Care Management in Scientific Production in Integrative Oncology in Latin America: An Integrative Review

Introduction: Including traditional, complementary and integrative medicines in national health systems is a point of discussion worldwide. This article focuses on the theme within the scope of oncology in Latin America. Objective: To analyze the health care management dimensions included in scientific production in integrative oncology in Latin America. Materials and method: This is an integrative literature review carried out in the LILACS, Mosaico, IBECS, PubMed and Embase databases, whose guiding question was prepared according to The PRISMA 2020 Statement recommendations. The search occurred by the association of free terms related to the descriptors "Integrative Oncology," "Complementary Therapies," "Health Care," "Care Management," and "Countries That Make Up Latin America." Data were interpreted from the conceptual perspective of health care management dimensions. Results: The study selection process identified 206 studies. The final sample was made up of eight articles available online in full, published between 2017 and 2022 in Portuguese, Spanish or English. Articles were developed in Brazil (n = 4), Chile, Colombia, Peru, and Uruguay (n = 1, respectively). There was a predominance of the individual health care management dimension as the focus of analyzed studies. The "professional," "family," "societal," and "organizational" dimensions were presented in the discussion of results. Conclusions: Despite the insufficiency of studies, analysis of interdependence between dimensions indicates the complexity of the management process for integrating traditional, complementary and integrative medicine in oncological care in Latin America, which suggests an epistemology in the construction process.

Introducción: la inclusión de las medicinas tradicionales, complementarias e integrativas en los sistemas nacionales de salud es un punto de discusión en el contexto mundial. En este artículo, el tema se centra en la oncología en Latinoamérica. Objetivo: analizar las dimensiones de la gestión de la salud contempladas en la producción científica sobre oncología integrativa en Latinoamérica. Materiales y método: se trata de una revisión bibliográfica integrativa en las bases de datos Lilacs, Mosaico, IBECS, PubMed y Embase, cuya pregunta orientadora se elaboró de acuerdo con las recomendaciones de The PRISMA 2020 Statement. La búsqueda se realizó asociando términos libres relacionados con los descriptores "oncología integrativa", "prácticas complementarias e integrativas", "atención a la salud", "gestión de la atención" y "países que conforman América Latina". Se interpretaron los datos desde la perspectiva conceptual de las dimensiones de la gestión de la atención en salud. Resultados: el proceso de selección de estudios resultó en la identificación de 206 producciones. La muestra final consistió en ocho artículos disponibles en línea, en su totalidad, publicados entre 2017 y 2022, en portugués, español o inglés. Los artículos se desarrollaron en Brasil (n = 4), así como en Chile, Colombia, Perú y Uruguay (n = 1, respectivamente). Hubo un predominio de la dimensión individual de la gestión de la atención como foco de los estudios analizados. Las dimensiones "profesional", "familiar", "social" y "organizacional" se presentaron en la discusión de los resultados. Conclusiones: a pesar de la falta de publicaciones, el análisis de la interdependencia entre las dimensiones indica la complejidad del proceso de gestión para la integración de la medicina tradicional, complementaria e integrativa en la atención oncológica en Latinoamérica, lo que sugiere una epistemología en proceso de construcción.

Introdução: a inserção das medicinas tradicionais, complementares e integrativas nos sistemas nacionais de saúde é ponto de discussão no contexto global. Neste artigo, focaliza-se a temática no âmbito da oncologia na América Latina. Objetivo: analisar as dimensões da gestão no cuidado em saúde contempladas na produção científica em oncologia integrativa na América Latina. Materiais e método: trata-se de revisão integrativa da literatura nas bases de dados Lilacs, Mosaico, IBECS, PubMED e Embase, cuja questão orientadora foi elaborada conforme recomendações do The PRISMA 2020 Statement. A busca ocorreu por associação de termos livres relacionados aos descritores "oncologia integrativa", "práticas complementares e integrativas", "atenção à saúde", "gestão do cuidado" e "países que integram a América Latina". Os dados foram interpretados na perspectiva conceitual das dimensões da gestão do cuidado em saúde. Resultados: o processo de seleção dos estudos resultou na identificação de 206 produções. A amostra final foi composta de de oito artigos disponíveis on-line, na íntegra, publicados entre 2017 e 2022, em português, espanhol ou inglês. Os artigos foram desenvolvidos no Brasil (n = 4), no Chile, na Colômbia, no Peru e no Uruguai (n = 1, respectivamente). Evidenciou-se predomínio da dimensão individual da gestão do cuidado como enfoque dos estudos analisados. As dimensões "profissional", "familiar", "societária" e "organizacional" se apresentaram na discussão dos resultados. Conclusões: apesar da insuficiência de publicações, a análise da interdependência entre as dimensões indica a complexidade do processo de gestão para a integração da medicina tradicional, complementar e integrativa na atenção oncológica na América Latina, o que sugere uma epistemologia em processo de construção.

