Percutaneous splanchnic nerve neurolysis analgesic efficacy and safety for cancer-related pain: a systematic review and meta-analysis.

PURPOSE: To perform a systematic review and meta-analysis of publications to evaluate the analgesic efficacy and safety of percutaneous splanchnic nerve neurolysis (SNN) for cancer-related pain. METHODS: We searched PubMed, Cochrane Library, and Ichushi-Web for English or Japanese articles published up to July 2022 and reporting patients who underwent percutaneous SNN for cancer-related pain. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales and morphine equivalents daily dose (MEDD) before and after the intervention and the rate of complications. RESULTS: Pooled pain measurement scores at pre-intervention, 1-2 weeks, and at 1, 2, 3, and 6 months post-intervention were 6.65 (95% confidence interval [CI], 5.77-7.67, I2 = 97%), 2.79 (95% CI, 2.00-3.88, I2 = 88%), 2.82 (95% CI, 2.49-3.20, I2 = 55%), 2.86 (95% CI, 2.64-3.10, I2 = 0%), 2.99 (95% CI, 2.56-3.46, I2 = 82%), and 3.09 (95% CI, 1.44-6.65, I2 = 70%), respectively. Mean MEDD was described in 8 of the 11 included articles. In all 8 articles, MEDD decreased up to 3 months post-intervention. The pooled minor complication rates for diarrhea and hypotension were 28% (95% CI, 13-49%, I2 = 85%) and 31% (95% CI, 16-51%, I2 = 80%), respectively. The pooled major complication rate was 2% (95% CI, 1-2%, I2 = 0%). CONCLUSIONS: Analysis indicates that percutaneous SNN for cancer-related pain can be performed safely with sustained reduction of pain measurement scales while reducing the administration of opioids.

Therapeutic experience with tramadol for opioid dependence in a patient with chronic low back pain: a case report.

BACKGROUND: Long-term opioid treatment for chronic non-cancer pain has become controversial, given the increasing prevalence of opioid dependence. However, there is little information on therapeutic strategies for this condition in Japanese patients. Here, we present a case of successful management of iatrogenic opioid dependence with tramadol in a patient with chronic low back pain. CASE PRESENTATION: A 68-year-old male suffering from intractable low back pain was referred to our pain clinic. He was previously treated in another hospital with transdermal fentanyl patches 6 mg/day and fentanyl sublingual tablets (100 µg as required) for this condition. On the basis of medical examination, including a review of the patient's medical history, physical examination, X-ray, and his family statement, we diagnosed him with iatrogenic opioid dependence due to inadequate fentanyl use. Then, we developed a treatment plan consisting in fentanyl detoxification with a weak opioid, tramadol. At first, the use of fentanyl sublingual tablets was interrupted after obtaining informed consent. Then, we reduced the dose of transdermal fentanyl 1 mg per 4-5 days replacing with oral sustained-release tramadol. The patient developed mild to moderate withdrawal symptoms during this period, which could be effectively managed by supportive treatments. The hospital psychiatry liaison team continuously provided the patient and his wife with information, counseling, and education regarding the treatment of opioid dependence. Throughout the detoxification process, his reported pain did not exacerbate, even slightly improved over time. The final prescription was sustained-release tramadol 300 mg/day without fentanyl, and his activities of daily living drastically improved. However, unfortunately, he died due to an aortic dissection of stent-graft edge 65 days after surgery. CONCLUSIONS: Our case highlighted that sustained-release tramadol could be effectively applied as a detoxification agent for iatrogenic opioid dependence in patients with chronic non-cancer pain.

General anesthesia in a patient with asymptomatic second-degree two-to-one atrioventricular block.

