Postmastectomy pain syndrome after preoperative stellate ganglion block: a randomized controlled trial.

BACKGROUND: This study investigated the effect of preoperative ultrasound (US) guided stellate ganglion block (SGB) with bupivacaine on the frequency of post mastectomy pain syndrome (PMPS). METHODS: Eighty patients scheduled for mastectomy with axillary dissection for breast cancer were included in this randomized controlled trial. Patients were randomized into two equal groups: Group A received US guided SGB one hour before surgery using five mL of 0.5% bupivacaine and multimodal systemic analgesia, Group B (control) received multimodal systemic analgesia only. Patients were followed up for six months. PMPS was assessed using the grading system for neuropathic pain (GSNP). Postoperative opioid consumption in the first 24 hours and numeric rating scale (NRS) were documented. Patient daily activity and functional capacity were evaluated using the Eastern Cooperative Oncology Group (ECOG) score. RESULTS: PMPS proportion was significantly lower in group A than group B (30% vs. 62.5%, P=0.004; 52% decrease [95% CI: 18.4%-71.8%]). Postoperative opioid consumption and NRS were significantly lower in group A as compared to group B. ECOG score was significantly higher in Group A than Group B. CONCLUSIONS: Following mastectomy with axillary dissection, preoperative US guided SGB is associated with less PMPS proportion, postoperative pain and opioid consumption and better patient daily activity and functional capacity.

The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan.

OBJECTIVE: To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births. METHODS: A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits. Participants and their families received educational materials and were counseled on how to diagnose excessive bleeding and the importance of seeking care at a facility if PPH occurs. In the intervention phase, participants were also given misoprostol and counselled on how to administer the four 200 mcg tablets for first aid in case of PPH. Participants were followed-up postpartum to collect data on use of misoprostol for Family First Aid at home deliveries (primary outcome) and record maternal and perinatal outcomes. RESULTS: Of the 4008 participants enrolled, 97% were successfully followed-up postpartum. Half of the participants in each phase delivered at home. Among home deliveries, the odds of reporting PPH almost doubled among in the intervention phase (OR 1.98; CI 1.43, 2.76). Among those reporting PPH, women in the intervention phase were significantly more likely to have received PPH treatment (OR 10.49; CI 3.37, 32.71) and 90% administered the dose correctly. No maternal deaths, invasive procedures or surgery were reported in either phase after home deliveries. CONCLUSIONS: The Family First Aid approach is a safe and feasible model of care that provides timely PPH treatment to women delivering at home in rural communities.

Testing a home-based model of care using misoprostol for prevention and treatment of postpartum hemorrhage: results from a randomized placebo-controlled trial conducted in Badakhshan province, Afghanistan.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. In Afghanistan, where most births take place at home without the assistance of a skilled birth attendant, there is a need for options to manage PPH in community-based settings. Misoprostol, a uterotonic that has been used as prophylaxis at the household level and has also been proven to be effective in treating PPH in hospital settings, is one possible option. METHODS: A double-blind, randomized placebo-controlled trial was conducted in six districts in Badakhshan Province, Afghanistan to test the effectiveness and safety of administering 800mcg sublingual misoprostol to women after a home birth for treatment of excessive blood loss. Consenting women were enrolled prior to delivery and given 600mcg misoprostol to self-administer orally as prophylaxis. Community health workers (CHW) were trained to observe for signs of PPH after delivery and if PPH was diagnosed, administer the study medication (misoprostol or placebo) and immediately refer the woman. A hemoglobin (Hb) decline of 2 g/dL or greater, measured pre- and post-delivery, served as the primary outcome; side effects, additional interventions, and transfer rates were also analyzed. RESULTS: Among the 1884 women who delivered at home, nearly all (98.7%) reported self-use of misoprostol for PPH prevention. A small fraction was diagnosed with PPH (4.4%, 82/1884) and was administered treatment. Hb outcomes, including the proportion of women with a Hb drop of 2 g/dL or greater, were similar between the study groups (misoprostol: 56.4% (22/39), placebo: 60.6% (20/33), p = 0.45). Significantly more women randomized to receive misoprostol experienced shivering (82.5% vs. placebo: 61.5%, p = 0.03). Other side effects were similar between study groups and none required treatment, including among the subset of 39 women, who received misoprostol for both of its PPH indications. CONCLUSIONS: While the study did not document a clinical benefit associated with misoprostol for treatment of PPH, study findings suggest that use of misoprostol for both prevention and treatment in the same birth as well as its use by lay level providers in home births does not result in any safety concerns. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov, number NCT01508429 Registered on December 1, 2011.

