<Superscript>123</Superscript>I MIBG Mapping with Intraoperative Gamma Probe for Recurrent Neuroblastoma

Intraoperative gamma probe guidance has become widely utilized for sentinel lymph node dissection in patients with breast cancer and melanoma, using ^99mTc sulfur colloid. However, new indications are possible and need to continue to be investigated. We report the use during a wedge liver biopsy of a new hand-held gamma probe designed for ¹²³I intraoperative guidance. The patient studied is a 5-year-old boy with history of stage 4 high-risk neuroblastoma. Anatomic imaging (CT, MRI), ^99mTc bone scintigraphy and 2-deoxy-2-[F-18]fluoro-d-glucose—positron emission tomography/computed tomography (FDG-PET/CT) were negative, but the ¹²³I MIBG scintigraphy suggested recurrent liver disease. A decision was made to biopsy these lesions to obtain histopathological confirmation. Intraoperative gamma probe mapping of the liver identified areas with signal above the background, but these were prove to be hemosiderin deposits on histo-pathology examination.     

Reducing Pain During Emergency Arterial Sampling Using Three Anesthetic Methods: A Randomized Controlled Clinical Trial

BackgroundTaking a sample of arterial blood is widely reported as a cause of significant pain.ObjectivesTo compare three anesthetic methods with standard practice (no anesthesia) to establish which was the most effective in reducing pain caused by radial artery puncture in patients requiring an arterial blood gas test in the emergency department (ED).MethodsA randomized controlled trial was conducted to compare the effectiveness between anesthetic cream, cryoanalgesia, and subcutaneous mepivacaine in reducing pain caused by radial artery puncture in ED patients.ResultsAfter comparing perceived pain during arterial puncture, the lowest median score was obtained in the mepivacaine group (1 interquartile range 0.6–1.3) and the highest median score in the control group (5 interquartile range 4.0–7.0). When comparing the control group with the three intervention groups, the Kruskal-Wallis test showed that mepivacaine (p = 0.023) and cryoanalgesia (p = 0.012) were associated with significantly lower pain scores. The anesthetic cream (p = 0.861) intervention group did not produce a statistically significant median difference compared with the control group.ConclusionsThe results of this study encourage the use of anesthetic methods like cryoanalgesia or mepivacaine for their proven effectiveness in reducing or eliminating pain during arterial puncture.     

临床早期乳腺癌前哨淋巴结活检替代腋清扫术的研究

目的　探讨前哨淋巴结活检术 (sentinellymphnodebiopsy ,SLNB)在乳腺癌治疗中的应用。 方法　使用蓝染料和 /或99mTc标记的硫胶体对 1999年 9月～ 2 0 0 2年 12月山东省肿瘤防治研究院连续收治的 42 3例临床查体腋窝淋巴结阴性乳腺癌患者行前哨淋巴结活检术 ,对 60例患者进行SLNB替代全腋窝淋巴结切除术 (axillarylymphnodedissection ,ALND)的前瞻性研究。结果　SLNB成功率为 98 6% (4 17/4 2 3 ) ,准确率为 93 0 % ,假阴性率为 16 5 %。单纯蓝染料法的分别为98 1% ,91 4%和 2 1 3 % ;联合使用蓝染料和99mTc标记的硫胶体组者分别为 10 0 % ,98 0 %和 4 1%。SLNB的方法对成功率和假阴性率有显著性影响。 60例患者进行了SLNB替代ALND的研究 ,其中 13例因术中发现前哨淋巴结转移而进行AL ND ,SLNB替代ALND者未发现明显术后并发症 ,47例仅行SLNB患者中位随访 8个月 ,未发现腋淋巴结复发者。结论　SLN能够准确预测腋窝淋巴结的转移状况 ,联合法的假阴性率明显低于单用染料法者。SLNB缩小了手术范围、减轻患者术后并发症 ,近期结果良好     

