Evaluation of pain experienced during breast ductal endoscopy

PURPOSE: Ductal endoscopy is valuable for the differential diagnosis of bloody nipple discharge; however, the pain associated with this procedure has not been evaluated. This study aims to assess the pain experienced by patients during ductal endoscopy. METHODS: We studied a consecutive series of women who underwent ductal endoscopy, to investigate the cause of bloody nipple discharge. The procedure was performed using standard local anesthesia (lidocaine 1% 10 ml without epinephrine, involving nipple block and periaureolar administration). Patients were asked to score the level of pain with a visual analog scale, 1, 4, 7, 12, 17, 22, 27, and 32 min after the procedure, and describe their overall and maximum pain. RESULTS: This series comprised 20 women aged from 27 to 68 years old. The overall pain (mean +/- SE) score was equal to 5.8 +/-0.3, and the maximum pain score was 8.3 +/- 0.2. The peak of pain corresponded with when the dilator was inserted through the sphincter. The group in which the dilator was inserted after 4 min experienced more intense maximum and overall pain after 7, 12, 17 and 22 min. CONCLUSIONS: Pain is an important factor in ductal endoscopy, and peaks relatively early. A standard, baseline local lidocaine dose of greater than 10 ml may be necessary at the beginning of the procedure. Late insertion of the dilator seems to be an indicator of the force of the procedure.     

Neuropathic Limb Pain and Spinal Cord Stimulation: Results of the Dutch Prospective Study

Baseline and 12‐month follow‐up data from a prospective controlled study on patients treated with SCS for neuropathic limb pain (NLP) are analyzed critically. The outcome on pain, use of medication, and quality of life are reported and compared with the literature. Patients enrolled from April 1999 to December 2001 were part of a quality system study by the Dutch Working Group on Neuromodulation. In two years, more than 400 patients were admitted for several indications of chronic neuropathic pain. Failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) were the largest cohorts. FBSS was defined as persistent limb pain with/or without concomitant minor back pain after prior surgery for a slipped lumbar disc or spinal instability. SCS was a last resort therapy. Two criteria were used for eligibility: a SCL‐90 score below 225 and a mean visual analog score (VAS) of four days according to Jensen of ≥ 5. One hundred sixty nine patients were registered for FBSS. Thirty four did not fulfill the eligibility criteria, and 135 received several questionnaires for baseline evaluation. Thirty patients did not have successful trial stimulation (< 50% pain relief), leaving 105 patients for implantation. The mean scores of the baseline evaluation were: SCL 137 (SD 28.3) and VAS 7.3 (SD 1.2), McGill pain questionnaire (MPQ) total PRI: 22.4 (9.4), Sickness Impact Profile (SIP) total score: 19.4 (SD10.1), ROLAND disability (RD) 16.9 (SD 3.5) and EUROQOL (EQ‐5D) 55.2 (SD 14.5) (simple linear index). Medication quantification scale at intake was 11.5 (SD 7.9). 56.2% of the patients used one or more narcotic drugs at intake. 82% of the patients did not have a paid job at the time of inclusion. 61% of the patients lost their job due to their medical problems. Scores at 12‐m follow‐up were VAS 3.0 (SD 2.4), MPQ 10.8 (SD 8), SIP 11.7 (SD 9.4), EQ‐5D 38.2 (SD 19.2) and RD 12.4 (SD 4.8). The difference between baseline and 12‐m follow‐up is statistically significant for all measures. We conclude that the outcome measures indicate that SCS significantly reduces pain and enhances quality of life in patients having NLP not responding to other adjuvant therapy. Recommendations are proposed to make studies more comparable.     

High affinity binding of an enkephalin analog in the cerebral ganglion of the insectLeucophaea maderae (Blattaria)

Specific high affinity binding sites for a synthetic enkephalin analog, DALA (D-Ala2-Met-enkephalinamide) were demonstrated in the cerebral ganglia of adults and nymphs of the insect Leucophaea. In both sexes binding was monophasic and saturable with respect to the concentration of the radioligand used. The same amount of brain tissue from adult females had 30% more binding sites for DALA than that from adult males. By contrast, no sex-related difference in binding-site density per mg protein was observed in the brains from immature (nymphal) specimens. The results strongly suggest the presence, in this invertebrate, of opiate receptors that appear to be confined to certain areas of the nervous tissue.     

