Intra-obturator bupivacaine injection and post-operative pain following the trans-obturator tension-free vaginal tape procedure: randomized study.

PURPOSE: To assess the effectiveness of a long-acting anesthetic injection into the obturator membrane for pain relief in women undergoing trans-obturator tension-free vaginal tape. METHODS: A total of 22 women were randomized for the intra-operative injection of bupivacaine into one of their obturator membranes: the left or right side. All the participants were asked to define their groin pain on a visual analog scale (scored 0-10 cm) at 1, 6, 12, and 24 h post-operative. For each woman, pain scores were compared between the local anesthetic-injected side and the opposite side. RESULTS: Statistically significant differences were not observed in groin pain scores between the bupivacaine injection side and the no injection side at 1 h (p = 0.76), 6 h (p = 1), 12 h (p = 0.95), and 24 h (p = 0.82) post-operative. CONCLUSION: In women who undergo trans-obturator tension-free vaginal tape procedures, intra-operative intra-obturator injection of local anesthetics is not effective in alleviating the characteristic post-operative groin pain. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov (NCT03479996).

Effects of topical vs injection treatment of cervical myofascial trigger points on headache symptoms in migraine patients: a retrospective analysis.

BACKGROUND: In migraine patients with cervical myofascial trigger points whose target areas coincide with migraine sites (M + cTrPs), TrP anesthetic injection reduces migraine symptoms, but the procedure often causes discomfort. This study evaluated if a topical TrP treatment with 3% nimesulide gel has similar efficacy as the injection but produces lesser discomfort with higher acceptability by the patients. METHODS: Retrospective analysis of medical charts of M + cTrPs patients in the period January 2012-December 2016 at a single Headache Center. Three groups of 25 patients each were included, all receiving migraine prophylaxis (flunarizine 5 mg/day) for 3 months and symptomatic treatment on demand. Group 1 received no TrP treatment, group 2 received TrP injections (bupivacaine 5 mg/ml at basis, 3rd, 10th, 30th and 60th day), group 3 received daily TrP topical treatment with 1.5 g of 3% nimesulide gel for 15 consecutive days, 15 days interruption and again 15 consecutive days. The following were evaluated: monthly number of migraine attacks and rescue medications, migraine intensity; pain thresholds to skin electrical stimulation (EPTs) and muscle pressure stimulation (PPTs) in TrP and target (basis, 30th, 60th and 180th days); discomfort from, acceptability of and willingness to repeat treatment (end of study). ANOVA for repeated measures and 1-way ANOVA were used to assess temporal trends in each group and comparisons among groups, respectively. Significance level was set at p < 0.05. RESULTS: Migraine improved over time in all groups, but significantly more and earlier in those receiving TrP treatment vs no TrP treatment (0.02 < p < 0.0001, 30-180 days for intensity and rescue medication, 60-180 days for number). All thresholds in the non-TrP-treated group did not change over time, while significantly improving in both the injection and nimesulide gel groups (0.01 < p < 0.0001, 30-180 days). Improvement of migraine and thresholds did not differ in the two TrP-treated groups. Discomfort was significantly lower, acceptability and willingness to repeat treatment significantly higher (0.05 < p < 0.0001) with gel than injection. CONCLUSION: In migraine patients, topical treatment of cervical TrPs with 5% nimesulide gel proves equally effective as TrP injection with local anesthetics but more acceptable by the patients. This treatment could be effectively associated to standard migraine prophylaxis to improve therapeutic outcomes.

Methods to reduce opioid use during surgical treatment of pediatric supracondylar fractures - a pilot study.

BACKGROUND: The current opioid epidemic is a national problem and an increasing concern for pediatric orthopedic patients. The utilization of non-opioid pain methods may help improve the over-prescribing and overuse of opioid medications. The present study is a pain medication usage study that aims to investigate the effects of an intraoperative bupivacaine (BP) fracture injection and IV paracetamol on postoperative opioid consumption when treating supracondylar fractures of the humerus in children. METHODS: The study was approved by the college of medicine's institutional review board (IRB). Forty-two patients treated for a type-III supracondylar extension-type fracture of the humerus by 2 surgeons were reviewed. Two cohorts (n = 21) were compared based on whether patients received an intraoperative fracture injection of BP. A sub-analysis was performed among the BP cohort by stratifying patients who received only BP and patients who received BP and intraoperative IV paracetamol. Data variables evaluated included baseline patient characteristics and postoperative inpatient analgesic use. RESULTS: The BP cohort received a lesser number of opioid doses during the total postoperative hospital stay (2.1 ± 1.8 versus 3.6 ± 2.5; p = 0.031) as well as average morphine-milligram equivalents (MME) (11.8 ± 15.9 versus 4.2 ± 5.2; p = 0.044). When the BP cohort was stratified by patients who did and did not receive intraoperative IV paracetamol, during their total postoperative hospital stay, the paracetamolgroup consumed analgesic medication less frequently (p = 0.005), consumed less opioid doses (p = 0.011), and consumed less morphine-milligram-equivalents of opioids (p = 0.043). DISCUSSION: Opioid abuse and overuse in children is part of a national healthcare crisis. The use of BP injected into the fracture at the time of surgery is safe, effective, and reduces the need for opioids. Furthermore, the combination of intraoperative BP and IV paracetamol demonstrated less utilization of opioids than BP alone.

Monocarboxylate transporter expression at the onset of skeletal muscle regeneration.

The onset of skeletal muscle regeneration is characterized by proliferating myoblasts. Proliferating myoblasts have an increased energy demand and lactate exchange across the sarcolemma can be used to address this increased demand. Monocarboxylate transporters (MCTs) are involved in lactate transport across the sarcolemma and are known to be affected by various physiological stimuli. However, MCT expression at the onset of skeletal muscle regeneration has not been determined. The purpose of this study was to determine if skeletal muscle regeneration altered MCT expression in regenerating tibialis anterior (TA) muscle. Male C57/BL6 mice were randomly assigned to either a control (uninjured) or bupivacaine (injured) group. Three days post injection, the TA was extracted for determination of protein and gene expression. A 21% decrease in muscle mass to tibia length (2.4 ± 0.1 mg/mm vs. 1.9 ± 0.2 mg/mm, P < 0.02) was observed. IGF-1 and MyoD gene expression increased 5.0-fold (P < 0.05) and 3.5-fold (P < 0.05), respectively, 3 days post bupivacaine injection. MCT-1 protein was decreased 32% (P < 0.03); however, MCT-1 gene expression was not altered. There was no difference in MCT4 protein or gene expression. Lactate dehydrogenase (LDH)-A protein expression increased 71% (P < 0.0004). Protein levels of LDH-B and mitochondrial enzyme cytochrome C oxidase subunit decreased 3 days post bupivacaine injection. CD147 and PKC-θ protein increased 64% (P < 0.03) and 79% (P < 0.02), respectively. MCT1 but not MCT4 expression is altered at the onset of skeletal muscle regeneration possibly in an attempt to regulate lactate uptake and use by skeletal muscle cells.