超声引导细针抽吸活组织检查探测乳腺癌前哨淋巴结转移

目的 分析皮下注射超声造影剂对探测乳腺癌患者前哨淋巴结及应用细针穿刺抽吸的意义;探讨乳腺癌前哨淋巴结细针穿刺抽吸的临床价值。 方法 收集经病理证实的乳腺癌患者32例。超声造影后观察前哨淋巴结,记录数目,进行细针穿刺抽吸检测淋巴结转移情况,并与手术病理结果进行比较。 结果 超声造影对前哨淋巴结的检出率为78.13%(25/32)。前哨淋巴结细针穿刺抽吸细胞学病理检查的敏感度为84.00%,特异度为100%,准确率为87.50%。 结论 乳腺癌前哨淋巴结细针抽吸在乳腺癌前哨淋巴结分期中有广阔的应用前景。     

Section 5. Breast: Sentinel lymph node biopsy in breast cancer using technetium-99m tin colloids of different sizes

Axillary lymph node dissection (ALND) in the treatment of breast cancer is essential for predicting the prognosis and regional control of the tumor. At the same time ALND is associated with pain, numbness and sometimes lymphedema. Sentinel lymph node biopsy (SLNB) is a potential alternative procedure to conventional ALND in clinically node-negative breast cancer. In this study, we prepared the technetium-99m-labeled tin colloids with different sizes and compared their efficacy in SLNB. From September 1998 to February 2002, 184 clinically node-negative breast cancer patients were enrolled in the study at Keio University Hospital. Sentinel lymph nodes (SLNs) were identified by both blue dye and radioisotope. We prepared small-sized technetium-99m-labeled tin colloid (particle size: 200–400 nm in diameter). Regular-sized technetium-99m-labeled tin colloid is 400–1000 nm in diameter. In 74 patients, a SLNB was performed using regular-sized tin colloid; small-sized tin colloid was used in 110 patients. Subsequently, all of the patients were immediately followed by ALND. All dissected lymph nodes were evaluated by routine histopathological examination. The clinicopathological characteristics of the two groups were comparable. The lymphoscintigram detected SLN more frequently in the small-sized colloid group than in the regular-sized colloid group (P < 0.01). Small-sized tin colloid was also superior to regular-sized tin colloid in the SLN identification rate (97.3% versus 86.5%; P = 0.01). The mean value for ex vivo counts of the hottest sentinel lymph nodes of the small-sized colloid group was significantly higher than the counts of the regular-sized colloid group (P < 0.01). There was no significant difference in the accuracy between the two groups. It was concluded that SLNB using the small-sized tin colloid was technically feasible and provided higher detection and identification rates than the regular-sized tin colloid.     

The Effects of Dexamethasone on the Time to Pain Resolution in Dental Periapical Abscess

BackgroundDental infections are frequently encountered in the emergency department (ED), with periapical abscesses being among the most painful. Traditional pain management strategies include local anesthetic injections, oral analgesics, and intravenous opioids.ObjectivesWe sought to identify an alternative pain management strategy with early use of dexamethasone as adjunct to conventional therapies for inflammation and pain at the site of infection.MethodsWe conducted a prospective, randomized, double-blind, placebo-controlled study comparing the analgesic effect of dexamethasone and placebo in ED patients with periapical abscess during a 2-year timeframe at two urban academic EDs. Adult patients presenting with physical examination findings consistent with a diagnosis of periapical abscess were randomized to receive oral dexamethasone or an identical placebo. Pain was assessed using the verbal numeric scale in person at discharge and via telephone at 12, 24, 48, and 72 h after discharge from the ED.ResultsSeventy-three patients were enrolled, with 37 receiving dexamethasone and 36 receiving placebo. Follow-up pain scores were obtained for 52 patients at 12, 24, 48, and 72 h. Ten patients from the dexamethasone group and 11 from placebo group were lost to follow-up. Patients who received dexamethasone reported a greater reduction in pain at 12 h compared with the placebo group (p = 0.029). Changes in pain scores from baseline and at 24, 48, and 72 h were not statistically significant. No adverse events were reported.ConclusionsSingle-dose dexamethasone as adjunct to conventional medical management for pain caused by periapical abscess demonstrated a significant reduction in pain 12 h post treatment compared with placebo.     