Evolving patterns in the diagnosis of reactive gastropathy: Data from a prospective Central European multicenter study with proposal of a new histologic scoring system

Histologic examination of gastric biopsies is crucial for determining the cause of gastritis. This prospective multicenter study was undertaken to investigate different histologic parameters arguing in favor or against the diagnosis of reactive gastropathy and to correlate findings with patient's symptoms and endoscopic findings. A total of 1123 individuals aged 15–93 years participated in a prospective multicenter study (histoGERD trial). Diagnosis of Helicobacter gastritis was made following the Updated Sydney System. Diagnosis of reactive gastropathy was based upon Dixon's parameters of foveolar hyperplasia, smooth muscle fibers in the lamina propria and vasodilatation and congestion of mucosal capillaries. Including paucity of acute and chronic inflammatory cells in analysis, a new score with visual analog scales for the diagnosis of reactive gastropathy was developed. All three histologic parameters in favor of the diagnosis of reactive gastropathy were positively associated with the endoscopic diagnosis of gastritis (p < 0.001), yet negatively with Helicobacter infection (p < 0.001). In contrast, presence of acute and chronic inflammatory cells in lamina propria was positively associated with Helicobacter infection (p < 0.001), yet not with the endoscopic diagnosis of gastritis. Our score demonstrated strong association between histologic and endoscopic diagnoses (p < 0.001), yet not with patient's symptoms. In conclusion, our data prove foveolar hyperplasia, smooth muscle fibers and vasodilatation and congestion as key histologic parameters for the diagnosis of reactive gastropathy. The proposed score may enhance the diagnostic accuracy. It should be validated in future studies.     

V-EMF treatment of facial scar: First results

Aim of studyThis is a retrospective study aimed at evaluating the effectiveness of the use of electromagnetic fields and negative pressure treatment (V-EMF) for facial scars, from an aesthetic and functional point of view, and considering the variations in the levels of hydration.Material and methods25 subjects with facial scarring were re-evaluated after being treated with the V-EMF method. The hydration levels of the scars before and after treatment were compared. The results were evaluated considering the satisfaction levels of the patients with the VAS, and of the medical specialists who performed the treatment, and of 3 independent dermatologists with the Likert scale.ResultsMean hydration levels of scars went from 41.8 to 53.3, with mean hydration levels of healthy reference points equal to 54.6. The minimum patient satisfaction level was 2 in the VAS. The minimum level of satisfaction of specialists and dermatologists was equal to IV on the Likert scale for all patients, except for 1 subject in which it was III for the specialist who had treated him. Anti-aging and re-pigmentation effects were also noted as secondary results.ConclusionsFrom an aesthetic and functional point of view, and for the overall anti-aging effect of the treated area, V-EMF applied to facial scars has shown extremely promising results.     

The important role of in-situ simulation in preparing surgeons for the COVID-19 pandemic

BackgroundEffective training is vital when facing viral outbreaks such as the SARS Coronavirus 2 (SARS-CoV-2) outbreak of 2019. The objective of this study was to measure the impact of in-situ simulation on the confidence of the surgical teams of two hospitals in assessing and managing acutely unwell surgical patients who are high-risk or confirmed to have COVID-19.MethodsThis was a quasi-experimental study with a pretest-posttest design. The surgical teams at each hospital participated in multi-disciplinary simulation sessions to explore the assessment and management of a patient requiring emergency surgery who is high risk for COVID-19. The participants were surveyed before and after receiving simulation training to determine their level of confidence on a Visual Analog Scale (VAS) for the premise stated in each of the nine questions in the survey, which represented multiple aspects of the care of these patients.Results27 participants responded the pre-simulation survey and 24 the one post-simulation. The level of confidence (VAS score) were statistically significantly higher for all nine questions after the simulation. Specific themes were identified for further training and changes in policy.ConclusionIn-situ simulation is an effective training method. Its versatility allows it to be set up quickly as rapid-response training in the face of an imminent threat. In this study, it improved the preparedness of two surgical teams for the challenges of the COVID-19 pandemic.     

