Circum-Psoas Block versus Supra-Inguinal Fascia Iliaca Block for Postoperative Analgesia in Patients Undergoing Total Hip Arthroplasty: A Randomized Clinical Trial.

Purpose: Total hip arthroplasty (THA) is often associated with moderate to severe pain. The present study compared the efficacy of circum-psoas block (CPB) with supra-inguinal fascia iliaca block (SIFIB) for postoperative analgesia in patients undergoing THA. Patients and Methods: In this randomized trial, sixty-four patients undergoing THA were allocated randomly to the CPB group or SIFIB group with 40 mL of 0.3% ropivacaine. The primary outcome was dynamic pain score at 6 h postoperatively. Secondary outcomes included dynamic pain scores at 12, 24 and 48 h; static pain scores; sensory and motor block; opioid consumption; time to first opioid request; length of hospital stay; patient satisfaction; and adverse events. Results: CPB patients showed significantly lower dynamic pain scores at 6 (3.11 ± 0.66 vs 4.47 ± 0.74, respectively; P = 0.000), 12 (2.52 ± 0.73 vs 3.53 ± 0.85, respectively; P = 0.000) and 24 h (2.30 ± 0.57 vs 2.87 ± 0.71, respectively; P = 0.001) after surgery, as well as lower static pain scores at 6 and 12h (P = 0.001 and P = 0.033 respectively) than SIFIB patients. Lower opioid consumption was observed in the CPB group at 24 and 48 h (P = 0.000, both) than in the SIFIB group. Patients in the CPB group reported improved quadriceps strength at 6 and 12 h (P = 0.000, both), as well as better muscle strength of hip flexion at 6, 12 and 24 h (P = 0.000, P = 0.000 and P = 0.025 respectively). Compared with SIFIB, CPB was associated with increased sensory block coverage at 6, 12 and 24 h (P = 0.000, P = 0.000, and P =0.022, respectively). Conclusion: CPB has a greater potential to alleviate postoperative pain and improve recovery in THA patients than SIFIB.

Evaluation of Sensory Loss and Postoperative Analgesia Obtained by Diaphragmatic Apposition Zone Block Under Direct Laparoscopic Visualization in Patients Undergoing Nephrectomy: A Descriptive Study.

Purpose: Local anesthetics can spread into the subendothoracic fascia compartment via the arcuate ligament and apposition zone of the diaphragm after the anterior quadratus lumborum blocks. Therefore, a new block may be achieved if local anesthetic is administered into the diaphragmatic apposition zone (DAZ) under direct laparoscopic visualization by surgeons. Therefore, we evaluated the sensory loss and postoperative analgesic efficacy of this new block in patients receiving laparoscopic nephrectomy. Methods: A total of 28 patients scheduled to receive elective laparoscopic nephrectomy under general anesthesia were enrolled in this study. The DAZ blocks were performed in patients under direct laparoscopic visualization with 20 mL of 0.5% ropivacaine before the dissected kidneys or renal tumors were taken out from the incision. All patients received the intravenous patient-controlled analgesia after surgery. The dermatomes of sensory loss and the muscle weakness of quadriceps femoris were assessed at 2 h post-surgery in the wards. The postoperative pain was scored. The opioid consumption in the first 24 h after surgery was recorded. Results: The average number of dermatomes of sensory block was 8.6 ± 1.2. The highest level of sensory loss was T6 (T5-T6) [median (interquartile range, IQR)], and the lowest level of sensory block was L1 (L1-L2). The postoperative pain scores at rest or on movement at 2 h, 6 h, 12 h, 24 h and 48 h were kept at the low levels (less than 4). The muscle strength of the quadriceps femoris evaluated was 5 (5-5) points [median (IQR)]. Total dose of intravenous morphine equivalent consumption in the first 24 h after surgery was 21.2 ± 4.1 mg. Conclusion: The DAZ block manifests a wide dermatomal coverage of sensory loss and is associated with the low levels of postoperative pain intensity and opioid use. It provides a new postoperative analgesia option for patients undergoing laparoscopic nephrectomy.