A double-blind, randomized controlled trial to explore oral tranexamic acid as adjunct for the treatment for postpartum hemorrhage.

BACKGROUND: Oral tranexamic acid (TXA), if effective in reducing blood loss after delivery for women experiencing primary PPH, could be administered where parenteral administration is not feasible. This trial assessed the efficacy, safety, and acceptability of oral TXA when used as an adjunct to sublingual misoprostol to treat postpartum hemorrhage (PPH) following vaginal delivery. METHODS: From October 2016 to January 2018, women presenting at four hospitals in Senegal and Vietnam for vaginal delivery were screened for enrollment in the trial. Women diagnosed with postpartum hemorrhage (defined as blood loss ≥700 ml) were randomized to receive either oral TXA (1950 mg) or placebo in addition to 800 mcg sublingual misoprostol. Postpartum blood loss was measured using a calibrated drape. Blood loss for all PPH cases was recorded for 2 h after administration of the drugs. The primary outcome measure was the proportion of women with bleeding controlled with the trial regimen without recourse to further treatment. Secondary outcomes including the rate of severe PPH, mean/median blood loss, use of additional uterotonics and/or interventions side effects, and acceptability were also recorded. RESULTS: Of the 258 women who received treatment for PPH, 128 received placebo and misoprostol and 130 received TXA and misoprostol. The proportion of women who had active bleeding controlled with trial drugs alone and no additional interventions was similar in both groups: 77(60.2%) placebo; 74 (56.9%) TXA, p = 0.59). Use of other interventions to control bleeding, including uterotonics, did not differ significantly between groups. Median blood loss at PPH diagnosis was 700 ml in both groups. Uterine atony alone or in addition to another cause contributed to over 90% of PPH cases reported (92.2% placebo vs. 91.5% TXA), other causes included perineal and cervical lacerations and retained placenta. Reports of side effects and acceptability were similar in the two groups. CONCLUSION: Adjunct use of oral TXA with misoprostol to treat PPH resulted in similar clinical and acceptability outcomes when compared to treatment with misoprostol alone. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov, number NCT02805426. Registered on 3 September 2016.

The impact of ultrasound-guided continuous serratus anterior plane block versus intravenous patient-controlled analgesia on the incidence and severity of post-thoracotomy pain syndrome: A randomized, controlled study.

OBJECTIVE: The aim of this randomized controlled trial was to evaluate U/S guided serratus anterior plane catheter block (SAPB) versus patient-controlled analgesia (PCA) on the emergence of post-thoracotomy pain syndrome (PTPS) after thoracotomies for thoracic tumours. METHODS: This trial included 89 patients with chest malignancies, scheduled for thoracotomy were randomly allocated into two groups: Group A "PCA-group N=44" receiving patient-controlled analgesia and group B "SAPB group N=45" where analgesia was provided by SAPB. The primary outcome measure was the assessment for the possible emergence of PTPS at 12 weeks. The secondary outcome measures were pain relief measured using visual analog scale (VAS) score, Quality of life was assessed using Flanagan Quality of Life Scale (QOLS) and Activity level was assessed using Barthel Activity of daily living (ADL) score. RESULTS: At week 8, PTPS incidence was significantly (p = .037) higher in the PCA group (45%) than in the SAPB group (24%) with a relative risk of 1.38 and 95% CI (1.01-1.9) while the incidence of PTPS at week 12 was significantly (p = .035) higher in the PCA group (43%) than in the SAPB group (22%) with a relative risk of 2.38 and 95% CI (1.23-4.57). The need for pain therapy in PTPS patients was significantly lower in the SAPB group (17.7%) than the PCA group (38.6%) (p = .028) at week 12. Pain intensity: VAS-R and VAS-D (pain scores at rest and with activity, respectively) was comparable (p > .05) between both groups at 6, 12, 18 and 24 hr, however VAS was significantly higher in the PCA group at week 8 (p = .046) and week 12 (p = .032) . Both groups were comparable regarding ADL and QOL scores (p > .05). CONCLUSION: Serratus anterior plane block is assumed to be a good alternative for post-thoracotomy analgesia following thoracotomies. The current work hypothesized that SAPB for a week postoperatively, may reduce the emergence of PTPS and may reduce the demand for pain therapy in those patients. SIGNIFICANCE STATEMENT: The current work hypothesized that SAPB for a week postoperatively, is a good loco-regional alternative for post-thoracotomy analgesia following thoracotomies for chest malignancies, it may reduce the emergence of PTPS and the demand for pain therapy in these patients.

