Superior hypogastric plexus block as an effective treatment method for endometriosis-related chronic pelvic pain: an open-label pilot clinical trial.

We aimed to investigate the effect of superior hypogastric plexus (SHP) block on pain relief and quality of life of patients with refractory endometriosis. Sixteen patients with refractory endometriosis underwent SHP block. The outcome measures included visual analogue scale (VAS) for chronic pelvic pain, VAS for dysmenorrhoea, and VAS for dyspareunia. The short-form endometriosis health profile (EHP-5) was used to measure quality of life. All the outcome measures were evaluated at weeks 0, 1, 4, 12 and 24. The mean baseline VAS scores significantly improved after the SHP block (p < .001 for all). The mean overall EHP-5 score also significantly improved from 54.3 ± 18.2 to 24.6 ± 13.3 (p < .001). The positive effects of SHP were not diminished over time. No serious adverse effect was noticed in any of the patients. Preliminary results suggest that SHP block could be used as an effective method in pain control and improvement of quality of life in refractory endometriosis.IMPACT STATEMENTWhat is already known on this subject? Safety and efficacy of SHP block in the treatment of CPP has been revealed in earlier investigations. However, the efficacy of SHP block for pain management in patients with refractory endometriosis has not been investigated in earlier investigations.What do the results of this study add? SHP block is an effective method for pain control and improvement of quality of life in patients with refractory endometriosis. The positive effects of this treatment did not diminish over 24-weeks follow-up of the study. No serious adverse effect was noticed in any of the patients.What are the implications of these findings for clinical practice and/or further research? Preliminary results suggest that SHP block could be used safely and effectively for controlling pain and improvement of quality of life in patients with refractory endometriosis.

Does transcutaneous electrical nerve stimulation reduce the laparoscopic related shoulder pain?

OBJECTIVE: Although laparoscopic surgery is a good substitute for laparotomy in reducing postsurgical pain, many patients complain of shoulder pain after laparoscopic surgery and require pain-relief. Post-operative pain management leads to increased patient satisfaction. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological, noninvasive modality that reduces pain by activating the descending inhibitory systems in the central nervous system. Given the importance of decreasing shoulder pain after gynecological laparoscopy, the current study aimed to investigate the management of shoulder pain in these patients using TENS. METHODS: This was a retrospective case-control study. A total of 112 women aged 18-45 years who experienced shoulder pain due to gynecologic laparoscopic surgery were included in the study. Patients were divided into TENS and control groups. In the TENS group, TENS was used twice for 20 minutes each, but in the control group, the patients received regular treatment. Patients were evaluated at intervals of 2, 4, 8, 24, 48, and 72 hours after laparoscopy for shoulder pain score. RESULTS: The results showed a significant decrease in visual analog scale scores at 2, 4, and 8-hour in the TENS group compared with the control group. At 24 hours evaluation, although the pain was reduced, the difference was not significant. At 48- and 72-hour assessment, all patients in each group reported zero score for severity of pain. CONCLUSION: The findings suggest that TENS significantly reduces postoperative shoulder pain.

Epidural and subdural hematoma following spinal anesthesia in infants rat model.

The aim of this study was to assess the epidural and subdural hematoma following spinal anesthesia in infants' rat model. We investigated during 10, 15, and 20 days' rats in group 1: intrathecal injection of bupivacaine 3.75 mg/kg (n = 7); group 2: received 37.5 µl midazolam 0.1% intrathecal with 37.5µl fentanyl 0.005% (no=7); injected into group 3 methylene blue 1 mg/ml (No. 7). Rats were exposed to spinal anesthesia in infancy and rotarod in motor function in adulthood. Histological evaluation and tissue extraction were also performed after the treatment and magnetic resonance imaging (MRI) of the head. MRI of the head of all rat pups that showed similar symptoms were performed. 4 rat pups showed the symptoms of hematoma Group1: small acute subdural hematoma at the left posterior temporal-parietal junction (PTPJ) and group 2 (one: right temporal epidural hematoma, two: Small acute subdural hematoma in the right temporomandibular area, and three: frontal-temporal-parietal-occipital hematoma). the rat pup that had epidural hematoma died 6 hours later. Finally, in the first group, one rat and the second group three rats showed hematoma symptoms. For these three rats, a histopathologic study was performed and indicate the presence of small acute subdural hematoma at the left posterior temporal-parietal junction, right temporal epidural hematoma, and frontal-temporal-parietal-occipital hematoma. In summary, because subdural or epidural hematoma of the skull can have serious consequences, differential diagnosis is very important for pain after spinal anesthesia.

Hysteroscopic polypectomy with endometrial resection preventing the recurrence of endometrial polyps: A single-blinded randomized clinical trial.