Upregulation of Hevin contributes to postoperative pain hypersensitivity by inducing neurexin1ß/neuroligin1-mediated synaptic targeting of GluA1-containing AMPA receptors in rat dorsal horn.

The astrocytes-secreted active molecule, Hevin considerably contributes in the transsynaptic bridge of neurexin1ß/neuligin1 in excitatory synapse. Previous studies have demonstrated that activity-dependent synaptic recruitment of spinal neuroligin1 and GluA1-containing AMPA receptors (AMPARs) is involved in incisional, inflammatory and neuropathic pain. Here, we hypothesized that Hevin induced postoperative pain hypersensitivity by enhancing the neurexin1ß/neuroligin1-mediated synaptic targeting of GluA1-containing AMPARs in spinal dorsal horns (DH). Our results showed that plantar incision induced significant postoperative pain behavior, which was described by the cumulative pain scores. At 1 d and 3 d post-incision, Hevin expression was considerably elevated in ipsilateral DHs, although it recovered to baseline value at 5 d following the incision. At 1 d post plantar incision, the neurexin1ß/neuroligin1 interactions significantly increased in ipsilateral DHs in rats subjected to incision when compared with those in control rats. Intrathecal pretreatments of small interference RNA targeting Hevin substantially suppressed postoperative pain hypersensitivity and reduced the neurexin1ß/neurolgin1 interaction as well as the synaptic targeting of GluA1 in ipsilateral spinal DHs. These data suggest that Hevin induced postoperative pain hypersensitivity by enhancing the neurexin1ß/neuroligin1 interaction and subsequent synaptic targeting of GluA1-containing AMPARs in ipsilateral spinal DHs. It provides new insights into the role of Hevin-mediated trans-synaptic regulation in postoperative pain hypersensitivity, which would help develop a novel therapeutic strategy.

Supra-Arcuate Ligament Blocks: Anatomy, Mechanisms, and Techniques.

Quadratus lumborum block (QLB) is clinically used for postoperative analgesia of abdominal or hip surgery, which can reduce the dose of general anesthetic, inhibit postoperative pain, and promote postoperative rehabilitation. However, accumulated studies have shown several drawbacks of QLB, such as only a small portion of local anesthetic spread into the thoracic paravertebral space, relatively longer onset time, and easily-influenced block effect by the integrity of lumbar fascia, etc. Therefore, on the basis of traditional anterior QLB, our group proposed the techniques of a supra-arcuate ligament block, which include a paramedian short-axis scanning approach, paramedian long-axis scanning approach, infra-lateral arcuate ligament QLB with the apposition zone between diaphragm and quadratus lumborum as drug diffusion target and supra-arcuate ligament block under direct laparoscopic visualization. Recent studies have demonstrated that the supra-arcuate ligament blocks have the advantages of clear anatomy, are easy to perform, and have rapid onset, which avoid some drawbacks of the conventional QLB techniques. This article reviews the anatomical basis, sonoanatomy, technical points, and clinical considerations of supra-arcuate ligament blocks.

Cynatratoside-C efficacy against theronts of Ichthyophthirius multifiliis, and toxicity tests on grass carp and mammal blood cells.

Infection by Ichthyophthirius multifiliis, a ciliated protozoan parasite, results in high fish mortality and causes severe economic losses in aquaculture. To find new, efficient anti-I. multifiliis agents, cynatratoside-C was isolated from Cynanchum atratum by bioassay-guided fractionation in a previous study. The present study investigated the anti-theront activity, determined the toxicity of cynatratoside-C to grass carp Ctenopharyngodon idellus and mammalian blood cells, and evaluated the protection of cynatratoside-C against I. multifiliis theront infection in grass carp. Results showed that all theronts were killed by 0.25 mg l-1 of cynatratoside-C in 186.7 ± 5.8 min. Cynatratoside-C at 0.25 mg l-1 was effective in treating infected grass carp and protecting naive fish from I. multifiliis infestation. The 96 h median lethal concentration (LC50) of cynatratoside-C to grass carp and 4 h median effective concentration (EC50) of cynatratoside-C to theront were 46.8 and 0.088 mg l-1, respectively. In addition, the hemolysis assay demonstrated that cynatratoside-C had no cytotoxicity to rabbit red blood cells. Therefore, cynatratoside-C could be a safe and effective potential parasiticide for controlling I. multifiliis.