Clinical Characteristics of Coronavirus Disease 2019 (COVID-19) among Patients at a Movement Disorders Center.

It is not established whether SARS-CoV-2 (COVID-19) patients with movement disorders, are at greater risk for more serious outcomes than the larger COVID-19 population beyond the susceptibility associated with greater age. We reviewed electronic health records and conducted telephone interviews to collect the demographics and clinical outcomes of patients seen at our Movement Disorders Center who tested positive for COVID-19 from 8 March 2020 through 6 June 2020. Thirty-six patients were identified, 23 men and 13 women, median age of 74.5 years. They primarily carried diagnoses of idiopathic Parkinson disease (n = 22; 61%) and atypical parkinsonism (n = 7; 19%) with the balance having other diagnoses. Twenty-seven patients (75%) exhibited alteration in mental status and fifteen (42%) had abnormalities of movement as common manifestations of COVID-19; in 61% and 31%, respectively, these were the presenting symptoms of the disease. Sixty-seven percent of patients in our cohort required hospitalization, and the mortality rate was 36%. These data demonstrate that in patients with movement disorders, the likelihood of hospitalization and death after contracting COVID-19 was greater than in the general population. Patients with movement disorders frequently presented with altered mental status, generalized weakness, or worsening mobility but not anosmia.

ATP1A3: an unusual antigen to consider in patients with subacute ataxia and vertical gaze palsy.

The anti-ATP1A3 antibody seems to be directed against a neuronal and cardiac surface protein of the proton ATPase. It was recently identified in a patient with a paraneoplastic syndrome characterized by cerebellar, neuro-ophthalmologic and other neurological symptoms. We report another patient with a similar clinical and radiological syndrome but with a different associated tumor and outcome.

Loss of HER2 and disease prognosis after neoadjuvant treatment of HER2+ breast cancer.

INTRODUCTION: HER2 overexpression/amplification occurs in 15-20% breast cancers (BC) and is associated with worse prognosis. The addition of anti-HER2 treatment to neoadjuvant chemotherapy significantly improves the pathological complete response (pCR) rate. Changes in HER2 status after neoadjuvant treatment (NAT) have been reported and may affect prognosis. The aim of this study was to assess the efficacy of NAT in patients with HER2+ BC and its influence on HER2 status and associated prognostic impact. METHODS: Retrospective chart review and pathologic evaluation of all consecutive patients with HER2+ BC (defined as IHC 3+ or IHC 2+ confirmed by SISH) submitted to NAT between 2010-2015 in three Portuguese Hospitals. RESULTS: One hundred eight female patients were included; 40 with stage II, 68 with stage III. Hormone receptors were positive in 70. pCR (ypT0/isN0) was achieved in 48 patients (44%). With a median follow-up of 52 months, there were 5 disease free survival (DFS) events among pCR patients and 19 among non-pCR (P = 0.02). Of the 60 patients with residual disease at surgery, 52 remained HER2+ and 8 (13%) lost HER2 overexpression/amplification. 5y-DFS and 5y-OS was 70% and 84%, respectively, for patients whose residual tumors remained HER2+, and 21% and 50% for patients whose residual tumors became HER2 negative (P = 0.02 and < 0.001). DISCUSSION: We confirmed the negative prognostic impact of NAT-induced HER2 loss on residual tumor leading to worse DFS and OS. Despite the retrospective design and small sample size, these results suggest that it is important to retest HER2 after NAT, to better refine patient outcome.

Continuous quadratus lumborum type II block in partial nephrectomy / Bloqueio do quadrado lombar tipo II contínuo para analgesia pós-operatória de nefrectomia parcial

Abstract Background and objectives: Quadratus lumborum block was first described in 2007 and currently there are descriptions of its achievement through four different injection points. This blockage provides abdominal wall and visceral analgesia, and one of its mechanisms is the dispersion of the local anesthetic into the paravertebral space. We describe the performance of a continuous quadratus lumborum type II block for postoperative analgesia in a partial nephrectomy. Case report: A 64-year-old woman, scheduled for partial left laparoscopic nephrectomy. During the procedure, due to technical difficulties, an incision was made in the left flank to facilitate the surgical approach. In the early postoperative period, a continuous quadratus lumborum type II block was performed using ultrasonography as part of the multimodal analgesic strategy. Initially, 20 ml of 0.2% ropivacaine was administered and 3 cm of catheter were introduced into the interfascial space. Subsequently, a continuous infusion of 5.2 mL.h−1 of 0.2% ropivacaine was given for 48 hours. In the first 24 postoperative hours, the patient reported no pain at rest or on movement. In the following 24 h, she was free of pain at rest and only a slight pain (2/10) on movement. Conclusions: Continuous quadratus lumborum type II block was an effective postoperative analgesic option. Blocking of somatic nerves and visceral afferent pathways provided abdominal and visceral wall analgesia, allowing the reduction of opioid consumption. We consider relevant to explore the analgesic capacity of the quadratus lumborum block and its different approaches, as well as the possibility of it becoming an alternative in patients scheduled for kidney surgery.

