A Comparison of Precision and Safety using Three Recognized Ultrasound-Guided Approaches to Cervical Medial Branch Blocks: A Cadaver Study.

BACKGROUND: Ultrasound (US) guidance is widely used for needle positioning for cervical medial branch blocks (CMBB) and radiofrequency ablation, however, limited research is available comparing different approaches. OBJECTIVE: We aimed to assess the accuracy and safety of 3 different US-guided approaches for CMBB. STUDY DESIGN: A cadaveric study divided into ultrasound-guided needle placement and fluoroscopy evaluation stages. SETTING: Department of Pathology, Forensic, and Insurance Medicine, Semmelweis University. METHODS: Sonographically guided third occipital nerve (TON), C3, C4, C5 and C6 medial branch injections and radiology evaluations were performed.The 3 approaches compared were:1. ES (published by Eichenberger-Siegenthaler): US probe in the coronal plane to visualize the cervical articular pillars, needle approach out of the plane, from anterior to posterior.2. Fi (published by Finlayson): US probe in the transverse plane to visualize a cervical articular pillar and its lamina, needle approach in the plane, from posterior to anterior.3. FiM (Modified Finlayson approach): Needles are placed as in Fi, but then adjusted with a coronal view of the cervical articular pillars.Fluoroscopy images were taken and later evaluated, for "crude", "high precision" and "dangerous" placement. RESULTS: One hundred and fifty-five needle placements were assessed (10 were excluded, as no anterior-posterior fluoroscopy images were saved). Interobserver agreement on position of needle placement between the 5 observers was very high; the Fleiss' Kappa was 0.921. For crude placement, no significant differences were identified between various approaches; (77.6%, 79.5%, and 75.6% for the ES, Fi, and FiM respectively). However, for placement in predefined high-precision zones, ES resulted in significantly more success (ES: 42.9%, Fi: 22.7%, and FiM: 24.4%, P = 0.032). Fi and FiM resulted in no dangerous placements, while ES led to the potential compromise of the exiting nerve root and vertebral artery on three occasions. In 10% of the placements, the levels were identified wrongly, with no difference between the various approaches. LIMITATIONS: Feedback from a live patient, may prevent some existing nerve root injections, unlike in a cadaver. Though a higher number of needles were placed in this study than in most available publications, the number is still low at each individual medial branch level. CONCLUSION: Fi proved safer than ES. Fi was equally successful in targeting the articular pillar, however, ES proved the most successful in placing the needle in the center of the articular pillar. Adding another, (coronal) US view to check needle position in FiM did not improve safety or precision. Identifying CMB levels with the US is challenging with all approaches, therefore we still recommend using fluoroscopy for level identification. While there were pros and cons with either procedure, the efficacy findings of previous papers were not replicated on elderly cadavers with arthritic necks.

Dual Role of Insulin-Like Growth Factor (IGF)-I in American Tegumentary Leishmaniasis.

BACKGROUND: Cytokines and growth factors involved in the tissue inflammatory process influence the outcome of Leishmania infection. Insulin-like growth factor (IGF-I) constitutively present in the skin may participate in the inflammatory process and parasite-host interaction. Previous work has shown that preincubation of Leishmania (Leishmania) amazonensis with recombinant IGF-I induces accelerated lesion development. However, in human cutaneous leishmaniasis (CL) pathogenesis, it is more relevant to the persistent inflammatory process than progressive parasite proliferation. In this context, we aimed to investigate whether IGF-I was present in the CL lesions and if this factor may influence the lesions' development acting on parasite growth and/or on the inflammatory/healing process. Methodology. Fifty-one CL patients' skin lesion samples from endemic area of L. (Viannia) braziliensis infection were submitted to histopathological analysis and searched for Leishmania and IGF-I expression by immunohistochemistry. RESULTS: In human CL lesions, IGF-I was observed preferentially in the late lesion (more than 90 days), and the percentage of positive area for IGF-I was positively correlated with duration of illness (r = 0.42, P < 0.05). IGF-I was highly expressed in the inflammatory infiltrate of CL lesions from patients evolving with good response to therapy (2.8% ± 2.1%; median = 2.1%; n = 18) than poor responders (1.3% ± 1.1%; median: 1.05%; n = 6; P < 0.05). CONCLUSIONS: It is the first time that IGF-I was detected in lesions of infectious cutaneous disease, specifically in American tegumentary leishmaniasis. IGF-I was related to chronicity and good response to treatment. We may relate this finding to the efficient anti-inflammatory response and the known action of IGF-I in wound repair. The present data highlight the importance of searching nonspecific factors besides adaptive immune elements in the study of leishmaniasis' pathogenesis.