The Effect of Using Virtual Reality During Breast Biopsy on Pain and Anxiety: A Randomized Controlled Trial

PurposeVirtual reality (VR) is a nonpharmacological method used in healthcare settings. This study aimed to determine the effectiveness of distraction through VR on pain and anxiety during fine needle aspiration (FNA) breast biopsy.DesignThis was a randomized controlled trial.MethodsA total of 60 Turkish females undergoing FNA breast biopsies were randomly divided into two groups. The patients in the experimental group (n = 30) viewed a specific scenario using VR from one minute before the procedure to the end of the procedure. The patients in the control group (n = 30) were subject to a standard protocol in which no anesthetic was given during the procedure. Immediately after the implementation of the FNA breast biopsy, the pain scores of all patients in groups were measured with the Visual Analogue Scale (VAS), and their anxiety levels were assessed with the State-Trait Anxiety Inventory.FindingsA statistically significant difference was determined between the post-procedure mean pain scores and average state anxiety scores of the patients in the experimental and control groups (P < .001).ConclusionsThe use of VR during FNA breast biopsy is effective in reducing pain and anxiety in adult female patients.     

64CuS‐labeled nanoparticles: a new sentinel‐lymph‐node‐mapping agent for PET–CT and photoacoustic tomography

Determining sentinel lymph node (SLN) status is critical to cancer staging and treatment decisions. Currently, in clinical practice, ^99mTc‐radiocolloid‐mediated planar scintigraphy and single‐photon emission computed tomography (SPECT) are used to guide the biopsy and resection of SLNs. Recently, an emerging technique that combines positron emission tomography (PET) and photoacoustic tomography (PAT; PET–PAT) may offer accurate information in detecting SLNs. Herein, we report a kind of ⁶⁴CuS‐labeled nanoparticle (⁶⁴CuS‐NP) for the detection of SLNs with PET–PAT. We subcutaneously injected ⁶⁴CuS‐NPs into the rats’ forepaw pads. After 24 h, the rats’ first draining axillary lymph nodes (i.e. the SLNs) could be clearly visualized with micro‐PET (μPET)–CT. Rats were sacrificed after μPET–CT imaging, their axillary lymph nodes were surgically identified, and then PAT was employed to discover ⁶⁴CuS‐NP‐avid SLNs, which were embedded inside tissues. Biodistribution, autoradiography, and copper staining analyses confirmed the SLNs’ high uptake of ⁶⁴CuS‐NPs. Our study indicates that ⁶⁴CuS‐NPs are a promising dual‐function agent for both PET–CT and PAT and could be used with multi‐modal imaging strategies such as PET–PAT to identify SLNs in a clinical setting. Copyright © 2016 John Wiley & Sons, Ltd.     

乳腺癌前哨淋巴结活检在新辅助化疗后的应用价值

目的通过对比术前未接受化疗和术前接受新辅助化疗两组乳腺癌患者前哨淋巴结活检的结果,探讨对术前接受新辅助化疗后降期的患者以核素法行前哨淋巴结活检的临床价值。方法以本院2006年4月~2009年3月期间收治的99例乳腺癌患者作为研究对象。术前未行化疗组60例,临床分期为T1~2N0M0,直接行前哨淋巴结活检。术前新辅助化疗组39例,临床分期T2~3N0M0,患者术前先给予3~4个疗程的新辅助化疗,降期为T1~2N0M0后再行前哨淋巴结活检。所有患者术前均经乳晕下4点平均注射99m锝标记的非过滤硫胶体,术中用γ探针探测腋窝具有放射活性的前哨淋巴结并切除,然后常规清扫腋窝Ⅰ、Ⅱ组淋巴结。术后对前哨淋巴结活检和腋窝淋巴结清扫的病理结果进行比较分析。结果A组成功率、假阴性率、灵敏度、特异度、准确性、阳性预测值和阴性预测值分别为98.3%、3.3%、96.7%、100%、98.3%、100%和96.7%。B组分别为100%、10%、90%、100%、94.9%、100%和90.5%。两组比较假阴性率、准确性均无统计学差异。(P均>0.05)。结论对新辅助化疗后降期的局部进展期乳腺癌患者,以核素法行前哨淋巴结活检仍能够获得较高的成功率,同早期乳腺癌患者相比假阴性率没有统计学差异。     