Background: Recurrence of endometrial polyp following the hysteroscopic polypectomy is a significant concern for both the patients and physicians. This study aimed to evaluate the efficacy of combining hysteroscopic polypectomy with endometrial resection in reducing the rate of recurrence in women over 40 years old. Methods: In a single-blinded clinical trial, 94 women with endometrial polyps who were unwilling to future pregnancy were identified and randomly allocated to the intervention (hysteroscopic polypectomy + endometrial resection) and control group (hysteroscopic polypectomy alone) group (n=47/each). Randomization was done using a simple randomization technique . The primary outcome measure was the polyp recurrence. The secondary outcome measure was the number of adverse events. Results: In total, polyp recurrence occurred in two (4.3%) patients of the intervention group and nine patients (19.1%) of the control group (P=0.019). All the recurrences occurred in the premenopausal patients (P=0.012). No adverse event was observed in any patients of both groups. Conclusion: Adding endometrial resection to hysteroscopic polypectomy, especially in postmenopausal women, is a safe method that significantly reduces the risk of recurrence of the endometrial polyp.

Contralateral and Lateral Views: Analysis of the Technical Aspects of Spinal Cord Stimulator Lead Insertion.

Background: Spinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. The critical part of this technique is safe access to the epidural space for lead placement. There have been innovations in radiological views, improving access to the epidural space. Objectives: This study analyzes the adoption of these technical advantages in daily practice. Methods: We conducted a survey of members in the Spine Intervention Society and American Society of Regional Anesthesia in regard to the practice patterns in SCS therapy. Here we present our findings regarding the use of contralateral oblique (CLO) and lateral views as well direct upper thoracic or cervicothoracic access for SCS lead insertion. Results: A total of 195 unique responses were received between March 20, 2020 and June 26, 2020. Forty-five percent of respondents "always used" the lateral view technique while 15% "always used" CLO view for SCS lead insertion. Overall, sixty-five percent of respondents used the CLO view with varying frequency. Cervical and upper thoracic approach for cervical SCS lead placement is always or often used by 66.8% of the respondents. Conclusions: A depth view (CLO or lateral) is always used by only 45 - 60% of the respondents and CLO view has been rapidly adopted in clinical practice for SCS lead insertion. Direct cervicothoracic and upper thoracic is the preferred approach for cervical lead placement by the majority.

Diagnostic Accuracy of Combined PET/CT with MRI, 18F-FDG PET/MRI, and 18F-FDG PET/CT in Patients with Oropharyngeal and Hypopharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis.

Introduction: The aim of this paper is to compare the diagnostic accuracy of PET/CT, PET/MRI, and the combination of PET/CT and MRI for detecting synchronous cancer and distant metastasis in patients with oropharyngeal and hypopharyngeal squamous cell carcinomas (OHSCC). Method: A large and growing body of literature has been conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA). The researchers collected all accessible literature existing through Cochrane Library (John Wiley & Sons) electronic databases, Embase (Elsevier), PubMed (U.S. National Library of Medicine), Scopus, and Google Scholar up to June 2020. Analyses were conducted using Stata version 12.0 (StataCorp LP). Results: A total of nine studies consisting of 1166 patients were included. The pooled sensitivity of combined PET/CT with MRI, 18F-FDG PET/MRI, and 18F-FDG PET/CT was 0.92, 0.80, and 0.79, respectively, and the corresponding specificities were 0.93, 0.91, and 0.88. The overall prevalence of distant metastases and synchronous cancer in patients with oropharyngeal and hypopharyngeal squamous cell carcinomas was 9.2% and 11.8%, respectively, with the esophagus (4.6%) being the most common site of synchronous cancer. The most common sites of distant metastases were lung (3%), bone (1.2%), and distant lymph nodes (1.2%), respectively. Conclusion: Our study showed an approximately similar diagnostic performance for PET/CT, PET/MRI, and the combination of PET/CT and MRI for metastasis assessment in advanced oropharyngeal and hypopharyngeal squamous cell carcinomas.

Conolidine: A Novel Plant Extract for Chronic Pain.