BACKGROUND: The major perioperative concern in patients with second-degree atrioventricular (AV) block is the progression to complete AV block. Therefore, the prophylactic implantation of a temporary pacemaker prior to surgery is recommended, especially in symptomatic patients. However, as no quantitative preoperative risk assessment from progression to complete AV block is available, there is currently no established indication for preoperative prophylactic pacemaker implantation. Here, we present a case of progression from asymptomatic second-degree two-to-one (2:1) AV block to complete AV block following the induction of general anesthesia. CASE PRESENTATION: A 69-year-old female with degenerative spinal stenosis was scheduled for transforaminal lumbar interbody fusion surgery under general anesthesia. She had no cardiac symptoms, but routine preoperative resting 12-lead electrocardiogram revealed second-degree 2:1 AV block. After discussion with the surgeon and referring cardiologist, we scheduled the surgery without implantation of a temporary pacemaker before surgery for the following reasons: (1) asymptomatic, (2) no evidence of underlying cardiac disease, and (3) a narrow QRS complex. On the day of surgery, general anesthesia was induced with 150 mg of intravenous thiamylal and 25 µg of fentanyl, followed by intravenous administration of 50 mg of rocuronium to facilitate endotracheal intubation. Sevoflurane (1.0-2.0%) was used to maintain anesthesia. A few minutes after induction, the 2:1 AV block progressively converted to complete AV block, and the surgery was postponed. During emergence from anesthesia, the third-degree AV block recovered to 2:1 AV block, similar with the preoperative pattern. The patient was monitored in the intensive care unit for 2 days and then transferred to the normal orthopedic ward uneventfully. One month later, the surgery was rescheduled with preoperative implantation of a temporary pacemaker. A slow mask induction using sevoflurane with oxygen was started. Upon loss of consciousness during the inhalation of initial sevoflurane, complete AV block developed and temporary pacing was immediately initiated. Subsequent anesthesia and surgery were uneventful. The patient made an uncomplicated recovery from surgery with stable hemodynamics. The temporary pacemaker was not required after surgery, and the pacemaker catheter was removed 1 day after surgery. CONCLUSIONS: The present case indicates that a prophylactic pacemaker should be implanted preoperatively in patients who have 2:1 AV block even without symptoms.

Peripheral nerve block with a high concentration of tetracaine dissolved in bupivacaine for intractable post-herpetic itch: a case report.

BACKGROUND: Post-herpetic itch (PHI) is a neuropathic itch syndrome following herpes zoster. It has been reported that PHI is occasionally sufficiently severe to compromise patients' quality of life and frequently refractory to treatment. Here, we present a case of severe chronic PHI successfully treated with supraorbital nerve block using a high concentration of tetracaine dissolved in bupivacaine. CASE PRESENTATION: An 82-year-old man presented with severe chronic itching in the ophthalmic branch of the left trigeminal nerve dermatome, following acute herpes zoster. The patient's itching was unresponsive to usual medical treatments for PHI including antiepileptic drugs, topical capsaicin cream, and supraorbital nerve radiofrequency thermo-coagulation. Topical lidocaine cream could relieve the itching, but could not provide long-term relief of itching and thus failed to achieve a satisfactory result. After these conventional treatments, left supraorbital nerve block using 4% tetracaine dissolved with 0.5% bupivacaine was conducted. Afterwards, the patient experienced long-lasting resolution of the itching with improvement of sleep disturbance. A transient, mild edema of the eyelids occurred, but there were no other complications. CONCLUSIONS: Peripheral nerve block using 4% tetracaine dissolved with 0.5% bupivacaine was beneficial in relieving PHI in the ophthalmic division of the trigeminal nerve.

Failure of lumbar puncture in a patient with spinal epidural lipomatosis: a case report.

We report a case of difficult lumbar puncture due to the inability to obtain adequate cerebrospinal fluid (CSF) in a patient later diagnosed with spinal epidural lipomatosis (SEL). A 76-year-old man with a body mass index (BMI) of 24.1 kg/m2 was scheduled for transurethral resection of a bladder tumor for superficial bladder cancer under spinal anesthesia. The patient had a 3-year history of inhaled steroid use for the management of chronic obstructive pulmonary disease. After placing the patient in the right lateral position, a lumbar puncture was performed via the median approach. However, CSF could not be tapped adequately despite repeated attempts at lumbar puncture, so general anesthetic was administered instead. Subsequently, both anesthesia and surgery proceeded uneventfully. On the first postoperative day, the patient developed mild postdural puncture headache (PDPH), which was treated conservatively. No postoperative neurological complications related to spinal anesthesia were observed. Approximately 2 months after discharge, the patient reported progressive lower back pain and was diagnosed with SEL by magnetic resonance imaging (MRI). A lumbar laminectomy and removal of excessive adipose tissue was performed. After surgery, the patient's symptoms resolved. The pathogenesis of SEL involves excess fat tissue deposition in the spinal canal, which can lead to obliteration of the spinal subarachnoid space. Therefore, in this patient, the SEL was thought to have caused the inability to obtain adequate CSF during lumbar puncture, and was associated with difficult spinal anesthesia.