Feasibility of a hospital outpatient day procedure for medication abortion at 13-18 weeks gestation: Findings from Nepal.

OBJECTIVES: To evaluate the safety, acceptability and feasibility of a one-day outpatient medication abortion service at gestations 13-18 weeks. STUDY DESIGN: Open-label prospective study in which participants received mifepristone 200 mg orally to swallow at home or at the clinic followed 24 h later by misoprostol 400 mcg buccally. They presented to the outpatient clinic 24-48 h after mifepristone for misoprostol 400 mcg buccally every three hours (no maximum dose). The primary outcome was successful abortion without transfer to overnight inpatient care. Secondary outcomes included time to abortion from initial misoprostol dose, safety, additional interventions and side effects. RESULTS: We enrolled 230 women from December 2017 to November 2018. Approximately nine of ten (n = 206, 89.6%) achieved a successful abortion without transfer to overnight care. Twenty-four were transferred to overnight inpatient care; of these 18 were to manage a complication, five for incomplete abortion and two by choice. Among these 24, three women experienced an SAE. The median time to successful abortion from time of the first misoprostol dose was 7.2 h (range: 0.75-92.3), with an average of three misoprostol doses. Most participants expelled the fetus and the placenta at or around the same time; median time between fetal and placental expulsion was 15 minutes (range: 0-4.5 h). Fifteen participants (6.6%) received more than five misoprostol doses and were transferred to inpatient care. Administration of more than five doses of misoprostol was associated with nulliparity. Provision of antibiotics (27.9%, n = 64), manual removal of placenta (15.3%, n = 35), uterotonics (4.4%, n = 10) and surgical interventions (4.4%, n = 10) were also reported. About one in four participants experienced nausea, vomiting and chills; fever was infrequent (2.5%, n = 5). CONCLUSIONS: For gestations 13-18 weeks, an outpatient day process for medication abortion is safe, effective and feasible. IMPLICATIONS: Medication abortion in 13 - 18 weeks need not be limited to inpatient care; nine of ten cases can be managed as an outpatient day service.

Ultrasound-guided continuous serratus anterior plane block: dexmedetomidine as an adjunctive analgesic with levobupivacaine for post-thoracotomy pain. A prospective randomized controlled study.

Purpose: The study aimed to evaluate the analgesic efficiency of dexmedetomidine (DEX) when added to levobupivacaine in continuous ultrasound-guided serratus anterior plane block (SAPB) performed at the end of major thoracic surgery. Methods: This randomized, double-blind trial included 50 adults undergoing thoracic surgery. Continuous SAPB was performed at the end of surgery. Patients were randomized into two groups. Group L (n=25) received levobupivacaine only while Group DL (n=25) received a mixture of levobupivacaine and DEX. All patients received intravenous (IV) paracetamol every 8 hrs. Morphine IV was given according to VAS score of pain as a 5 mg loading dose. The primary outcome measure was postoperative pain intensity. Secondary outcome measures were postoperative morphine consumption and adverse effects. Results: Analgesia was satisfactory in the two groups up to 24 hrs. VAS score was significantly lower in group DL compared to group L between 6 and 24 hrs postoperatively. Total morphine consumption was significantly lower in group DL compared to group L (p<0.001). Up to 12 hrs postoperatively, sedation score was significantly lower in group DL compared to group L. Afterwards, all patients were fully alert. All values of mean arterial pressure and heart rate were within the clinically accepted ranges. There were no recorded cases of hypotension or bradycardia in the whole studied group. Conclusions: Continuous SAPB with levobupivacaine plus DEX seems to be a promising analgesic alternative following thoracotomy. Combined with IV paracetamol, this approach provided adequate analgesia and proper sedation. Trial registration: ISRCTN registry; study ID: ISRCTN35517318.