Section 5. Breast: Sentinel node biopsy for breast cancer patients in Japan

Sentinel node biopsy may become a standard procedure to detect lymph node metastases in early breast cancer. Numerous studies have confirmed and demonstrated the reliability of the hypothesis of sentinel node biopsy, with a high identification rate and overall accuracy connected with dye-guided and radio-guided sentinel node biopsy. To assess the benefit of sentinel node biopsy, randomized clinical trials are underway in Western countries comparing sentinel node biopsy with conventional axillary lymph node dissection. In Japan, feasibility studies on sentinel node biopsy started in the mid-1990s. The dye and radiopharmaceuticals associated with sentinel node biopsy commonly used in Western countries are not available in Japan. Japanese investigators have attempted to perform sentinel node biopsy using other dyes and radiopharmaceuticals. The results from feasibility studies have been similar to those reported previously. In conclusion, sentinel node biopsy for breast cancer patients is successful in Japan. The current status and the problems are discussed.     

Gastric lymphatic basin dissection for sentinel node biopsy using hybrid natural orifice transluminal endoscopic surgery (NOTES)

Abstract

The aim of the present study was to describe a method of gastric lymphatic basin dissection for sentinel node biopsy using natural orifice transluminal endoscopic surgery with laparoscopic assistance (hybrid NOTES) in a porcine model. Lymph node dissection was performed in three healthy female domestic farm pigs (each around 40 kg) between October, 2007, and December, 2007. The pigs were administered a general anesthetic and laparoscopy-guided transvaginal colpotomy was performed. A two-channel endoscope was then inserted through the incision into the peritoneal cavity via the transvaginal route. An endoscope was inserted simultaneously into the mouth and indocyanine green solution was injected into the submucosal layer of the gastric wall at four sites. Dyed omentum and lymphatics were dissected using a laparoscopic dissector and the grasping forceps of a transvaginal endoscope. Lymphatics and omentum (mean 13.3 cm, range 8–20 cm) were removed transvaginally. The mean number of detected and resected sentinel nodes was 2.6 (range 1–4, diameter 2～12 mm). Sentinel lymphatic basin dissection was performed successfully and without intraoperative complications in all three cases. Hybrid NOTES is technically feasible, and this procedure may represent an alternative to laparoscopic sentinel lymph node dissection of the stomach.     

Exploration of the Nociception Level (NOL™) Index for Pain Assessment during Endotracheal Suctioning in Mechanically Ventilated Patients in the Intensive Care Unit: An Observational and Feasibility Study

BackgroundMany patients in the intensive care unit (ICU) suffer from pain and are non-communicative. Therefore, alternative pain measures are necessary. Although behavioral pain measures are available, physiological measures are lacking. The Nociception Level index (NOL™) provides a value from combination of multiple physiological parameters to measure pain and its use in the ICU is new.AimTo explore the use of a multiple physiological parameter measure for pain assessment, the NOL™ index, in mechanically ventilated patients able to self-report pain in the ICU.MethodsA prospective cohort study was performed. Data were collected before, during, and 15 minutes after a non-nociceptive procedure (noninvasive blood pressure using cuff inflation) and a nociceptive procedure (endotracheal suctioning). NOL index, 0 to 10 pain intensity, and Critical-Care Pain Observation Tool (CPOT) scores were also obtained. Data were analyzed using Friedman and Mann-Whitney tests. Feasibility of study procedures was described.ResultsOut of 28 patients who consented, 17 remained eligible and data were analyzed for 15. Technical issues prevented obtaining a NOL signal in 2 patients. NOL values were higher during endotracheal suctioning (median = 41.6) compared with before (median = 11.2) and after the procedure (median = 11.8) and compared with cuff inflation (median = 15.1; Friedman test, p < .001). NOL values were associated with pain intensity and CPOT scores (Mann-Whitney tests, p < .05).ConclusionsThe study procedures with the NOL were found feasible; NOL values could discriminate between nociceptive and non-nociceptive procedures, and values were associated with reference pain measures. Further NOL testing is required in other ICU patient groups and procedures.     