Insulin-Like Growth Factor-I as an Effector Element of the Cytokine IL-4 in the Development of a Leishmania major Infection.

Certain cytokines modulate the expression of insulin-like growth factor- (IGF-) I. Since IL-4 and IGF-I promote growth of the protozoan Leishmania major, we here addressed their interaction in downregulating the expression of Igf-I mRNA using small interfering RNA (siRNA) in Leishmania major-infected macrophages. Parasitism was decreased in the siRNA-treated cells compared with the nontreated cells, reversed by the addition of recombinant IGF-I (rIGF-I). In IL-4-stimulated macrophages, parasitism and the Igf-I mRNA amount were increased, and the effects were nullified upon siRNA transfection. IGF-I downregulation inhibited both parasite and macrophage arginase activation even in IL-4-stimulated cells. Searching for intracellular signaling components shared by IL-4 and IGF-I, upon siRNA transfection, phosphorylated p44, p38, and Akt proteins were decreased, affecting the phosphatidylinositol-3-kinase (PI3K)/Akt pathway. In L. major-infected C57BL6-resistant mice, the preincubation of the parasite with rIGF-I changed the infection profile to be similar to that of susceptible mice. We conclude that IGF-I constitutes an effector element of IL-4 involving the PI3K/Akt pathway during L. major infection.

Procedimentos intervencionistas para o manejo da dor no câncer / Interventional procedures for cancer pain management

OBJETIVO: Descrever tipos de procedimentos (seu uso racional e alguns de seus benefícios) realizados em pacientes com câncer tratados em um hospital privado de São Paulo. MÉTODOS: Estudo quantitativo de corte transversal, que usou informações oriundas dos prontuários de pacientes submetidos a procedimentos intervencionistas para dor durante os anos de 2007 e 2008. Os dados foram analisados por meio de estatística descritiva e inferencial (frequência e média, e teste t). RESULTADOS: Durante esse período, 137 pacientes foram submetidos a procedimentos intervencionistas para a dor e, desse total, 14 possuíam dores de natureza oncológica. A intensidade média da dor nos pacientes tratados foi de 7,1 antes do procedimento e, após, 1,3. A redução da dor foi estatisticamente significativa nessa população (t=9,09; p=0,001). Em cerca de 70% dos pacientes (n=10), houve redução de 50% no uso de opioide 1 mês após a realização do procedimento. CONCLUSÃO: Estes resultados estão de acordo com a literatura e confirmam a eficácia dos procedimentos intervencionistas para diversos tipos de dor oncológica.

OBJECTIVE: To describe types of interventional medical procedures its rationale use and benefits for a population with cancer assisted at a private hospital in São Paulo. METHODS: Quantitative and descriptive cross-sectional study using data from patients submitted to interventional procedures between 2007 and 2008. We used descriptive and inferential statistics (frequency, mean, and t-test) to analyze data. RESULTS: A total of 137 patients were submitted to interventional procedures for pain and, out of this total, 14 mentioned cancer-related pain. The mean pain intensity was 7.1 before the procedure and 1.3 after it. Reduction in pain intensity was statistically significant in this population (t=9.09; p=0.001). In almost 70% of patients (n=10) a reduction of 50% of the consumption of opioid a month after the procedure was realized. CONCLUSION: These results are in accordance with the literature and support the efficacy of interventional procedures for several types of cancer pain.

[Importance of quality of life assessment in patients with endometriosis]. / Importância da avaliação da qualidade de vida em pacientes com endometriose.