Prolonged post-dural puncture headache in a patient during treatment with selective serotonin reuptake inhibitor: a case report and animal experiment.

We report a case of prolonged post-dural puncture headache (PDPH) in a patient with panic disorder. A 41-year-old woman received spinal anesthesia for interstitial cystitis. She noticed headache after surgery but did not report it to her doctor. As her headache worsened, she was readmitted to the hospital and diagnosed with PDPH 1 month after surgery. She had panic disorder, controlled by treatment with a selective serotonin reuptake inhibitor, sertraline. Conservative treatments were performed for 1 week, but her headache persisted. Successful resolution of PDPH was achieved following two epidural blood patch applications. A recent study showed that the duration of PDPH was prolonged with a history of depression. Therefore, we conducted a reverse translational experiment to investigate the effects of sertraline on the production of cerebrospinal fluid (CSF) in rats. Our results demonstrated that a clinically relevant dose of sertraline decreased the production of CSF. Our findings imply that treatment with sertraline may have contributed to the development of prolonged PDPH in this case.

Effects of sulfur amino acids on tyrosyl or serine/threonine phosphorylation and translocation of cytosolic compounds to cell membrane in stimulus-treated human neutrophils.

We investigated the effects of various sulfur amino acids on the phosphorylation of proteins and the translocation of cytosolic compounds to cell membrane in stimulus-treated human neutrophils using specific monoclonal antibodies. D,L-homocysteine and D,L-homocysteine-thiolactone enhanced fMLP-induced tyrosyl phosphorylation of proteins and the translocation of p47phox, p67phox, and rac to the cell membrane in a concentration-dependent manner. L-cystathionine, NAc-L-cysteine and carboxymethylcysteine suppressed the tyrosyl phophorylation and translocation of cytosolic compounds to the cell membrane. L-cystathionine, L-cysteine and NAc-L-cysteine suppressed PMA-induced serine/threonine phosphorylation and the translocation of cytosolic compounds to the cell membrane. L-cysteine, NAc-L-cysteine and D,L-homocysteine enhanced AA-induced serine/threonine phosphorylation and the translocation of cytosolic compounds to the cell membrane, but L-cystathionine had opposite effects. These results indicated that the effects of sulfur amino acids on tyrosyl or serine/threonine phosphorylation and the translocation of p47phox, p67phox, and rac to the cell membrane in the stimulus-treated human neutrophils were in parallel with those of the stimulus-induced superoxide generation reported in previous paper. L-cysteine, D,L-homocysteine and L-cystathionine weakly inhibited lipid peroxidation, but the other sulfur amino acids tested had no effect.

Activity of prolidase isoenzymes in the rat brain: subcellular and regional distribution during development.

Prolidase deficiency is characterized by chronic ulcerative dermatitis, mental retardation, and frequent infections. In the present study we examined the characteristics of rat brain prolidase isoenzymes. Prolidase isoenzymes (PD I and PD II) were isolated from the rat brain using DEAE cellulose column chromatography. PD I showed higher activity against seryl-proline and alanyl-proline, while PD II was particularly active against methionyl-proline. Prolidase activity in the whole brain and in the different brain regions showed higher activity against methionyl-proline and seryl-proline. PD II activity was highest in the hippocampus, followed by the cerebellum, cerebral cortex, caudatum, and the midbrain. The most rapid changes in the activities of PD I and PD II occurred perinatally, with a peak at three days before birth and a nadir at two days after birth, which then gradually increased until 21 days. N-benzyloxycarbonyl-l-proline inhibited PD I activity against various substrates in a dose-dependent manner. In contrast, there was no inhibition of PD II activity against methionyl-proline at low concentrations. In summary, these data suggest that maintenance of levels of proline, other amino acids and peptides containing proline in the rat brain is regulated by prolidase isoenzymes. The age-related alterations in PD I and PD II also may help to elucidate the fundation of prolidase isoenzymes in brain nervous system.

Prolidase isoenzymes in the rat: their organ distribution, developmental change and specific inhibitors.