Identification and effect of two flavonoids from root bark of Morus alba against Ichthyophthirius multifiliis in grass carp.

Ichthyophthirius multifiliis (Ich) is an important ciliate that parasitizes gills and skin of freshwater fish and causes massive fish mortality. In this study, two flavonoids (kuwanons G and O) with anti-Ich activity were isolated by bioassay-guided fractionation from the root bark of Morus alba, an important plant for sericulture. The chemical structures of kuwanons G and O were elucidated by spectroscopic analyses. Kuwanons G and O caused 100% mortality of I. multifiliis theronts at the concentration of 2 mg/L and possessed a median effective concentration (EC50) of 0.8 ± 0.04 mg/L against the theronts. In addition, kuwanons G and O significantly reduced the infectivity of I. multifiliis theronts at concentrations of 0.125, 0.25, 0.5, and 1 mg/L. The median lethal concentrations (LC50) of kuwanons G and O to grass carp were 38.0 ± 0.82 and 26.9 ± 0.51 mg/L, which were approximately 50 and 35 times the EC50 for killing theronts. The results indicate that kuwanons G and O have the potential to become safe and effective drugs to control ichthyophthiriasis.

Antiparasitic effect of cynatratoside-C from Cynanchum atratum against Ichthyophthirius multifiliis on grass carp.

Ichthyophthirius multifiliis (Ich), a fish ectoparasite, comprises an important challenge in the aquaculture industry. In this study, a steroidal glycoside, cynatratoside-C, isolated from Cynanchum atratum roots by bioassay-guided fractionation was used to treat I. multifiliis. The cynatratoside-C at 0.25 mg/L demonstrated a 100% mortality of I. multifiliis in vitro after 5 h exposure. The 5 h median effective concentration (EC50) of cynatratoside-C to nonencysted tomonts was 0.083 mg/L. In addition, cynatratoside-C at concentrations of 0.125 and 0.06 mg/L could completely terminate the reproduction of encysted tomonts. The cynatratoside-C at 2 mg/L could cure the infected grass carp within 48 h. The exact mechanism of cynatratoside-C for killing I. multifiliis is unknown, but it manifests itself microscopically through loss of membrane integrity of nonencysted tomonts or through releasing immature theronts from encysted tomonts. The immature theronts finally died before infecting fish. On the basis of these results, cynatratoside-C could be used as a natural anti-I. multifiliis agent.

Parasiticidal effects of Morus alba root bark extracts against Ichthyophthirius multifiliis infecting grass carp.

Ichthyophthirius multifiliis (Ich), an important fish parasite, can cause significant losses in aquaculture. To find efficacious drugs to control Ich, the root bark of white mulberry Morus alba was evaluated for its antiprotozoal activity. Bark was powdered and extracted with 1 of 5 organic solvents: petroleum ether, chloroform, ethyl acetate, acetone, or methanol. The extracts were concentrated, dissolved in 0.1% (v/v) DMSO, and used for anti-Ich trials. Acetone and ethyl acetate extracts significantly reduced the survival of Ich tomonts and theronts. In vitro, acetone extract at 25 mg l-1 killed all non-encysted tomonts, at 50 mg l-1 eradicated all encysted tomonts, and at 8 mg l-1 caused mortality of all theronts. Ethyl acetate extract at 50 mg l-1 eliminated all non-encysted tomonts, at 100 mg l-1 killed all encysted tomonts and terminated tomont reproduction, and at 8 mg l-1 killed all theronts. Low concentrations (2 and 4 mg l-1) of acetone and ethyl acetate extracts could not kill all theronts after 4 h exposure, but a significant decrease in theront infectivity was observed following 30 min of pretreatment with the extracts. The 96 h LC(50) values of acetone and ethyl acetate extracts to grass carp were 79.46 and 361.05 mg l-1, i.e. much higher than effective doses for killing Ich theronts (8 mg l-1 for both extracts) and non-encysted tomonts (12.5 and 25 mg l-1, respectively). Thus M. alba extract may be a potential new, safe, and efficacious drug to control Ich.