PURPOSE: The present study examined the relationship between some clinical variables and quality of life in a group of patients with endometriosis. METHODS: A total of 130 women seen at a multidisciplinary center specializing in gynecology endometriosis in 2008 participated in the study. This was a cross-sectional study conducted with a convenience sample. The diagnosis of endometriosis was performed by biopsy according to the criteria of the American Society for Reproductive Medicine. The clinical and demographic data were collected from the patients' records. Pain intensity was assessed by a visual numerical scale (0-10), and data on the quality of life were collected using the SF-36. Data analysis consisted of descriptive and inferential statistical tests, Spearman correlation coefficient and Kruskal-Wallis test to compare scores between groups. Nonparametric tests were used for analysis because data were not normally distributed. RESULTS: The patients were 21 to 54 years of age or 34, standard diversion (SD)=6.56], 87% had a university degree, and 75% were married. Seventeen percent reported cases of endometriosis in the family. The average time of onset of symptoms was 4.5 years (SD=6.6), 63% of patients were in stage 3 or 4 of endometriosis 36% of patients had severe or disabling dysmenorrhea and the average intensity of pain according to a visual numerical scale was of 5.6 (SD=3.5). Results suggest that the staging of the disease did not determine the intensity of pain. The time of onset of symptoms also showed no relationship to pain intensity and SF-36 scores. On the other hand, the intensity of pain was associated with lower scores on some scales of the SF-36. CONCLUSION: Patients with endometriosis had lower scores of quality of life than the general population and lower than those of some other diseases.

Importância da avaliação da qualidade de vida em pacientes com endometriose / Importance of quality of life assessment in patients with endometriosis

OBJETIVO: Examinar a relação entre aspectos clínicos e qualidade de vida em um grupo de pacientes com endometriose. MÉTODOS: Participaram desse estudo 130 mulheres atendidas durante o ano de 2008 em um centro multiprofissional de ginecologia especializado em endometriose. Este é um estudo de corte transversal realizado com uma amostra de conveniência. O diagnóstico de endometriose foi realizado por biopsia pós-laparoscopia, segundo os critérios da Sociedade Americana de Medicina Reprodutiva. Os dados clínicos e demográficos foram coletados a partir dos prontuários dos pacientes. A intensidade da dor foi avaliada com o uso de uma escala visual numérica (0-10) e os dados referentes à qualidade de vida foram coletados por meio do questionário SF-36. A análise dos dados consistiu de estatística descritiva e inferencial, teste de coeficiente de correlação de Spearman e o teste de Kruskal-Wallis para comparar escores entre grupos. RESULTADOS: As pacientes apresentaram idade entre 21 e 54 anos [ ou = 34, desvio padrão (DP)=6,56], sendo que 87 por cento tinham terceiro grau completo e 75 por cento eram casadas. Dezessete por cento referiram casos de endometriose na família. O tempo médio de manifestação dos sintomas foi de 4,5 anos (DP=6,6), 63 por cento das pacientes estavam no estágio 3 ou 4 de endometriose, 36 por cento das pacientes sofriam de dismenorreia severa ou incapacitante e a intensidade média da dor, segundo escala visual numérica, foi de 5,6 (DP=3,5). Os resultados sugeriram que o estadiamento da doença não é determinante da intensidade da dor. Por um lado, o tempo de manifestação dos sintomas também não apresentou relação com a intensidade da dor e com os escores do SF-36. Por outro, a intensidade da dor apresentou associação com menores escores em algumas escalas do SF-36. CONCLUSÃO: As pacientes com endometriose apresentaram escores de qualidade de vida inferiores ao da população em geral e inferiores a algumas outras patologias.

PURPOSE: The present study examined the relationship between some clinical variables and quality of life in a group of patients with endometriosis. METHODS: A total of 130 women seen at a multidisciplinary center specializing in gynecology endometriosis in 2008 participated in the study. This was a cross-sectional study conducted with a convenience sample. The diagnosis of endometriosis was performed by biopsy according to the criteria of the American Society for Reproductive Medicine. The clinical and demographic data were collected from the patients' records. Pain intensity was assessed by a visual numerical scale (0-10), and data on the quality of life were collected using the SF-36. Data analysis consisted of descriptive and inferential statistical tests, Spearman correlation coefficient and Kruskal-Wallis test to compare scores between groups. Nonparametric tests were used for analysis because data were not normally distributed. RESULTS: The patients were 21 to 54 years of age [ or = 34, standard diversion (SD)=6.56], 87 percent had a university degree, and 75 percent were married. Seventeen percent reported cases of endometriosis in the family. The average time of onset of symptoms was 4.5 years (SD=6.6), 63 percent of patients were in stage 3 or 4 of endometriosis 36 percent of patients had severe or disabling dysmenorrhea and the average intensity of pain according to a visual numerical scale was of 5.6 (SD=3.5). Results suggest that the staging of the disease did not determine the intensity of pain. The time of onset of symptoms also showed no relationship to pain intensity and SF-36 scores. On the other hand, the intensity of pain was associated with lower scores on some scales of the SF-36. CONCLUSION: Patients with endometriosis had lower scores of quality of life than the general population and lower than those of some other diseases.