Combination of hydroxyapatite,platelet rich fibrin and amnion membrane as a novel therapeutic option in regenerative periapical endodontic surgery: Case series

IntroductionPeriapical surgery is the last resort in the arsenal of an endodontist to effectively deal with periapical lesions that result from necrosis of the pulp. Bone grafts, growth factors and membranes form an array of regenerative materials that influence the healing outcome of periapical surgery.Presentation of caseThe main purpose of the two cases reported here was to assess the potential benefits of a combination of bone graft, platelet-rich fibrin (PRF) and amnion membrane in terms of reduced post-operative discomfort, radiographic evidence of accelerated periapical bone healing and present a novel therapeutic option in the management of large periapical lesions. Two cases of radicular cysts were treated through a combined regenerative approachof Bio-Gen mix^®, PRF and amnion membrane. The patients were assessed for discomfort immediate post-operatively and after a week. The patients were recalled every month for the next 6 months for radiographic assessment of the periapical healing.DiscussionLiterature is replete with articles that have substantiated the role of demineralized bone matrix comprising a mixture of cancellous and cortical bone graft particles in enhancing regeneration. To the best of our knowledge, there has been no evidence related to the application of a human placental membrane in periapical surgery. Hence, the rationale of using a combined approach of Bio-Gen mix^®, PRF and amnion membrane was to combine the individual advantages of these materials to enhance clinical and radiographic healing outcomes. Our present case reports provide an insight into this novel therapeutic option.ConclusionThe results of this case seriessubstantiatesthe credibility of using a combination ofamnion membrane with a bone graft and PRF to enhance radiographic healing outcome with decreased post-operative discomfort and present a viable regenerative treatment modality in periapical surgery.     

Symptom improvement in dry eye subjects following intranasal tear neurostimulation: Results of two studies utilizing a controlled adverse environment

PurposeTo evaluate the safety and effectiveness of the intranasal tear neurostimulator (ITN) in improving dry eye symptoms assessed in a controlled adverse environment (CAE®).MethodsStudy 1: Multicenter, subject-masked, randomized-sequence, crossover design. Single intranasal (active) and extranasal (control) ITN administration during CAE exposure. Study 2: Single-arm, open-label design. Intranasal ITN administration ≥2 times/day for 45 days, CAE assessment at days 0 and 45. In both studies, upon CAE entry, and every 5 min thereafter, subjects assessed eye dryness score (visual analog scale, 0–100 mm; EDS-VAS), and ocular discomfort score (ODS; Ora Calibra™, 0–4), for ≈2 h. Study 1: when ODS was ≥3 at 2 consecutive timepoints, subjects applied ITN intranasally or extranasally for ≈3 min, and again when achieving the same ODS criteria in randomized sequence. Study 2: days 0 and 45, ITN was applied for ≈3 min employing the same ODS criteria as Study 1.ResultsStudy 1: Significantly greater pre- to post-application reductions in mean [SEM] EDS (−16.5 [1.7] vs −3.1 [1.7], P < 0.0001) and ODS (−0.93 [0.08] vs −0.34 [0.08], P < 0.0001; n = 143) with intranasal vs extranasal stimulation. Study 2: On day 0 (n = 52) and day 45 (n = 48), significant pre- to post-application reductions in mean [SEM] EDS (−15.9 [2.7] and −15.2 [2.4]; P < 0.0001), and ODS (−1.3 [0.2] and −1.3 [0.1]; P < 0.0001). Few device-related adverse events were reported, none serious.ConclusionsAcute symptom relief is significant with the ITN and remains undiminished after daily use.