Could second-trimester medical abortion be offered as a day service? Assessing the feasibility of a 1-day outpatient procedure using pooled data from six clinical studies.

OBJECTIVES: Current service delivery models for second-trimester medical abortion typically include routine inpatient admission and overnight stays. To assess the feasibility of a day-service model, we evaluated outpatient administration of abortion medications and analyzed the proportion of clients who could avoid an overnight stay. We also examined additional key elements of medical abortion care to evaluate the practicality of this model. STUDY DESIGN: We pooled data from six clinical studies of second-trimester medical abortion conducted by Gynuity over the past 10 years. We include 868 individuals receiving mifepristone-misoprostol abortion between 13 and 22 weeks' gestation. RESULTS: At 8 h post misoprostol initiation, 309/521 (59.3%) participants at 13-18 weeks' gestation had a successful abortion; by 10 h, 382/521 (73.3%) were successful. Taking the mifepristone at home lowered neither the efficacy of the method nor satisfaction with the experience. Nonphysician providers played a significant role in the provision of care. Needed interventions were relatively rare; serious complications were very rare. CONCLUSIONS: Our findings support the provision of second-trimester medical abortion in a day-clinic setting, especially at ≤18 weeks' gestation. Such a model could increase access to quality care in many settings. IMPLICATIONS: Second-trimester medical abortion can safely and effectively be offered as a day service. Nonphysician providers are well suited to provide the majority of care. Developing guidelines for a 1-day model could increase access to quality care in many settings worldwide.

The Possible Preventive Role of Pregabalin in Postmastectomy Pain Syndrome: A Double-Blinded Randomized Controlled Trial.

CONTEXT: Chronic postmastectomy pain syndrome (PMPS) has a considerable negative impact on the quality of life of breast cancer patients. OBJECTIVE: The objective of this study was to assess the possible preventive role of perioperative pregabalin in PMPS. METHODS: This randomized controlled study included 200 patients with breast cancer scheduled for elective breast cancer surgery. They were randomly assigned to one of two treatment groups. The pregabalin group received 75 mg of pregabalin twice daily for seven days and the control group received oral equivalent placebo capsules. The primary outcome was development of neuropathic PMPS. Neuropathic pain was assessed using the Grading System for Neuropathic Pain. Secondary outcome measures were safety and Visual Analogue Scale scores. RESULTS: Neuropathic pain was significantly less frequent in the pregabalin group compared to the control group at four weeks (P = 0.005), 12 weeks (P = 0.002), and 24 weeks (P < 0.001) postoperatively. PMPS was diagnosed in 11 patients (11%) of the pregabalin group and 29 patients (29%) of the control group (P < 0.001, relative risk: 0.26, 95% CI: 0.12-0.56). At the three follow-up time points, Visual Analogue Scale scores during the first three postoperative weeks were comparable in both groups while they were significantly lower in the pregabalin group at 4, 12, and 24 weeks. These two groups were comparable in the frequency of adverse events (P = 0.552). CONCLUSION: Perioperative oral pregabalin 75 mg twice daily, starting at the morning of surgery and continued for one week, could reduce the frequency of postmastectomy pain syndrome.

Using misoprostol to treat postpartum hemorrhage in home deliveries attended by traditional birth attendants.