Resumo Justificativa e objetivos: O bloqueio do quadrado lombar foi descrito pela primeira vez em 2007 e atualmente existem descrições da sua realização através de quatro pontos de injeção. Esse bloqueio promove analgesia da parede abdominal e analgesia visceral e um de seus mecanismos é a dispersão do anestésico local para o espaço paravertebral. Descrevemos a realização do bloqueio do quadrado lombar tipo II contínuo para analgesia pós-operatória numa nefrectomia parcial. Relato de caso: Mulher de 64 anos, agendada para nefrectomia parcial à esquerda por via laparoscópica. Durante o procedimento, por dificuldades técnicas, foi feita uma incisão no flanco esquerdo para facilitar a abordagem cirúrgica. No pós-operatório imediato, fez-se o bloqueio do quadrado lombar tipo II contínuo, recorrendo-se a ultrassonografia, como parte da estratégia analgésica multimodal. Inicialmente foram administrados 20 ml de ropivacaína 0,2% e introduzidos 3 cm de cateter no espaço interfascial. Posteriormente, colocou-se uma perfusão contínua de 5,2 mL.h−1 de ropivacaína 0,2% durante 48 horas. Nas primeiras 24 horas de pós-operatório, a paciente não referiu dor em repouso ou com movimento. Nas 24 horas seguintes, manteve-se sem dor em repouso e apenas com dor ligeira (2/10) com o movimento. Conclusões: A realização do bloqueio quadrado lombar tipo II contínuo foi uma opção analgésica pós-operatória eficaz. O bloqueio de nervos somáticos e das vias aferentes viscerais promoveu analgesia da parede abdominal e visceral, permitiu reduzir o consumo de opioides. Consideramos relevante explorar a capacidade analgésica do bloqueio do quadrado lombar e suas diferentes abordagens, bem como a possibilidade de se tornar uma opção em doentes propostos para cirurgia renal.

Botulinum Toxin in Restless Legs Syndrome-A Randomized Double-Blind Placebo-Controlled Crossover Study.

BACKGROUND: Restless Legs Syndrome (RLS) is a common movement disorder with an estimated prevalence of up to 12%. Previous small studies with onabotulinumtoxin A (OnaA) for RLS have shown inconsistent results. METHODS: Twenty-four patients with an International RLS score (IRLS) of >11 (moderate-severe) were enrolled in this blinded, placebo-controlled crossover study. Twenty-one patients completed the evaluations at 4, 6, and 8 weeks after each injection. One-hundred units of Incobotulinumtoxin A (IncoA) or normal saline were injected into tibialis anterior, gastrocnemius, and biceps femoris muscles each side. RESULTS: Improvement from a severe (IRLS >21) to a mild/moderate (IRLS ≤20) score was significant at four weeks (p = 0.0036) and six weeks (p = 0.0325) following IncoA administration compared to placebo. Additionally, there was significant improvement in pain score at six weeks as measured by Visual Analogue Scale (p = 0.04) and the Johns Hopkins Quality of Life Questionnaire (p = 0.01) in the IncoA group. Definite or marked improvement on Patient Global Impression of Change was seen in 7 out of 21 patients in the IncoA group vs. 1 out of 21 patients in the placebo group at 4 weeks (p = 0.012). CONCLUSION: IncoA injection lead to a reduction in severity of RLS symptoms, pain score, and quality of life, without any adverse effects.

Superior gluteal nerve: a new block on the block? / Nervo glúteo superior: um novo bloqueio a caminho?

