The Influence of Local Anesthesia Depth on Procedural Pain During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial.

OBJECTIVES: The aim of the study was to evaluate the influence of the depth of local anesthesia application on procedural pain during lumbar transforaminal epidural steroid injection. DESIGN: Sixty-eight patients were enrolled who were scheduled for single-level, unilateral fluoroscopically guided lumbar transforaminal epidural steroid injection. Patients were randomly allocated to receive either subcutaneous local anesthesia (group S) or deep local anesthesia (group D) for transforaminal epidural steroid injection. The data related to pain and technical performance during the procedure was compared. In addition, the incidence of injection site soreness was assessed 2 wks after transforaminal epidural steroid injection. RESULTS: Sixty-seven patients completed all assessments (group S, n = 33; group D, n = 34). There was no significant difference in procedural pain and discomfort level between the groups (P = 0.151, P = 0.183, respectively). Patients in group D showed lower behavioral pain scores (P = 0.017). There was no significant difference in the numbers of needle manipulations, fluoroscopy time, and radiation dose during the procedure between the groups. Two patients in group S and three in group D complained of injection site soreness after transforaminal epidural steroid injection for a few days, but there was no significant difference in its incidence (P = 0.667). CONCLUSIONS: Deep local anesthesia to reduce procedural pain during transforaminal epidural steroid injection seems to have no significant clinical benefit compared with conventional subcutaneous local anesthesia. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Reduce procedural pain by considering clinical factors of the patient during fluoroscopically guided lumbar transforaminal epidural injections.Upon completion of this article, the reader should be able to: (1) Understand the potential impact of procedural pain on the performance of transforaminal epidural steroid injections; (2) Distinguish cutaneous nociceptive afferents from nociceptive afferents in muscle; and (3) Explain the factors to reduce procedural pain during fluoroscopically guided lumbar transforaminal epidural injections. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Comparing the injectate spread and nerve involvement between different injectate volumes for ultrasound-guided greater occipital nerve block at the C2 level: a cadaveric evaluation.

PURPOSE: The spread patterns between different injectate volumes have not yet been investigated in ultrasound-guided greater occipital nerve (GON) block at the C2 level. This cadaveric study was undertaken to compare the spread pattern and nerve involvements of different volumes of dye using this technique. MATERIALS AND METHODS: After randomization, ultrasound-guided GON blocks with 1 or 5 mL dye solution were performed at the C2 level on the right or left side of five fresh cadavers. The suboccipital regions were dissected, and nerve involvement was investigated. RESULTS: Ten injections were successfully completed. In all cases of 5 mL dye, we observed the deeply stained posterior neck muscles, including the suboccipital triangle space. The suboccipital and third occipital nerves, in addition to GONs, were consistently stained when 5-mL dye was used in all injections (100%). Although all GONs were successfully stained in the 1-mL dye cases, three of five injections (60%) concomitantly stained the third occipital nerves. CONCLUSION: The clinical efficacy of this technique using the 5-mL injectate seems unlikely to arise from the blockade of GON alone. Instead, its efficacy likely arises from the blockade of most nerves originating from the dorsal ramus of the upper cervical spinal nerve at the suboccipital area. Even using 1 mL of injectate may not guarantee blockade of the GON alone.

Predictors of analgesic efficacy of neurolytic celiac plexus block in patients with unresectable pancreatic cancer: the importance of timing.

BACKGROUND: Neurolytic celiac plexus block (NCPB) is a safe and effective method for reducing abdominal cancer pain. However, the analgesic efficacy of NCPB is not always guaranteed. The aim of this retrospective study was to identify predictors for the analgesic efficacy of NCPB in patients with unresectable pancreatic cancer. METHODS: Patients with unresectable pancreatic cancer who underwent NCPB from 2006 to 2015 were enrolled. Good analgesia after NCPB was defined as ≥ 50% reduction in pain score at day 30. Patient demographics, cancer characteristics, and pain-related factors were evaluated using a logistic regression analysis to identify predictors for good analgesia after NCPB. Additionally, survival outcomes were compared between patients with poor and good analgesia after NCPB. RESULTS: A total of 112 patients satisfied the study protocol requirements. Forty-seven patients (41.9%) showed good analgesia after NCPB. Better performance status, lower serum CA 19-9 level, shorter pain duration, and lower opioid dose were observed in patients with good analgesia after NCPB. Good performance status (ECOG performance status 1 vs. 2 or 3, OR = 2.737, 95% CI = 1.149 to 6.518, P = 0.023) and low daily opioid use (< 150 vs. ≥ 150 mg, OR = 2.813, 95% CI = 1.159 to 6.831, P = 0.022) before NCPB were independent predictors of good analgesia after NCPB. The median survival was significantly lower for patients with poor analgesia after NCPB (68 vs. 150 days, P < 0.001). CONCLUSION: NCPB should be offered early to selected patients to improve its analgesic efficacy in advance of deterioration from disease and pain in this population.