OBJECTIVE: To explore the clinical and programmatic feasibility of using 800 µg of sublingual misoprostol to prevent and treat postpartum hemorrhage (PPH) during home delivery. METHODS: The present double-blind randomized controlled trial included women who underwent home deliveries in Chitral district, Khyber Pakhtunkhwa province, Pakistan, after presenting at healthcare facilities during the third trimester of pregnancy between May 28, 2012, and November 27, 2014. Participants were randomized in a 1:1 ratio to receive either 800 µg of misoprostol or placebo sublingually if PPH was diagnosed, having previously received a prophylactic oral dose of 600 µg misoprostol. The primary outcome, hemoglobin decrease of 20 g/L or greater from pre- to post-delivery assessment, was compared on a modified intention-to-treat basis. RESULTS: There were 49 patients allocated to receive misoprostol and 38 allocated to receive placebo; the incidence of a 20 g/L decrease in hemoglobin was similar between the groups (20/43 [47%] vs 19/33 [58%], respectively; P=0.335). CONCLUSION: There was no significant difference in clinical outcomes between the two trial arms. ClinicalTrials.gov:NCT01485562.

The impact of intravenous dexamethasone on the efficacy and duration of analgesia of paravertebral block in breast cancer surgery: a randomized controlled trial.

PURPOSE: The study aimed at the evaluation of the impact of intravenous (IV) dexamethasone on efficacy and duration of analgesia of paravertebral block (PVB) in patients undergoing modified radical mastectomy (MRM). PATIENTS AND METHODS: This randomized, double-blind controlled trial included 50 patients with breast cancer scheduled for unilateral MRM. Ultrasound-guided PVB was performed in out-of-plane technique. The technique was repeated at each segment from C7 to T6. The participants were randomly allocated to one of two groups. Group BD (n=25) received IV 8 mg dexamethasone diluted with 8 mL of normal saline to reach 10 mL solution, while Group B received IV 10 mL normal saline. Top-up local infiltration analgesia into the surgical field was performed by the surgeon if needed using lidocaine 1% intraoperatively. Propofol infusion of 50-100 µg/kg/min was maintained throughout the surgery. The time to administration of the first postoperative analgesic dose, pain intensity as visual analog scale (VAS) score, number of patients who required rescue morphine analgesia, total morphine consumption, postoperative nausea and vomiting (PONV) impact scale, and the overall satisfaction of patients with pain management were measured. RESULTS: Fifty patients were randomized and analyzed. The time to first rescue analgesic dose was significantly longer in Group DB (P<0.001). The VAS scores were significantly lower in Group DB compared to Group B up to 12 hours postoperatively. Morphine consumption was lower in Group DB compared to Group B. PONV Impact Scale score was significantly higher in Group B. CONCLUSION: Systemic dexamethasone increased the efficacy and duration of the single-shot multilevel PVB in breast cancer surgery. TRIAL REGISTRATION: ISRCTN registry, study ID: ISRCTN15920148.

A Novel Technique of Saddle Rhizotomy Using Thermal Radiofrequency for Intractable Perineal Pain in Pelvic Malignancy: A Pilot Study.

BACKGROUND: The prevalence of pain in advanced pelvic cancer may reach up to 95%. Control of such pain is often difficult owing to a variety of neuroanatomical and functional peculiarities. Different modalities have been utilized to treat this pain including saddle chemical rhizolysis with the potential for jeopardizing the neural control of the sphincters. OBJECTIVE: The aim of this pilot study is to determine the feasibility of using selective thermal radiofrequency as an alternative to saddle chemical rhizolysis in patients with refractory perineal pain associated with pelvic malignancies. STUDY DESIGN: Pilot study. SETTING: Pain Relief Department of the National Cancer Institute, Cairo University. METHODS: Forty patients, 18 years of age or older, who had pelvic malignancy and were complaining of moderate or severe perineal pain not controlled with maximum tolerable doses of morphine sulfate for at least 4 weeks were randomly allocated to receive selective saddle rhizotomy using thermal radiofrequency ablation of S3 on one side and bilateral ablation of S4 and S5 (RF group, n = 20) or conventional chemical rhizotomy using hyperbaric 6% phenol in glycerin (Phenol group, n = 20). Patients were assessed for the intensity of pain, daily consumption of analgesics, functional improvement, overall patient satisfaction, degree of disability and occurrence of procedure-related side effects at 1,4, and 12 weeks. RESULT: The results were comparable in both groups regarding the control of pain and functional improvement. The incidence of specific procedure-related adverse outcomes was also equivalent for both interventions, although per-patient incidence of major complications was significantly higher in the phenol group. LIMITATION: Small sample size to demonstrate statistical significance of the relatively small frequency of events, and the patients could not be blinded to the intervention they received owing to the technical uniqueness of either intervention. CONCLUSION: Selective thermal radiofrequency ablation of the S3 root on one side, S4 root on both sides, and S5 roots could serve as a feasible alternative to conventional saddle rhizotomy using hyperbaric phenol. KEY WORDS: Perineal cancer pain, chemical rhizotomy, thermal radiofrequency.