Abstract Background and objectives The superior gluteal nerve is responsible for innervating the gluteus medius, gluteus minimus and tensor fascia latae muscles, all of which can be injured during surgical procedures. We describe an ultrasound-guided approach to block the superior gluteal nerve which allowed us to provide efficient analgesia and anesthesia for two orthopedic procedures, in a patient who had significant risk factors for neuraxial techniques and deep peripheral nerve blocks. Clinical report An 84-year-old female whose regular use of clopidogrel contraindicated neuraxial techniques or deep peripheral nerve blocks presented for urgent bipolar hemiarthroplasty in our hospital. Taking into consideration the surgical approach chosen by the orthopedic team, we set to use a combination of general anesthesia and superficial peripheral nerve blocks (femoral, lateral cutaneous of thigh and superior gluteal nerve) for the procedure. A month and a half post-discharge the patient was re-admitted for debriding and correction of suture dehiscence; we performed the same blocks and light sedation. She remained comfortable in both cases, and reported no pain in the post-operative period. Conclusions Deep understanding of anatomy and innervation empowers anesthesiologists to solve potentially complex cases with safer, albeit creative, approaches. The relevance of this block in this case arises from its innervation of the gluteus medius muscle and posterolateral portion of the hip joint. To the best of our knowledge, this is the first report of an ultrasound-guided superior gluteal nerve block with an analgesic and anesthetic goal, which was successfully achieved.

Resumo Justificativa e objetivos O nervo glúteo superior é responsável pela inervação dos músculos glúteo médio, glúteo mínimo e tensor da fáscia lata, todos podem ser lesados durante procedimentos cirúrgicos. Descrevemos uma abordagem guiada por ultrassom para bloqueio do nervo glúteo superior, o que nos permitiu fornecer analgesia e anestesia eficientes para dois procedimentos ortopédicos a uma paciente que apresentava fatores de risco significativos para técnicas neuraxiais e bloqueios profundos de nervos periféricos. Relato de caso Paciente do sexo feminino, 84 anos, cujo uso regular de clopidogrel contraindicava técnicas neuraxiais ou bloqueios profundos de nervos periféricos, apresentou-se para hemiartroplastia bipolar urgente em nosso hospital. Levando em consideração a abordagem cirúrgica escolhida pela equipe de ortopedia, estabelecemos o uso de uma combinação de anestesia geral e bloqueios superficiais de nervos periféricos (femoral, cutâneo lateral da coxa e nervo glúteo superior) para o procedimento. Um mês e meio após a alta, a paciente foi readmitida para desbridamento e correção da deiscência de sutura quando fizemos os mesmos bloqueios e sedação leve. A paciente permaneceu confortável em ambos os casos, sem queixa de dor no período pós-operatório. Conclusões A compreensão profunda da anatomia e da inervação capacita os anestesiologistas a resolver casos potencialmente complexos com abordagens mais seguras, até criativas. A relevância desse bloqueio neste caso resulta da sua inervação do músculo glúteo médio e da porção posterolateral da articulação do quadril. De acordo com nossa pesquisa, este é o primeiro relato de um bloqueio do nervo glúteo superior guiado por ultrassom com objetivo analgésico e anestésico que foi obtido com sucesso.

Quadratus lumborum block: are we aware of its side effects? A report of 2 cases / Bloqueio do quadrado lombar: estamos cientes de seus efeitos colaterais? Relato de dois casos

Abstract Background and objectives The quadratus lumborum block was initially described in 2007 and aims at blocking the same nerves as the ones involved on the Transverse Abdominis Plane block, while accomplishing some visceral enervation as well due to closer proximity with the neuroaxis and sympathetic trunk. Given its versatility, we have successfully used it in a wide range of procedures. We report two cases where we believe the dispersion of local anesthetic is likely to have led to a previously undescribed complication. Clinical reports We report two cases in which we performed a quadratus lumborum type II block and general anesthesia for total gastrectomy and right hemicolectomy. There were no noteworthy events while performing the block and inducing general anesthesia, but within 30-40 min serious hypotension and tachycardia were noted. As other motives for hypotension were ruled out, the event was interpreted as block-induced sympatholysis due to cephalad dispersion of the local anesthetic to the paravertebral and epidural space, and successfully managed with ephedrine and increase of the crystalloid infusion rate. Conclusions The quadratus Lumborum block is safe to execute and provides effective abdominal wall and visceral analgesia. However, the possibility of eliciting undesired episodes should prompt caution when performing this block and practitioners should thereafter remain vigilant. Questions regarding ideal dosing, volumes, timing of block and pertinence of catheters remain to be answered.