Interventional procedures for cancer pain management.

OBJECTIVE: To describe types of interventional medical procedures its rationale use and benefits for a population with cancer assisted at a private hospital in São Paulo. METHODS: Quantitative and descriptive cross-sectional study using data from patients submitted to interventional procedures between 2007 and 2008. We used descriptive and inferential statistics (frequency, mean, and t-test) to analyze data. RESULTS: A total of 137 patients were submitted to interventional procedures for pain and, out of this total, 14 mentioned cancer-related pain. The mean pain intensity was 7.1 before the procedure and 1.3 after it. Reduction in pain intensity was statistically significant in this population (t=9.09; p=0.001). In almost 70% of patients (n=10) a reduction of 50% of the consumption of opioid a month after the procedure was realized. CONCLUSION: These results are in accordance with the literature and support the efficacy of interventional procedures for several types of cancer pain.

Síndrome dolorosa miofascial do músculo psoas: complicação do tratamento intervencionista: relato de caso / Psoas muscle miofascial painful syndrome: complication of the interventional treatment: case report

JUSTIFICATIVA E OBJETIVOS: A infiltração anestésica do músculo psoas para tratamento da síndrome dolorosa miofascial apresenta reconhecida eficácia, tendo como complicações estabelecidas a infecção local e o hematoma. O objetivo do presente estudo foi relatar um caso de síndrome dolorosa miofascial do músculo psoas com complicação decorrente do tratamento intervencionista.RELATO DO CASO: Paciente do sexo feminino, 49 anos, com queixa de dor lombar e abdominal há cinco anos, com piora há dois anos. Na consulta relatou dor lombar, com irradiação para a região inguinal esquerda, contínua, com intensidade 8 pela escala analógica visual (EAV), apesar do uso de fórmula contendo fluoxetina, meloxicam e amitriptilina. A hipótese diagnóstica foi de síndrome dolorosa miofascial do psoas, sendo realizada infiltração anestésica do músculo, com alívio imediato e completo da dor. Dezoito dias após o procedimento a paciente apresentou dor de intensidade 6 e com história clínica compatível com hematoma subagudo. Trinta e cinco dias após o primeiro exame, a ressonância nuclear magnética (RNM) mostrou regressão total da coleção intramuscular, com persistência apenas de tênue área de edema e realce mio-fibrilar. Realizou-se infiltração muscular com toxina botulínica medicamentosa com duloxetina (60 mg/dia), sendo obtida a remissão total do quadro doloroso. CONCLUSÃO: O caso mostrou a eficácia da infiltração do músculo psoas com anestésico local e corticoide como medida terapêutica indicada para relaxamento muscular imediato, com desativação dos pontos-gatilho e consequente alívio da dor, acelerando assim o processo de recuperação e mostrou que o hematoma é uma complicação que pode ser resolvida com tratamento clínico.

BACKGROUND AND OBJECTIVES: Anesthetic infiltration of the psoas muscle to treat painful myofascial syndrome is recognized as effective and has as established complications local infection and hematoma. This study aimed at reporting a case of psoas muscle painful myofascial syndrome with a complication caused by the interventional treatment.CASE REPORT: Female patient, 49 years old, with lumbar and abdominal pain complaint for five years which has worsened in the last two years. Patient reported lumbar pain, with irradiation to the left inguinal region, continuous, with intensity 8 according to visual analog scale (VAS), in spite of using a formula with fluoxetine, meloxicam and amitriptyline. Diagnostic hypothesis was painful psoas myofascial syndrome. The muscle was infiltrated with anesthetics with immediate and complete pain relief. Eighteen days after the procedure, patient presented pain of intensity 6 and with clinical history compatible with sub-acute hematoma. Thirty-five days after the first exam, MRI has shown total regression of the intramuscular collection with persistence of just a subtle area of edema and myo-fibrillary enhancement. Muscle was infiltrated with botulinic toxin drug with duloxetine (60 mg/day), with total remission of pain. CONCLUSION: This case has shown the efficacy of infiltrating the psoas muscle with local anesthetics and steroid as therapeutic measure indicated for immediate muscle relaxation, with deactivation of trigger-points and consequent pain relief, thus accelerating the recovery process, and has shown that hematoma is a complication which may be solved with clinical treatment

Uso terapêutico da radiofrequência pulsátil no gânglio dorsal da raiz de L2 na lombalgia discogênica / Uso terapéutico de la radiofrecuencia pulsátil en el ganglio dorsal de la raíz de L2 en la lumbalgia discogénica / Pulsed radiofrequency on L2 dorsal root ganglion as a therapeutic method for lumbar discogenic pain