Acceptability and feasibility of outpatient medical abortion with mifepristone and misoprostol up to 70 days gestation in Singapore.

OBJECTIVES: The aim of the study was to examine the acceptability and feasibility of using a combined regimen of 200 mg mifepristone and 800 µg buccal misoprostol in an outpatient abortion service in Singapore, where mifepristone is not currently registered. STUDY DESIGN: The pilot prospective study enrolled 130 women who sought termination of pregnancies up to 70 days gestation at two public hospitals in Singapore. Women received 200 mg mifepristone to take at the clinic or at home, followed 24 h later by 800 µg buccal misoprostol administered at home. A follow-up visit was scheduled seven to ten days after mifepristone to confirm the outcome of the abortion. The primary outcome was rate of successful abortion and secondary outcomes were women's preference for location of mifepristone administration and satisfaction with the method. RESULTS: The large majority of women (96.8%) had successful abortions without recourse to surgical intervention. Most women (88.2%) chose to take mifepristone at the clinic. Most women reported the side effects as acceptable (68.3%) or neutral (26.0%). Almost all women (94.4%) were very satisfied or satisfied with the method. CONCLUSIONS: Outpatient medical abortion with mifepristone and misoprostol up to 70 days gestation is acceptable and feasible and has the potential to expand available options in Singapore.

Thermal Versus Super Voltage Pulsed Radiofrequency of Stellate Ganglion in Post-Mastectomy Neuropathic Pain Syndrome: A Prospective Randomized Trial.

BACKGROUND: Breast cancer is the second most common cancer world-wide following lung cancer. Post-mastectomy pain syndrome (PMPS) is one of the chronic post-surgical pain disorders (CPSP) of neuropathic character; nearly 20-50% of patients may develop PMPS. Stellate ganglion blockade has been performed as a diagnostic, prognostic, or therapeutic intervention for different pain syndromes. OBJECTIVE: The aim of this study is to evaluate and compare the efficacy and safety of thermal versus super voltage pulsed radiofrequency (RF) application of stellate ganglion in neuropathic PMPS in cancer patients. STUDY DESIGN: A prospective, double-blind, randomized, and controlled trial. METHODS: Eighty patients with PMPS after surgery for breast cancer were recruited from the pain clinic of the National Cancer Institute with pain duration of more than 6 months and less than 2 years, visual analog scale (VAS) >/= 40 mm, and not responding to oxycodone and pregabalin for at least 4 weeks. The pain had to be of positive neuropathic character, as detected by the grading system for neuropathic pain (GSNP; score of 3 or 4). The patients were allocated into 2 equally sized groups: Group A: Pulsed RF; super voltage pulsed RF was applied with a time of 360 seconds at 42º C, with a pulse width of 20 m/sec and voltage of 60-70 v. Group B: Thermal RF; thermal RF neurolysis was applied with a time of 60 seconds at 80º C, and was then was repeated twice after needle-tip rotation. Stellate ganglion RF therapy was done under fluoroscopy, integrated by ultrasound guidance. The patients were assessed for pain relief by change in VAS score, functional improvement, and the analgesic concomitant medication (oxycodone and pregabalin) consumption prior to block and at 1, 4, 12, and 24 weeks thereafter. The impact of treatment on quality of life (assessed by short-form health survey questionnaire [SF-36]) and patient function capacity (assessed by the Eastern Cooperative Oncology Group [ECOG]) were also recorded. RESULTS: The percentage of patients who had successful response was significantly higher in the thermal RF group compared to the pulsed RF group at the first week and first, third, and sixth months, with significant difference in post-mastectomy pain intensity, functional improvement, and less rescue analgesia. There was no significant difference in quality of life or patient functional capacity. LIMITATIONS: A longer follow-up period may be needed for the evaluation of RF effect on PMPS. CONCLUSIONS: Thermal RF of the stellate ganglion is a safe and successful treatment for PMPS. It appears to be more effective than pulsed RF of the stellate ganglion in this pain syndrome. KEY WORDS: Cancer breast, post mastectomy pain syndrome, stellate ganglion block, radiofrequency therapy.