Lack of prolidase I (PD I) leads to prolidase deficiency, a disease characterized by intractable skin lesions, recurrent respiratory infections, and mental retardation. The present study was undertaken to characterize and determine the physiologic roles of different prolidase isoenzymes. Two isoforms of prolidase were isolated from rat kidney. PD I showed higher activity against seryl-proline and alanyl-proline, whereas PD II was active especially against methionyl-proline. PD I was highly concentrated in the small intestine and kidney, whereas PD II was shown not to vary in the organs examined. Expression of PD I and PD II in the small intestine were maximal within 1 wk of birth, and then rapidly declined. The changes of prolidase in the kidney and heart were found to differ slightly. N-benzyloxycarbonyl-l-proline and captopril inhibited PD I dose-dependently, but showed no inhibition of PD II at low concentrations. NiCl2 inhibited PD II much more effectively than PD I. Our findings suggest that PD I functions by way of an intestinal peptide carrier, which may also be regulated by the uptake of various iminodipeptides. Similarly, age-related alterations of prolidase isoenzymes suggest that intestinal PD II also participates in absorption of proline and other amino acids early in life.

Blood flow velocity of the femoral vein with foot exercise compared to pneumatic foot compression.

STUDY OBJECTIVE: To compare the effects of foot exercise with an intermittent pneumatic foot compression (IPC) device on blood flow velocity of the femoral veins. DESIGN: Prospective, controlled study. SETTING: General intensive care unit of a university hospital. PATIENTS: 20 patients on bed rest in the intensive care unit. INTERVENTIONS: Patients were divided into 2 groups: group A, foot exercise (n = 10); and group B, IPC device (n = 10). The foot exercise was done once by a nurse for 5 minutes with the dorsiflexion of the ankle (15 times per minute) in group A patients. The IPC device (A-V Impulse System, compression setting: 130 mm Hg for 3 seconds followed by a resting period of 60 seconds) was used for 2 hours in group B. MEASUREMENTS: Peak blood flow velocity of the femoral vein was measured using the ultrasound unit with a 7.5-MHz linear array probe (ALOKA SSD-5500) at 0, 5, 15, 30, 60, and 120 minutes. MAIN RESULTS: Peak blood flow velocities in both groups increased significantly vs the control values during the study. At 5 minutes, group A showed a significant increase in the peak blood flow velocity compared with group B. CONCLUSIONS: Foot exercise by a nurse for 5 minutes was equally or more effective compared with the IPC device in increasing peak blood flow velocity of the femoral vein. The effect of the 5-minute foot exercise lasted for 2 hours.

Effect of sulfur amino acids on stimulus-induced superoxide generation and translocation of p47phox and p67phox to cell membrane in human neutrophils and the scavenging of free radical.

BACKGROUND: Various cystathionine metabolites are in the urine of the patients with cystathioninuria. Among these metabolites, cystathionine ketimine significantly enhanced N-formyl-methionyl-leucyl-phenylalanine (fMLP)-induced superoxide generation in parallel with tyrosyl phosphorylation of 45 kDa protein in human neutrophils. METHODS: We investigated the effect of various sulfur amino acids on fMLP-, phorbol-12-myristate-13-acetate (PMA)- and arachidonic acid (AA)-induced superoxide generation in human neutrophils. In addition, the effects of these sulfur amino acids on the membrane translocation of cytosolic compounds p47(phox) and p67(phox) and on the scavenging of superoxide anions were investigated. RESULTS: When the cells were preincubated with various sulfur amino acids, fMLP-induced superoxide generation was enhanced by D,L-homocysteine and D,L-homocysteine-thiolactone but was inhibited by other sulfur amino acids in a concentration-dependent manner. The AA-induced superoxide was enhanced by L-cysteine, N-acetyl-L-cysteine and D,L-homocysteine. The strength of enhancing effect was: L-cysteine>>N-acetyl-L-cysteine>D,L-homocysteine. On the other hand, the superoxide generation was weakly inhibited by L-cystathionine. The superoxide generation induced by PMA was weakly inhibited by L-cysteine, N-acetyl-L-cysteine and L-cystathionine. Homocysteine and D,L-homocysteine-thiolactone had no effect. In addition, D,L-homocysteine also enhanced translocation to the cell membrane of cytosolic compounds p47(phox) and p67(phox). Conversely, L-cystathionine and N-acetyl-L-cysteine inhibited the translocation to membrane of p47(phox) and p67(phox) in a concentration-dependent manner. N-acetyl-L-cysteine and L-cysteine revealed scavenging activity against 2,2-diphenyl-1-picrylhydrazyl (DPPH) radicals. The sulfur amino acids tested also indicated radical scavenging activity on superoxide anion generated by phenazine methoxysulfate (PMS)-NADH system. CONCLUSION: D,L-homocysteine and D,L-homocysteine-thiolactone enhanced fMLP-induced superoxide generation by the increment of translocation to membrane of p47(phox) and p67(phox). L-cystathionine and N-acetyl-L-cysteine suppressed fMLP- and PMA-induced superoxide generation by the inhibition of translocation to membrane of p47(phox) and p67(phox). N-acetyl-L-cysteine also had scavenging activity against DPPH radicals and superoxide anion.