Resumo Justificativa e objetivos O bloqueio do quadrado lombar foi primeiramente descrito em 2007 e tem como objetivo o bloqueio dos mesmos nervos envolvidos no bloqueio do plano transverso abdominal, ao atingir algumas inervações viscerais, bem como devido à maior proximidade com o neuroeixo e cadeia simpática. Dada a sua versatilidade, temos usado esse bloqueio com sucesso em uma grande variedade de procedimentos. Relatamos dois casos nos quais acreditamos que a dispersão do anestésico local pode ter levado a uma complicação não descrita previamente. Relatos clínicos Relatamos dois casos nos quais realizamos o bloqueio do quadrado lombar tipo II e anestesia geral para gastrectomia total e hemicolectomia direita. Não houve eventos notáveis durante o bloqueio e a indução da anestesia geral, mas, dentro de 30 a 40 minutos, observamos grave hipotensão e taquicardia. Como outros motivos para a hipotensão foram descartados, o evento foi interpretado como simpatólise induzida pelo bloqueio devido à dispersão cefálica do anestésico local para os espaços paravertebral e epidural e tratado com sucesso com efedrina e aumento da taxa de infusão de cristaloides. Conclusões O bloqueio do quadrado lombar oferece segurança na execução e fornece analgesia eficaz à parede abdominal e vísceras. Porém, a possibilidade de provocar episódios indesejáveis requer cautela em sua execução e, por conseguinte, os médicos precisam estar atentos. As questões relacionadas à dosagem ideal, aos volumes, ao tempo de bloqueio e à pertinência dos cateteres permanecem indefinidas.

Botulinum toxin in essential hand tremor - A randomized double-blind placebo-controlled study with customized injection approach.

INTRODUCTION: To evaluate the safety and efficacy of incobotulinumtoxinA (IncoA) injection for treatment of essential hand tremor. In essential tremor and Parkinson's disease tremor, administration of onabotulinumtoxinA via a fixed injection approach improves the tremor but a high percentage of patients (30-70%) develop moderate to severe hand weakness which has limited its use in clinical practice. METHODS: This study was performed from July 2013 to July 2016 on 33 subjects. This is a double-blind, placebo-controlled, crossover trial injecting 80-120 units of IncoA into 8-14 hand and forearm muscles using a customized approach. The subjects were followed for 28 weeks. The treatment efficacy was evaluated by the Fahn Tolosa Marin tremor rating score and NIH genetic criteria for tremor severity at 4 and 8 weeks after each of the two sets of treatments. Hand strength was assessed by an ergometer. RESULTS: There was statistically significant improvement in clinical rating score of tremor at 4 and 8 weeks following the IncoA injection. CONCLUSION: In this study, injection of IncoA treatment via a customized approach improved essential tremor on the clinical scales and patient's perception with a low occurrence of significant hand weakness.

[Continuous quadratus lumborum type II block in partial nephrectomy]. / Bloqueio do quadrado lombar tipo II contínuo para analgesia pós­operatória de nefrectomia parcial.

BACKGROUND AND OBJECTIVES: Quadratus lumborum block was first described in 2007 and currently there are descriptions of its achievement through four different injection points. This blockage provides abdominal wall and visceral analgesia, and one of its mechanisms is the dispersion of the local anesthetic into the paravertebral space. We describe the performance of a continuous quadratus lumborum type II block for postoperative analgesia in a partial nephrectomy. CASE REPORT: A 64-year-old woman, scheduled for partial left laparoscopic nephrectomy. During the procedure, due to technical difficulties, an incision was made in the left flank to facilitate the surgical approach. In the early postoperative period, a continuous quadratus lumborum type II block was performed using ultrasonography as part of the multimodal analgesic strategy. Initially, 20ml of 0.2% ropivacaine was administered and 3cm of catheter were introduced into the interfascial space. Subsequently, a continuous infusion of 5.2mL.h-1 of 0.2% ropivacaine was given for 48hours. In the first 24 postoperative hours, the patient reported no pain at rest or on movement. In the following 24hours, she was free of pain at rest and only a slight pain (2/10) on movement. CONCLUSIONS: Continuous quadratus lumborum type II block was an effective postoperative analgesic option. Blocking of somatic nerves and visceral afferent pathways provided abdominal and visceral wall analgesia, allowing the reduction of opioid consumption. We consider relevant to explore the analgesic capacity of the quadratus lumborum block and its different approaches, as well as the possibility of it becoming an alternative in patients scheduled for kidney surgery.

Use of olive leaves (whether or not fortified with sodium selenate) in rabbit feeding: Effect on performance, carcass and meat characteristics, and estimated indexes of fatty acid metabolism.

Sixty New Zealand White weaned rabbits were divided into three groups and subjected to different dietary treatments: a standard diet for the control (C), a standard feed supplemented with 10% of plain olive leaves (OL) and a standard feed supplemented with 10% of selenium-fortified olive leaves (100 mg/L of foliar spray sodium selenate solution; SeOL). The productive performance was recorded at the time of slaughter (after 35 days); the carcass and meat traits were determined and estimated indexes of fatty acid metabolism were calculated. No significant differences were found on the rabbit productive performance and the physical-chemical characteristics of the meat. Both group of rabbits on the enriched diet showed leaner and thinner carcasses and a higher meat concentration of oleic acid. The estimated index of Δ5 + Δ6-desaturase, starting from n-6 fatty acids, was lower in both groups supplemented with leaves. The use of selenium-fortified olive leaves, positively affected the lipid oxidative stability of rabbit meat.