Pain, the most common symptom reported among patients in the primary care setting, is complex to manage. Opioids are among the most potent analgesics agents for managing pain. Since the mid-1990s, the number of opioid prescriptions for the management of chronic non-cancer pain (CNCP) has increased by more than 400%, and this increased availability has significantly contributed to opioid diversion, overdose, tolerance, dependence, and addiction. Despite the questionable effectiveness of opioids in managing CNCP and their high rates of side effects, the absence of available alternative medications and their clinical limitations and slower onset of action has led to an overreliance on opioids. Conolidine is an indole alkaloid derived from the bark of the tropical flowering shrub Tabernaemontana divaricate used in traditional Chinese, Ayurvedic, and Thai medicine. Conolidine could represent the beginning of a new era of chronic pain management. It is now being investigated for its effects on the atypical chemokine receptor (ACK3). In a rat model, it was found that a competitor molecule binding to ACKR3 resulted in inhibition of ACKR3's inhibitory activity, causing an overall increase in opiate receptor activity. Although the identification of conolidine as a potential novel analgesic agent provides an additional avenue to address the opioid crisis and manage CNCP, further studies are necessary to understand its mechanism of action and utility and efficacy in managing CNCP.

Dorsal Root Ganglion (DRG) and Chronic Pain.

CONTEXT: Chronic neuropathic pain is a common condition, and up to 11.9% of the population have been reported to suffer from uncontrolled neuropathic pain. Chronic pain leads to significant morbidity, lowered quality of life, and loss of workdays, and thus carries a significant price tag in healthcare costs and lost productivity. dorsal root ganglia (DRG) stimulation has been recently increasingly reported and shows promising results in the alleviation of chronic pain. This paper reviews the background of DRG stimulation, anatomical, and clinical consideration and reviews the clinical evidence to support its use. EVIDENCE ACQUISITION: The DRG span the length of the spinal cord and house the neurons responsible for sensation from the periphery. They may become irritated by direct compression or local inflammation. Glial cells in the DRG respond to nerve injury, producing inflammatory markers and contribute to the development of chronic pain, even after the resolution of the original insult. While the underlying mechanism is still being explored, recent studies explored the efficacy of DRG stimulation and neuromodulation for chronic pain treatment. RESULTS: Several reported cases and a small number of randomized trials were published in recent years, describing different methods of DRG stimulation and neuromodulation with promising results. Though evidence quality is mostly low, these results provide evidence to support the utilization of this technique. CONCLUSIONS: Chronic neuropathic pain is a common condition and carries significant morbidity and impact on the quality of life. Recent evidence supports the use of DRG neuromodulation as an effective technique to control chronic pain. Though studies are still emerging, the evidence appears to support this technique. Further studies, including large randomized trials evaluating DRG modulation versus other interventional and non-interventional techniques, are needed to further elucidate the efficacy of this method. These studies are also likely to inform the patient selection and the course of treatment.

Programmable Pump for Intrathecal Morphine Delivery to Cisterna Magna: Clinical Implications in Novel Management of Refractory Pain Above Middle Thoracic Vertebrae Level Utilizing a Prospective Trial Protocol and Review.

BACKGROUND: The cisterna Intrathecal Drug Delivery system (IDDS) with morphine has proven to be effective in treating refractory cancer pain above the middle thoracic vertebrae level in some countries. However, it has not been fully investigated in others. We designed the current project to investigate the efficacy and safety of cisterna IDDS for pain relief in refractory pain above the middle thoracic vertebrae level in advanced cancer patients. METHODS: This study protocol allows for eligible cancer patients to receive the cisterna IDDS operation. Pain intensity (Visual Analogue scale, VAS), quality of life (36-Item Short-Form Health Survey, SF-36), and depression (Self-Rating Depression scale, SDS) are assessed along with side effects in the postoperative follow-up visits. Recent literature suggests a potential role for cisterna IDDS morphine delivery for refractory pain states above the middle thoracic level. CONCLUSION: The results of this study may provide further evidence that cisterna IDDS of morphine can serve as an effective and safe pain relief strategy for refractory pain above the middle thoracic vertebrae level in advanced cancer patients.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in evaluating the endometrial polyps in women with abnormal uterine bleeding: a systematic review and meta-analysis.

INTRODUCTION: In women with abnormal uterine bleeding (AUB), endometrial polyps are a frequent finding, and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women is important. AIM: To evaluate and compare the diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in detecting endometrial polyps in women with AUB. MATERIAL AND METHODS: The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until the end of 30/06/2019. We searched for published literature in English language in MEDLINE, EMBASETM, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The risk of bias of every article was evaluated by using QUADAS-2. RESULTS: After selection and quality assessment, 11 studies were included. Based on the random effect model the total prevalence of endometrial polyps in women with abnormal uterine bleeding was 38%. The sensitivity and specificity of saline infusion sonohysterography in diagnosis of endometrial polyps were 0.87 and 0.86, respectively. The sensitivity and specificity of transvaginal ultrasonography were 0.62 and 0.73 and the sensitivity and specificity of hysteroscopy were 0.92 and 0.85, respectively. CONCLUSIONS: Although that sonohysterography is a safe and relatively cheap method, which allows ruling out or confirming endometrial polyps, it cannot be replaced with hysteroscopy due to the fact that hysteroscopy combined with biopsy is the gold standard for ruling out malignancies in an endometrial polyp.

