTIVE: Intravenous morphine has been used as a common method of pain control in emergency care. Nebulized fentanyl is also an effective temporary substitute. This study was designed to compare the effectiveness of nebulized fentanyl with intravenous (IV) morphine on management of acute limb pain. METHODS: This was a placebo-controlled, double-blind randomized clinical trial. Ninety emergency department patients with moderate to severe pain aged 15 to 50 years were blocked randomized and enrolled in this study. Forty-seven patients in the experimental group received nebulized fentanyl (4 µg/kg) and IV normal saline as placebo, and the remaining 43 patients in the control group received IV morphine (0.1 mg/kg) and nebulized normal saline as placebo. All participants' pain scores were assessed by Numerical Rating Scale before and after intervention at 5-, 10-, 15-, 30-, 45-, and 60-minute intervals. Patients' vital sign and possible adverse effects were recorded respectively. Finally, all participants were assessed for their satisfaction. RESULTS: The mean initial pain score in the experimental group was 8.7 and 8.4 in the control group (P = .1). Pain relief in both groups after 5 and 10 minutes were similar (P = .72). Although the pain relief was significantly greater with fentanyl at 15 minutes, this difference is not clinically significant. Pain management in both groups was successful and was more than 3 scores reduction in Numerical Rating Scale. Patient satisfaction in both groups was similar. No adverse effects were reported in the experimental group. CONCLUSION: This study suggests that nebulized fentanyl is a rapid, safe, and effective method for temporary control of acute limb pain in emergency department patients.

The PICHFORK (Pain InCHildren Fentanyl OR Ketamine) trial comparing the efficacy of intranasal ketamine and fentanyl in the relief of moderate to severe pain in children with limb injuries: study protocol for a randomized controlled trial.

BACKGROUND: The effectiveness of intranasal (IN) fentanyl as an analgesic for painful pediatric limb injuries in the Emergency Department (ED) has been reported previously. However, efficacy of IN ketamine in sub-dissociative doses is not well studied in the ED setting. A non-blinded pilot study undertaken by this study group suggested that IN ketamine showed similar analgesic effectiveness to that reported with IN fentanyl in similar non-blinded studies. The aim of this randomized, controlled, equivalence trial is to compare the analgesic effect of sub-dissociative dose IN ketamine with IN fentanyl for children with isolated musculoskeletal limb injuries. METHODS/DESIGN: This is a prospective, randomized, controlled, double-blind equivalence trial of children agedthree to thirteen years and less than 50 kg body weight, with isolated musculoskeletal limb injury, presenting to the ED with moderate to severe pain, defined as a verbal response of at least six to a standard 11-point scale (0=none, 10=worst pain imaginable). Pain score, sedation, satisfaction with analgesic intervention, and adverse effects will be assessed over a 60 minute interval for each participant. Intranasal ketamine (1 mg/kg) or fentanyl (1.5 microgram/kg) will be administered via blinded syringe and mucosal atomization device in a standardized volume at 0.03 ml/kg, with a maximum volume of 1.5 ml divided equally to both nares. Participants will also receive 10 mg/kg ibuprofen orally. The primary outcome measure will be median change in pain score from pre-administration to 30 minutes post-administration. Non-parametric Mann-Whitney U tests will be computed to compare median change in the primary outcome measure for IN ketamine and fentanyl. A sample size of 36 participants per group is needed to detect the expected 40 mm reduction in pain rating with a 95% confidence interval (CI) no greater than ±10 mm at 30 minutes. Rescue analgesia will be given as IN fentanyl or intravenous morphine. DISCUSSION: This is the first randomized-controlled trial comparing the efficacy of these two analgesic agents via the intranasal route. If IN ketamine is found to be equally effective to IN fentanyl for this indication, it will provide another analgesic agent that may be considered for the relief of acute pain in children in the ED. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000795897.

Intranasal sufentanil for the treatment of acute pain in a winter resort clinic.

INTRODUCTION: Painful extremity injuries are common patient complaints in resort clinics, urgent care clinics, and emergency departments. We hypothesized that intranasal (IN) sufentanil could provide rapid, noninvasive, effective pain relief to patients presenting with acute extremity injuries. METHODS: This was an unblinded, nonrandomized, observational study that enrolled a convenience sample of patients presenting to a university-affiliated ski clinic with acute moderate to severe pain associated with a traumatic injury between the months of January and March 2011. Patients were excluded if they reported an allergy to sufentanil or had hypoxia, significant head injury, or hypotension. Nurses administered IN sufentanil using an IN atomizer device. The nurse recorded patient-reported pain scores (0-10 scale) on arrival and at 10, 20, and 30 minutes after administration of sufentanil. RESULTS: During the study period, 40 patients were enrolled; 75% were men. The average age was 32 years (range, 16-60 years). The average dose of sufentanil was 37.7 µg. Five patients (12.5%) were given additional IN analgesia. Average pain on arrival was 9 (on a 10-point scale), and the mean reduction in pain scores was 4.7 (95% confidence interval [CI], 3.67-5.57) at 10 minutes, 5.79 (95% CI, 4.81-6.77) at 20 minutes, and 5.74 (95% CI, 4.72-6.76) at 30 minutes. CONCLUSION: In this limited observational trial, IN sufentanil provided rapid, safe, and noninvasive pain relief to patients presenting with acute traumatic extremity injuries. Given the ease of administration, this may serve as a viable option for use in other settings, such as urgent care clinics and emergency departments.