[Case of ventricular tachycardia induced by coronary spasm during surgery in prone position].

A 55-year-old man with hypertension was scheduled for resection of spinal tumor at S1 in the prone position. Anesthesia was induced with midazolam 10 mg, fentanyl 0.2 mg and vecuronium 10 mg, and maintained with sevoflurane 1.5-2% in oxygen 3 l x min(-1) and fentanyl 0.4 mg. When the interspinal ligament was handled, severe ST depression on the ECG was observed for 1 minute, followed by ventricular tachycardia (VT). Immediately, 60 mg of lidocaine was administered intravenously, and ventricular rhythm recovered to sinus rhythm with normal ST level within a few minutes, but the surgery was postponed. In the preoperative examinations, the patient had been evaluated as a low risk case except for a long history of hypertension. Coronary spasm was suspected to have induced VT, because it followed severe ST depression. This experience taught us that in order to avoid critical arrhythmia, patients under general anesthesia, especially those undergoing surgery in the prone position, require particular attention because of the difficulty in cardiac resuscitation.

[A case of dissociative stupor with decorticated posture after neck clipping of brain aneurysm].

We experienced a case of dissociative stupor with decorticated posture in a 71-year-old woman after neck clipping of the brain aneurysm. Decorticated posture is observed with severe midbrain disorder caused by brain herniation. In this case, therefore, severe brain stem damage was suspected, although light reflex was observed and respiration was stable. In addition, in this case, the aneurysm was located at the junction of the internal carotid artery and the posterior communicating artery. Therefore, surgical damage to midbrain was not likely to have happened. Postoperative computed tomography showed no abnormality in this region. Two days later, her symptom disappeared, and she could clearly recollect memory of these two days just after surgery. However, she could not follow directions because of a sense of fear. Thus her symptom might be based on a kind of mental disorder. Patients with conversion disorder react abnormally to stimulus or stress. Stupor was diagnosed as due to defect of reaction to stimulus of sound, light and touch. She was diagnosed as dissociative stupor of the conversion disorder type. In this case, decorticated posture was caused by mental disorder. We have to pay attention not only to brain tissue damage but also to psychological damage of patients.

Effect of three triterpenoid compounds isolated from root bark of Aralia elata on stimulus-induced superoxide generation and tyrosyl phosphorylation and translocation of p47(phox) and p67(phox) to cell membrane in human neutrophil.

BACKGROUND: Root bark of Aralia elata is used as a folk medicine for neurasthenia, rheumatism, diabetes, hepatitis virus and spasm of the stomach in China, Japan and Russia. METHODS: The effect of three triterpenoid compounds isolated from root bark of A. elata on stimulus-induced superoxide generation and tyrosyl phosphorylation and translocation of p47(phox) and p67(phox) to cell membrane was investigated. The three compounds examined were Elatoside A, Elatoside C, and Tarasaponin V. RESULTS: When the cells were preincubated with these compounds, the superoxide generation induced by N-formyl-methionyl-leucyl-phenylalanine (fMLP) was suppressed in a low concentration range. However, the superoxide generation was significantly enhanced by 40 micromol/l triterpenoid, and was again suppressed in the higher concentration range. In the case of superoxide generation induced by phorbol 12-myristate 13-acetate (PMA), the compounds had no obvious effect on the superoxide generation in low concentration but suppressed that at 40 micromol/l. These compounds also efficiently suppressed the superoxide generation induced by arachidonic acid (AA) at 10 micromol/l. In parallel to the effect on the fMLP-induced superoxide generation, these compounds suppressed fMLP-induced tyrosyl phosphorylation and the translocation to membrane of cytosolic compounds, p47(phox) and p67(phox) at 10 and 80 micromol/l but not at 40 micromol/l. CONCLUSIONS: Triterpenoid saponins examined in this study effect stimulus-induced superoxide generation and tyrosyl phosphorylation and translocation to membrane of p47(phox) and p67(phox) in a concentration-dependent manner, and may have some pharmaceutical applications.