Cyanide toxicity during cardiopulmonary bypass with small dose of nitroprusside: a case report.

Sodium nitroprusside (SNP) is an anti-hypertensive drug, commonly used to decrease the systemic vascular resistance and lower the blood pressure. When the amount of cyanide generated by the SNP exceeds the metabolic capacity for detoxification, cyanide toxicity occurs. Under general anesthesia and cardiopulmonary bypass (CPB), it may be difficult to detect the development of cyanide toxicity. In cardiac surgical patients, hemolysis, hypothermia and decreased organ perfusion, which emphasize the risk of cyanide toxicity, may develop as a consequence of CPB. In particular, hemolysis during CPB may cause an unexpected overproduction of cyanide due to free hemoglobin release. We experienced a patient who demonstrated SNP tachyphylaxis and cyanide toxicity during CPB, even though the total amount of SNP administered was much lower than the recommended dose. We therefore report this case with a review of the relevant literature.

Evolution of phase and morphology of titanium dioxide induced from peroxo titanate complex aqueous solution.

We demonstrate the growth of anatase TiO2 in nanospheres and rutile TiO2 in nanorods, by the hydrolysis of titanium tetraisopropoxide (TTIP) in the presence of hydrogen peroxide at 100 degrees C using sol-gel method. X-ray diffraction (XRD), Raman spectroscopy, transmission electron microscopy (TEM), high resolution transmission electron microscopy (HRTEM), selected area electron diffraction (SAED), scanning electron microscopy (SEM), and surface area measurement techniques are used to characterize the phase and shape developments of TiO2 obtained from peroxo titanate complex in an aqueous solution at 100 degrees C. Peroxo titanate complexes were prepared by a reaction of titanium hydroxide, formed by hydrolysis of titanium tetraisopropoxide (TTIP), and different amounts of hydrogen peroxide (H2O2). TEM and XRD investigations reveal that the size of spheres (anatase) and rods (rutile) are about 8 nm (diameter) and about 13 x 29 nm approximately 20 x 75 nm (width x length) respectively. The influence of molar ratio of H2O2/TTIP on the phase and morphology of TiO2 is presented. A mixture of anatase spheres and short rutile rods are formed at low H2O2/TTIP ratio while predominantly rutile a quit long rods are formed at higher H2O2/TTIP ratio.

ZnSe colloidal nanoparticles synthesized by solvothermal method in the presence of ZrCl4.

The nanocrystalline ZnSe was synthesized from precursors of zinc acetate and Se powder in a high boiling trioctylphosphine (TOP), oleic acid, and ZrCl(4) by solvothermal method. The produced ZnSe nanoparticles showed gradual absorption edge shifting towards blue wavelength region as well as transformation of crystal phase from cubic to hexagonal with increasing ZrCl(4) concentrations in precursor solutions. The particle size calculated from XRD measurements for ZnSe nanoparticles was decreased with increasing ZrCl(4) concentrations for a reaction time of 240 min, from 6.5 nm to 5.1 nm whereas from TEM measurements it was 7.0 to 6.1 nm at 0.0 and 22.5 mol% of ZrCl(4), respectively. No trace of zirconium was found in solid ZnSe nanoparticles by SEM-EDS analysis but the atomic percentage of Se with respective to Zn was decreased with increasing ZrCl(4). The absorption edge blue shifting was explained on the basis of decreased particle size. The crystal phase transformation may be due to the combined effect of small internal energy difference between the two phases and the decrease of crystallite size.

Ligand-dependent particle size control of PbSe quantum dots.

Colloidal solutions of monodisperse PbSe quantum dots (QDs) were synthesized by a hot solution chemical method from a reaction mixture of lead oleate and TOPSe (TOP: tri-n-octylphosphine). The synthesis was carried out at a fixed temperature (170 degrees C) and time, while the particle sizes of the PbSe QDs were controlled by using two different kinds of organic ligands with varied chain length. It was seen that the tuning of PbSe QDs are possible by using the proper molar ratio of the co-ligands, such as acetic acid or hexanoic acid, at a fixed reaction temperature and time, verified by TEM and XRD as well as NIR absorption analysis. The effects of different organic acids were studied and the role of additional organic acids might be due to the extent of ligand exchange efficiency between the Pb oleate and acetic/hexanoic acid in the initial stage, which is caused by the steric hindrance effects of the acids.

Core/shell silica-based in-situ microencapsulation: a self-templating method.

Core/shell SiO2 and (RSiO1.5)(1-x)-(SiO2)x (R = alkyl) microcapsules were synthesized via a single-step O/W emulsion system using a self-templating method; the facile synthetic process provides an in-situ encapsulation route for a wide range of lipophilic functional compounds.