抗人粒细胞单克隆抗体的研制和鉴定及其放射免疫显像

以人粒细胞常规免疫和融合BALB／c小鼠，建立一株稳定的高效价的抗人粒细胞单克隆抗体杂交瘤细胞株SZ-102，并对其组织特异性进行签定及探讨在炎症模型显像中的潜在价值。结果表明，McAb SZ-102免疫球蛋白亚类为IgGl。流式细胞术测定显示其与外周血液中的粒细胞和单核细胞呈强阳性反应，而与淋巴细胞、红细胞和血小板不起反应，但与正常人骨髓中的较成熟的粒细胞、单核前体细胞发生反应。SP免疫组化法检测正常人组织切片中Sz-102抗原阳性细胞分布的结果显示，该抗原主要表达在肝、肺、脾、胸腺、淋巴结组织个的巨噬细胞表面。以亚氨基建咏(2—IT)修饰，99Tcm标记葡庚糖酸钠(GH)配体交换法标记SZ-102。给具有左下肢炎症模型的家兔，由耳缘静脉注入99Tcm-抗人粒细胞单克隆抗体SZ-102进行SPECT显像，以99Tcm标记非特异性鼠IgG作为阴性对照，结果表明99Tcm-Sz-102在家兔炎症部位显像清晰，其最佳显像时间为注射后2—4小时，而四Tcm标记非特异性鼠IgG在家兔炎症部位未能清晰显像。结论：99Tcm-SZ-102具有活体内炎症定位导向能力，显像时间短，对隐匿性炎症疾病或肿瘤感染病灶的放射免疫显像诊断有一定的潜在临床价值。     

Lung clearance of inhaled aerosol of Tc‐99m‐methoxyisobutyl isonitrile: relationships with cigarette smoking,age and gender

Tc‐99m‐methoxyisobutyl isonitrile (Tc‐99m‐MIBI) is a radiolabelled xenobiotic, the disappearance rate of which from lungs following inhalation as a radioaerosol correlates inversely with bronchopulmonary multidrug resistance protein 1 (MRP1) expression. Tc‐99m‐MIBI clearance has previously been shown to be delayed in cigarette smokers. The aim of the current study was to determine whether smoking correlates with bronchopulmonary MRP1 expression, to confirm that Tc‐99m‐MIBI disappearance rate from the lungs following inhalation is delayed in smokers, and to determine the effects of gender and age on disappearance rate. Participants underwent dynamic imaging for 40 min over the lungs following inhalation of Tc‐99m‐MIBI using a double‐headed gamma camera. The half‐time of clearance was obtained from geometric mean of anterior and posterior counts and averaged between the two lungs. Paraffin‐embedded tissue obtained from healthy lung during surgery in 13 patients was graded immunohistochemically for MRP1 as negative (0), weak (1), moderate (2) or strong (3). In 4 non‐smokers, grading was 1 in three and 0 in one. In 9 smokers, in contrast, expression was graded 2–3 in 8 and 1 in one (P<0·02). Mean clearance half‐time in smokers (142 ± 29 min; n = 17) was longer than in non‐smokers (91 ± 14 min; n = 18; P<0·0001). In non‐smokers, half‐times were not significantly different between men (96 ± 16; n = 6) min and women (88 ± 12 min; P = 0·2). Combining genders into one group, half‐time correlated with participant age (P = 0·0005). We conclude that smoking upregulates MRP1 and delays clearance of inhaled Tc‐99m‐MIBI. There is no significant gender difference in non‐smokers but ageing is associated with longer clearance half‐times.     