Type II Quadratus Lumborum block for a sub-total gastrectomy in a septic patient / Bloqueio do quadrado lombar tipo II para uma gastrectomia subtotal em um paciente séptico

Abstract Introduction and objectives: Quadratus Lumborum block was recently described and has already shown good results as an analgesic technique in abdominal surgeries, having the potential to significantly reduce opioids consumption and be a valid alternative to epidural catheter. We performed a type II Quadratus Lumborum block for analgesia in a septic patient having a sub-total gastrectomy. Case report: An 80 year-old, ASA III, male patient, weighting 50 kg, with a history of arterial hypertension and hypercholesterolemia, diagnosed with sepsis due to purulent peritonitis was submitted to an open laparotomy. Bilateral ultrasound-guided type II Quadratus Lumborum block was performed before surgery, using 10 mL of levobupivacaine 0.25% and 5 mL of mepivacaine 1%, per side. Pain relief was achieved 5 minutes after injection and the patient referred no pain in the immediate postoperative period. Discussion: Type II Quadratus Lumborum block may be considered a valid alternative for postoperative analgesia in a septic patient undergoing major abdominal surgery with some relative contraindications to epidural catheter placement. It allowed us to achieve excellent pain management avoiding opioids usage. However, more reports are still needed to properly access its usefulness.

Resumo Introdução e objetivo: O bloqueio do quadrado lombar (QL) foi descrito recentemente e já mostrou bons resultados como técnica analgésica em cirurgias abdominais, com potencial para reduzir significativamente o consumo de opioides e ser uma opção válida ao cateter peridural. Fizemos um bloqueio do QL tipo II para analgesia em um paciente séptico para gastrectomia subtotal. Relato de caso: Paciente do sexo masculino, 80 anos de, ASA III, 50 kg, com história de hipertensão arterial e hipercolesterolemia, diagnosticado com sepsis devido a peritonite purulenta, foi submetido a uma laparotomia aberta. O bloqueio bilateral do QL tipo II guiado por ultrassom foi feito antes da cirurgia com 10 mL de levobupivacaína a 0,25% e 5 mL de mepivacaína a 1%, por lado. O alívio da dor foi obtido em 5 minutos após a injeção e o paciente não referiu dor no pós-operatório imediato. Discussão: O bloqueio do quadrado lombar (QL) tipo II pode ser considerado uma opção válida para analgesia no pós-operatório em um paciente séptico submetido a cirurgia abdominal de grande porte, com algumas contraindicações relativas à colocação do cateter peridural. Permitiu-nos obter um excelente manejo da dor e evitar o uso de opioides. Contudo, mais relatos ainda são necessários para avaliar corretamente a sua utilidade.

[Type II Quadratus Lumborum block for a sub-total gastrectomy in a septic patient]. / Bloqueio do quadrado lombar tipo II para uma gastrectomia subtotal em um paciente séptico.

INTRODUCTION AND OBJECTIVES: Quadratus Lumborum block was recently described and has already shown good results as an analgesic technique in abdominal surgeries, having the potential to significantly reduce opioids consumption and be a valid alternative to epidural catheter. We performed a type II Quadratus Lumborum block for analgesia in a septic patient having a sub-total gastrectomy. CASE REPORT: An 80 year-old, ASA III, male patient, weighting 50kg, with a history of arterial hypertension and hypercholesterolemia, diagnosed with sepsis due to purulent peritonitis was submitted to an open laparotomy. Bilateral ultrasound-guided type II Quadratus Lumborum block was performed before surgery, using 10mL of levobupivacaine 0.25% and 5mL of mepivacaine 1%, per side. Pain relief was achieved 5minutes after injection and the patient referred no pain in the immediate postoperative period. DISCUSSION: Type II Quadratus Lumborum block may be considered a valid alternative for postoperative analgesia in a septic patient undergoing major abdominal surgery with some relative contraindications to epidural catheter placement. It allowed us to achieve excellent pain management avoiding opioids usage. However, more reports are still needed to properly access its usefulness.

[Quadratus lumborum block: are we aware of its side effects? A report of 2 cases]. / Bloqueio do quadrado lombar: estamos cientes de seus efeitos colaterais? Relato de dois casos.