Avaliar a eficácia da radiofrequência pulsátil sobre o gânglio da raiz dorsal de L2 no tratamento dos pacientes com lombalgia discogênica. Métodos: Realizou-se análise retrospectiva de 50 pacientes portadores de lombalgia crônica discogênica atendidos no período de janeiro de 2004 a julho de 2007. O processo diagnóstico foi constituído por exame físico, ressonância magnética e bloqueio diagnóstico do gânglio da raiz dorsal de L2. Todos os pacientes foram submetidos à radiofrequência pulsátil no gânglio da raiz dorsal de L2 e acompanhados por, no mínimo, 12 meses. A intensidade de dor foi medida pela escala visual analógica (EVA) de dor. Resultados: A análise estatística mostrou melhora significativa da intensidade de dor (p<0,001) após 12 meses de seguimento. O uso da radiofrequência pulsátil no gânglio da raiz dorsal de L2 mostrou-se um método alternativo inespecífico eficaz às cirurgias convencionais, apesar do curto seguimento desta série.

To evaluate the effectiveness of pulsate radio-frequency on L2 dorsal root ganglion for chronic discogenic low back pain. Of L2 in the treatment of the patient with discogenic low back pain. Methods: Between January 2004 and July 2007, 50 patients with diagnosis of low back discogenic pain were retrospectively assessed based on physical examination, magnetic resonance imaging findings and selective L2 dorsal root ganglion diagnostic block, and then submitted to pulsed radiofrequency on L2 dorsal root ganglion, and evaluated after a minimum follow-up of 12 months. Pain was evaluated by the visual analog scale. Results: Statistical analysis showed significant improvement of pain intensity (p<0.001) after a minimum 12-month follow-up period. Conclusion: Pulsed radiofrequency on L2 dorsal root ganglion is an effective, non-specific therapeutic method for low back discogenic pain, despite the short follow-up period of this series.

Evaluar la eficacia de la radiofrecuencia pulsátil sobre el ganglio de la raíz dorsal de L2 en el tratamiento de los pacientes con lumbalgia discogénica. Métodos: fue realizado un análisis retrospectivo de 50 pacientes portadores de lumbalgia crónica discogénica, atendidos en el periodo de Enero de 2004 a Julio de 2007. El proceso diagnóstico constó de un examen físico, resonancia magnética y bloqueo diagnóstico del ganglio de la raíz dorsal de L2. Todos los pacientes fueron sometidos a la radiofrecuencia pulsátil en el ganglio de la raíz dorsal de L2 y seguidos por 12 meses, como mínimo. La intensidad del dolor fue medida por la escala visual analógica del dolor. Resultados: el análisis estadístico mostró mejoría significativa de la intensidad del dolor (p<0.001) después de 12 meses de seguimiento. Conclusión: El uso de la radiofrecuencia pulsátil en el ganglio de la raíz dorsal de L2 mostró ser un método inespecífico, eficaz y alternativo a las cirugías convencionales, a pesar del corto seguimiento de hecho en esta serie.

Treatment of African trypanosomiasis with cordycepin and adenosine deaminase inhibitors in a mouse model.

There is an urgent need to discontinue the use of highly toxic compounds still in use for treatment of the encephalitic stage of human African trypanosomiasis (HAT). We show here that intraperitoneal injection of the adenosine analogue cordycepin (3'-deoxyadenosine), together with an adenosine deaminase (ADA) inhibitor (coformycin or deoxycoformycin), cures Trypanosoma brucei brucei infection in mice. Treatment was also effective at a stage when the trypanosomes had penetrated into the brain parenchyma, as determined by double immunolabeling of parasites and cerebral vessel endothelial cells in brain sections. At this stage, the parasites were eliminated not only from the blood but also from the brain parenchyma. In parallel with the elimination of parasites, in treated mice, the number of CD45+ inflammatory cells in the brain parenchyma was reduced. Treatment was not immunosuppressive. In vitro incubation with cordycepin reduced the growth of T. brucei brucei and T. cruzi, as well as Leishmania major and L. amazonensis. Administration of cordycepin plus deoxycofomycin to T. cruzi-infected mice also significantly reduced parasitemia. Accordingly, we propose nucleoside analogues resistant to ADA as candidates for treatment of late-stage HAT.