[Optimization of the components of regulation of vascular tone and microcirculatory hemostasis during prolonged regional block in local cold injury].

The impact of prolonged conduction block of the brachial plexus on the regulatory components of vascular tone, the state of vascular platelet hemostasis, and the activity of an inflammatory process was studied in patients with second-to-fourth degree local arm frostbites. The block alleviated arterial spasm, indirectly lowered myogenic tone, and decreased shunt blood flow. Nutritive circulation increased in the presence of a total increase in blood flow to the arm. There were increases in the intensity, rate, and potential of platelet aggregation. The concentration of proinflammatory cytokines reduced. This resulted in more efficient treatment.

Dolor neuropático en cáncer de mama gabapentina versus carbamazepina / Neuropatic pain in breast cancer, gabapentina vs carbamazepina

El dolor neuropático en cáncer de mama es por efecto de las lesiones y disfunción en el sistema nervioso. Se caracteriza por presencia de alodinia, disestesia, parestesia y paroxismos de dolor agudo. Se realizó un estudio prospectivo, aleatorizado, fase III para determinar la eficacia, en términos de respuesta clínica, del tratamiento con gabapentina comparada con carbamazepina en mujerescon cáncer de mama estadios I, II, III y IV, con dolor neuropático. Las pacientes eran aleatorizadas a recibir (brazo A) gabapentina dosis de 300 mg de inicio y cada tres días se aumentaba 300 mg (25 pacientes) el (brazo B) carbamazepina 200 mg (25 pacientes) hasta obtener respuesta completa o la mayor dosis establecida. Las tasas de respuesta global fue 63 por ciento en el brazo A y 25 por ciento en el brazo B (P=0,032). Respuesta completa 19 por ciento vs 6 por ciento en el brazo A y B respectivamente. Respuesta parcial 44 por ciento (brazo A) vs 19 por ciento (brazo B). Enfermedad estable 31 por ciento vs 38 por ciento en el brazo A y brazo B respectivamente, progresión de enfermedad 6 por ciento (brazo A) y 38 por ciento (brazo B). Con toxicidades similares en ambos grupos. El esquema de tratamiento con gabapentina es más eficaz y bien tolerado que el de carbazepina, en pacientes con dolor neuropático y cáncer de mama.

Effectiveness of therapy with iloprost in hand-arm vibration syndrome.

AIM: To evaluate the efficacy and tolerance of therapy with iloprost in hand-arm vibration syndrome. METHODS: We describe a clinical case of a male aged 53 years, who was a heavy smoker for 30 years and a mason working with vibrating tools since 1962. He presented with a history of 10 years of attacks of vasospasm, functional impairment and digital ulceration. He was diagnosed as having hand-arm vibration syndrome vascular stage 4 on the Stockholm Workshop 1986 Scale. Besides suspension from work and abstention from smoking, we began intravenous infusion of iloprost for 6 h in cycles of 3-6 consecutive days, arriving at a dose of 1.5-2.0 ng/kg/min. RESULTS: After eight cycles, he reported significant symptomatic and functional improvement. Iloprost was seen to be efficacious: the trophic skin lesions disappeared and his microcirculatory perfusion tests improved. There were no significant side effects. CONCLUSIONS: We suggest that the use of iloprost in the treatment of the most advanced stages of vascular hand-arm vibration syndrome warrants further study

Calcium supplement and osteoporosis medication use in women and men with recent fractures.

Patients with low-trauma fractures are at risk of future fractures and so should be evaluated and treated for osteoporosis. This study was conducted to assess and compare bone medication use and calcium and vitamin D intake at the time of and after an acute fracture. One hundred and six patients, mean age 66.7+/-10.3 years, were administered medical history and diet questionnaires at enrollment (in an urban hospital) and again 6 and 12 months later (by telephone). Of 86 patients who could be contacted 6 months after their fracture, 36.2% of the women and 7.4% of the men had recently discussed osteoporosis with their primary care doctor. At 6 months, 24.2% of the women and 3.6% of the men were taking bone medications (compared with 27.8% and 3.6% before the fracture; NS). At 6 months, 52.6% of the women and 10.7% of the men indicated that their doctor had recently recommended calcium or vitamin D. Among the women who had recently been advised by their primary care doctor to use calcium or vitamin D, supplement use increased from 63.3% to 90.0% (P = 0.021) and dairy food intake increased from 1.5+/-1.1 to 2.4+/-1.9 servings/day (P = 0.016). Only three men received this advice and two of them heeded it. Among women and men not receiving this advice, there was no significant increase in calcium supplement use or dairy food intake. At 12 months, the treatment profiles were unchanged from 6 months and 9.6% of the women and 4.3% of the men had had another fracture. In conclusion, the occurrence of a fracture did not increase likelihood of pharmacologic treatment for osteoporosis. After their fractures, the women did increase their intake of calcium supplements and dairy foods when this was recommended by their doctor. This suggests that the primary care physician is well positioned to bring about much needed change in the quality of care of fracture patients.