乳腺癌前哨淋巴结活检指导腋窝淋巴结清扫

目的探讨前哨淋巴结活检（SLNB）对乳腺癌腋窝淋巴结（ALN）转移状态的预测价值,为指导乳腺癌患者是否行腋窝淋巴结清扫（ALND）提供科学依据。方法2005～2008年本院手术治疗的乳腺癌患者36例患者,采用术前2 h注射99M锝-右旋糖苷（99M Tc-dx）1 ml于肿瘤周围腺体内和术中1%亚甲蓝2 ml（总剂量）四点法注射于肿瘤覆盖皮肤之皮内,术中前哨淋巴结活检,随后行包括ALND的不同方式的根除术。所有前哨淋巴结（SLN）术中冷冻病理检查为单切片HE染色,所有SLN和非SLN均再行多层切片HE染色及免疫组织化学病理学检查。结果根据术中切片病理和术后腋窝淋巴结病理,SLN检出成功率为94.4%（34/36）;SLN预测ALN转移的准确性为94.1%（32/34）,灵敏度为85.7%（12/14）,特异性为100%（20/20）,假阴性率为14.3%（2/14）,总的阳性、阴性预测值分别为100%（12/12）和90.9%（20/22）。与单切片HE染色相比,多层切片HE染色和免疫组织化学检查使灵敏度提高至92.9%（13/14）,假阴性率降低至7.14%（1/14）。结论亚甲蓝法和放射性示踪法联合应用能准确检测出SLN,SLN能反映腋窝淋巴结的状态。术中多层切片HE染色可降低前哨淋巴结假阴性率。     

早期乳腺癌腋窝前哨淋巴结活检阴性保留腋窝淋巴结与腋窝淋巴结清扫的非随机对照临床研究

目的探讨前哨淋巴结活检术替代腋窝巴结清扫术在早期乳腺癌手术中应用的可行性。方法对2006年1月至2010年12月临床52例T1-2N0M0乳腺癌患者行前哨淋巴结活检术,25例前哨淋巴结阴性患者不行腋窝清扫,27例前哨淋巴结阴性患者加做腋窝清扫术。结果不行腋窝清扫患者术后并发症发生率低于腋窝清扫患者,随访6月至5年,未发现腋窝淋巴结复发患者,所有患者均健在。结论腋窝前哨淋巴结活检可以缩小手术范围,减少患者术后并发症。腋窝前哨淋巴结活检阴性可替代腋窝清扫术。     

乳腺癌前哨淋巴结解剖学定位及其临床意义的研究

目的探讨乳腺癌前哨淋巴结（sentinel lymphnode,SLN）解剖学定位及临床意义,为临床提供参考。方法回顾性分析2011年1月至2012年7月行乳腺癌前哨淋巴结活检患者152例,染料组术前15min将1％亚甲蓝2m1注射在肿瘤周围皮下组织的方法检测前哨淋巴结;观察组在染料法的基础上联合核素法,参照腋窝淋巴结结果,计算2组前哨淋巴结活检的诊断准确性、敏感度和假阴性率,分析前哨淋巴结的解剖学定位和前哨淋巴结活检的临床意义。结果观察组和染料组检出率、灵敏度、假阴性率及阳性预测率进行比较,其中检出率和假阴性率,差异有统计学意义（P〈0．05）;而两组的灵敏度及阳性预测率,差异无统计学意义（P〉0．05）。结论采用染料法联合核素法检测前哨淋巴结,是最可靠的定位方法,值得临床推广应用。     