BACKGROUND AND OBJECTIVES: The quadratus lumborum block was initially described in 2007 and aims at blocking the same nerves as the ones involved on the Transverse Abdominis Plane block, while accomplishing some visceral enervation as well due to closer proximity with the neuroaxis and sympathetic trunk. Given its versatility, we have successfully used it in a wide range of procedures. We report two cases where we believe the dispersion of local anesthetic is likely to have led to a previously undescribed complication. CLINICAL REPORTS: We report two cases in which we performed a quadratus lumborum type II block and general anesthesia for total gastrectomy and right hemicolectomy. There were no noteworthy events while performing the block and inducing general anesthesia, but within 30-40min serious hypotension and tachycardia were noted. As other motives for hypotension were ruled out, the event was interpreted as block-induced sympatholysis due to cephalad dispersion of the local anesthetic to the paravertebral and epidural space, and successfully managed with ephedrine and increase of the crystalloid infusion rate. CONCLUSIONS: The quadratus Lumborum block is safe to execute and provides effective abdominal wall and visceral analgesia. However, the possibility of eliciting undesired episodes should prompt caution when performing this block and practitioners should thereafter remain vigilant. Questions regarding ideal dosing, volumes, timing of block and pertinence of catheters remain to be answered.

[Superior gluteal nerve: a new block on the block?] / Nervo glúteo superior: um novo bloqueio a caminho?

BACKGROUND AND OBJECTIVES: The superior gluteal nerve is responsible for innervating the gluteus medius, gluteus minimus and tensor fascia latae muscles, all of which can be injured during surgical procedures. We describe an ultrasound-guided approach to block the superior gluteal nerve which allowed us to provide efficient analgesia and anesthesia for two orthopedic procedures, in a patient who had significant risk factors for neuraxial techniques and deep peripheral nerve blocks. CLINICAL REPORT: An 84-year-old female whose regular use of clopidogrel contraindicated neuraxial techniques or deep peripheral nerve blocks presented for urgent bipolar hemiarthroplasty in our hospital. Taking into consideration the surgical approach chosen by the orthopedic team, we set to use a combination of general anesthesia and superficial peripheral nerve blocks (femoral, lateral cutaneous of thigh and superior gluteal nerve) for the procedure. A month and a half post-discharge the patient was re-admitted for debriding and correction of suture dehiscence; we performed the same blocks and light sedation. She remained comfortable in both cases, and reported no pain in the post-operative period. CONCLUSIONS: Deep understanding of anatomy and innervation empowers anesthesiologists to solve potentially complex cases with safer, albeit creative, approaches. The relevance of this block in this case arises from its innervation of the gluteus medius muscle and posterolateral portion of the hip joint. To the best of our knowledge, this is the first report of an ultrasound-guided superior gluteal nerve block with an analgesic and anesthetic goal, which was successfully achieved.

Botulinum Toxin in Parkinson Disease Tremor: A Randomized, Double-Blind, Placebo-Controlled Study With a Customized Injection Approach.

BACKGROUND: In essential tremor and Parkinson disease (PD) tremor, administration of onabotulinumtoxinA via a fixed injection approach improves the tremor, but many patients (30%-70%) develop moderate to severe hand weakness, limiting the use of onabotulinumtoxinA in clinical practice. OBJECTIVE: To evaluate the safety and efficacy of incobotulinumtoxinA (IncoA) injection for the treatment of tremor in PD. PATIENTS AND METHODS: In this double-blind, placebo-controlled, crossover trial, 30 patients each received 7 to 12 (mean, 9) IncoA injections into hand and forearm muscles using a customized approach. The study was performed from June 1, 2012, through June 30, 2015, and participants were followed for 24 weeks. Treatment efficacy was evaluated by the tremor subsets of the Unified Parkinson's Disease Rating Scale and the Patient Global Impression of Change 4 and 8 weeks after each of the 2 sets of treatments. Hand strength was assessed using an ergometer. RESULTS: There was a statistically significant improvement in clinical rating scores of rest tremor and tremor severity 4 and 8 weeks after the IncoA injection and of action/postural tremor at 8 weeks. There was a significant improvement in patient perception of improvement at 4 and 8 weeks in the IncoA group. There was no statistically significant difference in grip strength at 4 weeks between the 2 groups. CONCLUSION: Injection of IncoA via a customized approach improved PD tremor on a clinical scale and patient perception, with a low occurrence of significant hand weakness. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02419313.