Efficacy and tolerability of escin/diethylamine salicylate combination gels in patients with blunt injuries of the extremities.

The aim of this confirmative, monocentre, double-blind, controlled clinical trial was to investigate whether different escin combinations show differences in comparison to placebo with regard to pain reactions in the topical treatment of sports injuries. A total of 126 patients with blunt injuries of the extremities were randomly allocated to four parallel groups: Reparil-Gel N (n = 32), Reparil-Gel (n = 31), Reparil-Sportgel (n = 32) and a placebo gel (n = 31). All patients were evaluated for efficacy (intention to treat) and tolerability. A per-protocol analysis was also carried out, in which 12 of the 126 patients were excluded due to protocol violations. The intention-to-treat and per-protocol analyses produced similar results. The patients had suffered contusions while participating in soccer, hockey, karate, tae-kwon-do, handball, American football, rugby or tennis. The measured variable was the pressure required at the centre of the lesion to elicit the first pain reaction (tenderness reaction) at measuring time 0 (baseline) and then 1, 2, 3, 4, 6 and 24 h after the injury. The primary variable was the area under the curve (AUC) for tenderness over a six-hour period. The mean AUC differed significantly in the four groups (Kruskal-Wallis test p = 0.0001). Then six pairwise comparisons of two treatment groups each were carried out using the Mann-Whitney test. To control the multiple significance level of 5%, the adjusted p-values according to the Holm-Shaffer method were used in these tests. The three active gels were significantly superior to the placebo gel (Mann-Whitney test, p = 0.0004 in each case) in terms of the AUC. There were no significant differences between the active test substances in terms of the primary variable. The intensity of the pain was also measured on a visual analogue scale (VAS). The pain diminished more rapidly with the Reparil gels than with the placebo. The tolerability of all test substances was good. No adverse events were observed in any of the 126 patients. Escin combination gels are more effective than a placebo and are also well tolerated. Therefore, they can be recommended for the treatment of blunt injuries caused during sports and leisure activities.

Partial rupture of the distal biceps tendon.

We report on 7 cases of partial rupture of the distal biceps tendon. The mean patient age was 52 years (range, 38-58 years). There were 5 men and 2 women. The dominant arm was affected in all 7 patients. Pain was the chief complaint in all patients. Immobilization and physiotherapy were attempted in all patients, and 4 had at least 1 local steroid injection. No patient improved from the conservative treatment. All patients eventually underwent surgical debridement and reattachment of the biceps tendon with use of a 1-incision technique with suture anchors. After a mean follow-up of 31 months (range, 25-44 months), all patients reported a significant decrease in their pain. No complications were noted.

A thermal burn to a prolapsed uterus.

Burns to the concealed area of the perineum, are relatively rare and usually associated with massive burns and a high mortality rate. A rare case of a thermal burn to a prolapsed uterus is described. The victim was a 72-year-old Bedouin woman, with a 70 per cent total body surface area deep burn from an open fire. In addition to the conventional treatment dictated by such a burn, two unique problems must be considered: (1) the common pathogens of the uterus, Neisseria gonorrhoeae, Chlamydia trachomatis and mycoplasma, are different from those of the skin; (2) the lymphatics of the uterus drain directly into the abdominal cavity and the risk of peritonitis and generalized infection is potentially higher. Intravenous, prophylactic, broad-spectrum antibiotics were therefore initiated immediately following admission. These included: cefoxitin, gentamicin and metronidazole a combination that covers both the potential pathogens of the uterus and the common pathogens of the skin. In addition, and for the same reason, Betadine substituted Flamazine for the local treatment of the exposed uterus. Our patient did not survive the burn, but in a similar, unusual case, the local and systematic remedies must protect against uterine pathogens that are not commonly seen in a burn victim.

Avaliaçåo clínica dos resultados terapêuticos do uso de nimesulide em condiçöes flogísticas do aparelho osteoarticular / Clinical efficacy of nimesulide in orthopedics and traumatology

Foram avaliados 30 pacientes com patologias inflamatórias agudas nåo infecciosas do aparelho locomotor. Houve melhora total ou parcial de todas as principais manifestaçöes da inflamaçåo em todos os pacientes estudados. A tolerabilidade foi excelente, e a maioria dos pacientes obteve resposta clínica em até 1 hora após a ingeståo do nimesulide