磁共振间质淋巴造影诊断乳腺癌腋窝淋巴结转移

目的 探讨MR间质淋巴造影诊断乳腺癌腋窝淋巴结转移的价值。方法 对36例浸润性乳腺癌患者于术前行MR间质淋巴造影检查,观察前哨淋巴结（SLN）、乳腺引流淋巴管情况;术中在美蓝引导下行SLN活检;根据活检结果评价MR间质淋巴造影显示 SLN的效果及诊断腋窝淋巴结转移敏感度、特异度及准确率。结果 MR间质淋巴造影显示每例患者SLN平均（1.33±0.53）枚,美蓝为示踪剂显示SLN 平均（1.19±0.47）枚,差异无统计学意义（t=1.711,P=0.096）。MR间质淋巴造影判断淋巴结转移阳性10例,术后病理结果全部为淋巴结转移;淋巴造影阴性25例,24例术后病理结果未见转移,1例为假阴性。MR间质淋巴造影诊断乳腺癌患者淋巴转移的敏感度为90.91%（10/11）,特异度为100%（24/24）,准确率为97.14%（34/35）。结论 MR间质淋巴造影能有效、可靠地显示乳腺癌引流区域淋巴管、淋巴结并判断良恶性,具有较好发展前景。     

Effectiveness of nitrous oxide and analgesic cream (lidocaine and prilocaine) for prevention of pain during intramuscular botulinum toxin injections in children

AimsTo evaluate the effectiveness of an analgesic protocol with nitrous oxide and anaesthetic cream (lidocaine and prilocaine, EMLA) for children undergoing botulinum toxin injections.Patients and methodsProspective study including 51 injection sessions, 34 children with a mean age of 5.94 (range 2–15) and 209 injected muscles. Pain was evaluated with the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), the Visual Analogue Scale (VAS) and the Face Pain Scale (FPS) for the children and with a VAS for the parents.ResultsCHEOPS score for the 51 sessions was 8.50 (S.D. 3.56). Forty-nine percent of scores were above the therapeutic threshold of 9; 25% of the children evaluated the pain above the therapeutic threshold of 3; 44.74% of the parents’ estimations exceeded 3. No correlation was found between age, weight, number of injected muscle and CHEOPS score.ConclusionThe association of MEOPA and anaesthetic cream is only effective for 50% of children. This is much lower than treatments for other types of acute induced pain in children. Botulinum toxin injections and cerebral palsy children present certain specificities which require improvements in this analgesic protocol.     

Dynamic Visualization of Lymphatic Channels and Sentinel Lymph Nodes Using Intradermal Microbubbles and Contrast‐Enhanced Ultrasound in a Swine Model and Patients With Breast Cancer

Objective. Sentinel lymph node (SLN) identification using intradermal micro‐bubbles and contrast‐enhanced ultrasound (CEUS) has been recently reported in swine models and patients with breast cancer. The objective of this study was to investigate the dynamics of intradermally administered microbubbles as they travel to draining SLNs in pigs. We also performed a detailed study of the passage of microbubbles through breast lymphatic channels in a small group of patients with breast cancer. Methods. Nine anesthetized healthy pigs were used for the study, and 5 female patients with primary breast cancer were recruited. Pigs received intradermal injections of a microbubble contrast agent in several territories to access lymphatic drainage to regional lymph nodes. Patients had periareolar intradermal injection of the microbubble contrast agent. Ultrasound examination was performed in the real‐time contrast pulse sequencing mode with a commercial scanner. Results. Sentinel lymph nodes were identified rapidly (<1 minute) and consistently in pigs. Intradermal microbubble injection and CEUS were found to have perfect concordance with the Evans blue dye method in locating swine SLNs. In all 5 patients with breast cancer, the microbubble contrast agent entered breast lymphatic channels and traveled to draining ipsilateral axillary SLNs within 3 minutes. Conclusions. Intradermally injected microbubbles traverse readily though lymphatic channels in pigs and human breast tissue. The ability to rapidly identify SLNs in the diagnostic period would enable targeted biopsy and may facilitate preoperative axillary staging in patients with early breast cancer.