Comparative study on the analgesic effect of acute ipsilateral shoulder pain after open thoracotomy between preoperative ultrasound guided suprascapular nerve block (SNB) and intraoperative phrenic nerve infiltration (PNI) in cancer lung patients.

INTRODUCTION: Acute ipsilateral shoulder pain (ISP) is a common complaint in patients after thoracotomy. The incidence ranges from 21% to 97%. Unfortunately, clinical studies did not put enough focus on ISP post thoracic surgery. AIM OF THE WORK: This study was designed to compare the effectiveness of suprascapular nerve block (SNB) and phrenic nerve infiltration (PNI) for controlling ISP. PATIENTS AND METHODS: One hundred and thirty-five lung cancer patients (135) scheduled for open-lung surgery were randomly allocated into three equal groups; control group: received thoracic epidural with general anesthesia, suprascapular group: (SNB) one hour before the operation with 10 ml bupivacaine plus thoracic epidural with general anesthesia and phrenic nerve group: (PNI) was performed by the operating surgeon with 10 ml bupivacaine plus thoracic epidural with general anesthesia. The visual analogue score (VAS) of ISP, rescue of ketorolac for break through shoulder pain, peak expiratory flow rate (PEFR) and arterial blood gases were measured every 6 h postoperatively for 48 h. RESULTS: The VAS, rescue doses of ketorolc and PEFR were significantly lower in the phrenic nerve group (P-value <0.05). There was no statistically significant difference between the three groups postoperatively as regards arterial blood gases (P-value >0.05). CONCLUSION: PNI is more effective than SNB for ISP.

Simultaneous Administration Compared With a 24-Hour Mifepristone-Misoprostol Interval in Second-Trimester Abortion: A Randomized Controlled Trial.

OBJECTIVE: To compare outcomes with simultaneous administration of mifepristone and misoprostol with a regimen in which the drugs are administered at a 24-hour interval for second-trimester abortion. METHODS: In this placebo-controlled, double-blind trial, participants were randomized to receive mifepristone either 24 hours before or at the same time as misoprostol. Participants were hospitalized to receive 400 micrograms buccal misoprostol at 3-hour intervals up to 48 hours or until uterine expulsion. The primary outcome was the proportion of women who experienced uterine expulsion within 24 hours after the first misoprostol dose and this required 504 women to examine our hypothesis that this rate would be 85% in the 24-hour interval arm compared with 70% in the simultaneous arm. Secondary outcomes included total abortion time from mifepristone and misoprostol. RESULTS: From February 2013 to April 2014, 509 women were enrolled. Women in the 24-hour interval arm were more likely to abort within 24 hours (94.4% compared with 85.0%, relative risk 1.11, 95% confidence interval [CI] 1.05-1.18). At 48 hours, the rate was similar in the two arms (96.8% [24-hour interval] and 95.7% [simultaneous], relative risk 1.01, 95% CI 0.97-1.04). Median misoprostol dosing time was shorter in the 24-hour interval arm (7.7 compared with 13 hours; P<.001) and consistent with the median misoprostol doses required (three compared with five; P<.001). Median time from mifepristone to uterine expulsion was longer in the 24-hour interval arm (32.3 compared with 13 hours; P<.001). Both regimens had high acceptability rates and reported similar side effects and pain scores. CONCLUSION: Administering mifepristone and misoprostol simultaneously results in lower expulsion rates within 24 hours of taking misoprostol, longer median misoprostol treatment times, and requires more misoprostol doses. At 48 hours, both regimens work equally well. Simultaneous dosing results in less total time from the first clinical contact to complete abortion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT01768299.

Outpatient medical abortion is safe and effective through 70 days gestation.