Sphenopalatine ganglion block for postdural puncture headache in ambulatory setting / Bloqueio do gânglio esfenopalatino para cefaleia pós-punção dural em contexto de ambulatório

Abstract Background and objectives: Postdural puncture headache (PDPH) is a common complication following subarachnoid blockade and its incidence varies with the size of the needle used and the needle design. Suportive therapy is the usual initial approach. Epidural blood patch (EBP) is the gold-standard when supportive therapy fails but has significant risks associated. Sphenopalatine ganglion block (SPGB) may be a safer alternative. Case report: We observed a 41 year-old female patient presenting with PDPH after a subarachnoid blockade a week before. We administrated 1 l of crystalloids, Dexamethasone 4 mg, parecoxib 40 mg, acetaminophen 1 g and caffeine 500 mg without significant relief after 2 hours. We performed a bilateral SPGB with a cotton-tipped applicator saturated with 0.5% Levobupivacaine under standard ASA monitoring. Symptoms relief was reported 5 minutes after the block. The patient was monitored for an hour after which she was discharged and prescribed acetaminophen 1 g and ibuprofen 400 mg every 8 hours for the following 2 days. She was contacted on the next day and again after a week reporting no pain in both situation. Conclusions: SPGB may attenuate cerebral vasodilation induced by parasympathetic stimulation transmitted through neurons that have synapses in the sphenopalatine ganglion. This would be in agreement with the Monro-Kellie concept and would explain why caffeine and sumatriptan can have some effect in the treatment of PDPH. Apparently, SPGB has a faster onset than EBP with better safety profile. We suggest that patients presenting with PDPH should be considered primarily for SPGB. Patients may have a rescue EBP if needed.

Resumo Justificativa e objetivos: Cefaleia pós-punção dural (CPPD) é uma complicação comum após bloqueio subaracnoideo e sua incidência varia de acordo com o tamanho e desenho da agulha usada. Geralmente, a terapia de apoio é a abordagem inicial. O tampão sanguíneo peridural (TSP) é o padrão de terapia quando a terapia de apoio falha, mas tem riscos significativos associados. O bloqueio do gânglio esfenopalatino (BGEP) pode ser uma opção mais segura. Relato de caso: Atendemos uma paciente de 41 anos, com CPPD após bloqueio subaracnoideo uma semana antes. Administramos cristaloides (1 L), dexametasona (4 mg), parecoxib (40 mg), acetaminofeno (1 g) e cafeína (500 mg), sem alívio significativo após 2 horas. Fizemos um bloqueio bilateral do gânglio esfenopalatino, com um aplicador com ponta de algodão saturada com levobupivacaína a 0,5% sob monitoração padrão ASA. O alívio dos sintomas foi relatado 5 minutos após o bloqueio. A paciente foi monitorada por uma hora e depois recebeu alta com prescrição de acetaminofeno (1 g) e ibuprofeno (400 mg) a cada 8 horas para os dois dias seguintes. A paciente foi contatada no dia seguinte e novamente após uma semana e, em ambos os contatos, relatou não sentir dor. Conclusões: O BGEP pode ter atenuado a vasodilatação cerebral induzida pelo estímulo parassimpático transmitido através dos neurônios que têm sinapses no gânglio esfenopalatino. Esse mecanismo estaria de acordo com o conceito de Monro-Kellie e explicaria por que a cafeína e o sumatriptano podem ter algum efeito no tratamento da CPPD. Aparentemente, o BGEP tem um início mais rápido do que o do TSP, com um melhor perfil de segurança. Sugerimos que os pacientes que se apresentam com CPPD devam ser considerados primeiro para BGEP. Os pacientes podem ser submetidos a um TSP de resgate, caso necessário.

[Sphenopalatine ganglion block for postdural puncture headache in ambulatory setting]. / Bloqueio do gânglio esfenopalatino para cefaleia pós­punção dural em contexto de ambulatório.

BACKGROUND AND OBJECTIVES: Postdural puncture headache (PDPH) is a common complication following subarachnoid blockade and its incidence varies with the size of the needle used and the needle design. Supportive therapy is the usual initial approach. Epidural blood patch (EBP) is the gold-standard when supportive therapy fails but has significant risks associated. Sphenopalatine ganglion block (SPGB) may be a safer alternative. CASE REPORT: We observed a 41 year-old female patient presenting with PDPH after a subarachnoid blockade a week before. We administrated 1l of crystalloids, Dexamethasone 4mg, parecoxib 40mg, acetaminophen 1g and caffeine 500mg without significant relief after 2hours. We performed a bilateral SPGB with a cotton-tipped applicator saturated with 0.5% Levobupivacaine under standard ASA monitoring. Symptoms relief was reported 5minutes after the block. The patient was monitored for an hour after which she was discharged and prescribed acetaminophen 1g and ibuprofen 400mg every 8hours for the following 2 days. She was contacted on the next day and again after a week reporting no pain in both situations. CONCLUSIONS: SPGB may attenuate cerebral vasodilation induced by parasympathetic stimulation transmitted through neurons that have synapses in the sphenopalatine ganglion. This would be in agreement with the Monro-Kellie concept and would explain why caffeine and sumatriptan can have some effect in the treatment of PDPH. Apparently, SPGB has a faster onset than EBP with better safety profile. We suggest that patients presenting with PDPH should be considered primarily for SPGB. Patients may have a rescue EBP if needed.