Comparison of Transforaminal Triamcinolone and Dexmedetomidine in Radicular Low-Back Pain: A Randomized Double-Blind Clinical Trial.

BACKGROUND: Administration of steroids in the lumbar transforaminal block for lumbar radicular pain is considered one of the preferred treatment methods though it is associated with some complications. OBJECTIVES: The effects and side effects of triamcinolone and dexmedetomidine in the lumbar transforaminal block were investigated in the present study. METHODS: In this study, 30 patients, aged 40 - 70 years, suffering from lumbar radicular pain arising from the lumbar disc protrusion were equally divided into two groups of triamcinolone (T) and dexmedetomidine (D). They all underwent lumbar transforaminal blocks. An injection solution of triamcinolone (20 mg) plus ropivacaine (0.2%) and another one containing dexmedetomidine (50 µg) plus ropivacaine (0.2%) were administered in the triamcinolone and dexmedetomidine groups, respectively. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Straight Leg Raise (SLR or lasègue's test), and Fasting Blood Sugar (FBS) were measured at 0, 2 weeks, 1, 3, and 6 months post-procedure. The levels of calcium, magnesium, and vitamin D, as well as potential complications, were also evaluated. RESULTS: Significant differences were found in the VAS and ODI during the measurement times within each group. The VAS and ODI were remarkably different between the dexmedetomidine group and the triamcinolone group. In addition, there were considerable differences in the increased FBS and reduced calcium and vitamin D levels in the triamcinolone group from changes in the dexmedetomidine group. CONCLUSIONS: The lumbar transforaminal block with triamcinolone or dexmedetomidine attenuates the lumbar radicular pain. Further, dexmedetomidine exerts a more potent pain relief effect than triamcinolone.

Pregnancy in Non-Communicating Rudimentary Horn of A Unicornuate Uterus.

Diagnosis and management of pre-rupture stage of the pregnant horn are difficult and usually missed on a routine ultrasound scan. Also most cases are detected after rupture of pregnant horn. We presented a 28-year-oldG2 L1 woman with diagnosis of rudimentary horn pregnancy (RHP) at 14 weeks of gestation. We diagnosed her with a normal intrauterine pregnancy, whereas a pregnancy in a right-sided non-communicating rudimentary horn with massive hemoperitoneum was later discovered on laparotomy. RHP has a high risk of death for mother, so there must be a strong clinical suspicion for the diagnosis of RHP. Although there is a major advancement in field of diagnostic ultrasound and other imaging modalities, prenatal diagnosis has remained elusive and a laparotomy surgery is considered as a definitive diagnosis.

Endometriosis of Diaphragm: A Case Report.

Endometriosis affects about 10% of women of reproductive age. Its main feature is the presence of stroma and endometrial glands in sites other than the uterus, mainly in pelvis. Pelvic peritoneum, ovaries, uterine ligaments, bladder, intestines, andcul-de-sac are among the affected areas. Sometimes endometriosis can be found outside of the pelvis and even above abdominal cavity, like indiaphragm.Herein, we present a case of an asymptomatic diaphragmatic endometriosis that was discovered incidentally during laparoscopy of pelvic endometriosis, as well as our appropriately proposed treatment protocol.

The impact of letrozole versus clomiphene citrate on uterine blood flow in patients with unexplained infertility.

OBJECTIVE: To compare the effectiveness of letrozole and clomiphene citrate (CC) on uterine blood flow rate in patients with unexplained infertility. MATERIALS AND METHODS: In this randomized clinical trial 90 women with unexplained infertility referred to a university clinic from January 2011- December 2013 were enrolled. Thirty patients were randomized for letrozole, 30 patients for CC and 3o patients for control group. On the day 3 of cycle the patients were given letrozole 2.5mg/day or CC 100 mg /day orally or did not receive any treatment. Resistance index (RI) and pulsatility index (PI) of uterine artery were calculated and chemical pregnancy rate was evaluated. RESULTS: Mean age was 26.4±3.2 (20-33) and mean BMI was 26.3± 3.2. After treatment using ultrasonography the Resistance index (RI) and Pulsatility index (PI) showed no significant difference among three groups (P > 0.05). Pregnancy rate in letrozole group (58%) was more in comparison to CC (53.6%) and control groups (46%) but the difference was not significant (P > 0.05). CONCLUSION: Our study showed that letrozole and clomiphene citrate have comparable impact on uterine blood flow and pregnancy rate in women with unexplained infertility.