Data show that an outpatient regimen of 200-mg mifepristone followed by a single dose of misoprostol is safe and effective for medical abortion for up to 70 days from last menstrual period (LMP). Yet, many clinics only provide services up to 63 days LMP, and some practice guidelines do not recommend the higher gestational age limit. We review the studies published to date that include women 64 to 70 days LMP and conclude that outpatient medical abortion is safe and effective in this interval and that there are no clinically meaningful differences between outcomes at 57 to 63 days LMP and 64 to 70 days LMP. Updating clinical protocols and revising the Food and Drug administration label for Mifeprex® to change the indication for termination of pregnancies through 70 days LMP will give women more choices and expand access to safe abortion services.

Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: a randomized clinical trial.

BACKGROUND: The pectoral nerves (Pecs) block types I and II are novel techniques to block the pectoral, intercostobrachial, third to sixth intercostals, and the long thoracic nerves. They may provide good analgesia during and after breast surgery. Our study aimed to compare prospectively the quality of analgesia after modified radical mastectomy surgery using general anesthesia and Pecs blocks versus general anesthesia alone. METHODS: One hundred twenty adult female patients scheduled for elective unilateral modified radical mastectomy under general anesthesia were randomly allocated to receive either general anesthesia plus Pecs block (Pecs group, n = 60) or general anesthesia alone (control group, n = 60). RESULTS: Statistically significant lower visual analog scale pain scores were observed in the Pecs group than in the control group patients. Moreover, postoperative morphine consumption in the Pecs group was lower in the first 12 hours after surgery than in the control group. In addition, statistically significant lower intraoperative fentanyl consumption was observed in the Pecs group than in the control group. In the postanesthesia care unit, nausea and vomiting as well as sedation scores were lower in the Pecs group compared with the control group. Overall, postanesthesia care unit and hospital stays were shorter in the Pecs group than in the control group. CONCLUSIONS: The combined Pecs I and II block is a simple, easy-to-learn technique that produces good analgesia for radical breast surgery.

Misoprostol for prevention and treatment of postpartum hemorrhage: what do we know? What is next?

Misoprostol is an effective and safe uterotonic for the prevention and treatment of postpartum hemorrhage (PPH). A 600-µg oral dose of misoprostol has been shown to prevent PPH in community-based randomized controlled trials. An 800-µg sublingual dose of misoprostol appears to be a good first-line treatment for controlling PPH. Adverse effects after use of misoprostol for PPH prevention or treatment may include shivering and fever. These effects are transient, resolve on their own, and are not life threatening. Misoprostol can play an important role in settings with limited access to oxytocin, and where there is no other option for PPH care.

Fluoroscopic stellate ganglion block for postmastectomy pain: a comparison of the classic anterior approach and the oblique approach.

OBJECTIVE: Stellate ganglion block is usually performed with the classic anterior paratracheal approach. The anatomy of the stellate ganglion being in close proximity to various critical structures renders a number of complications, which are potentially associated with its blockade. The aim of this study was to assess the analgesic efficacy and safety of a new approach of the stellate ganglion block using an oblique fluoroscopic view. METHODS: Fifty patients with postmastectomy pain syndrome were randomly allocated into 1 of 2 groups: the anterior paratracheal stellate block group and the oblique fluoroscopic stellate block group. Four blocks were performed for each patient using the same approach each time. The results were evaluated in terms of pain intensity as assessed by the visual analog scale score, morphine consumption, and allodynia surface area (in cm). Patient satisfaction score (PSS), skin temperature, side effects, and complications were recorded and compared between the 2 studied groups after each block had been performed. RESULTS: The mean visual analog scale score, daily morphine consumption, and areas of allodynia were significantly decreased and the PSS was significantly increased after each block and for up to 3 months after the last block in both the groups. However, there were no statistically significant differences between the 2 groups at the same study period apart from PSS, which was statistically more significant in group oblique at certain times. The incidences of side effects were significantly more in group classic than in group oblique. CONCLUSIONS: The oblique fluoroscopic approach of the stellate ganglion block is as effective as the anterior paratracheal approach but is safer and more satisfactory to the patients.