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We report the anaesthetic management of a female patient with Spinal Muscular Atrophy (SMA) presented for laparoscopic cholecystectomy. In order to avoid prolonged recovery; we chose to use total intravenous anaesthesia (TIVA) with propofol and remifentanil. No neuromuscular blocking agent was used.

Background: The Chronic Pain Grade Questionnaire (CPGQ) was developed to assess the global severity of chronic pain based on pain intensity and pain-related disability. This study aimed to translate, culturally adapt, and validate the Greek version of the CPGQ (CPGQ-Gr). Methods: Adaptation into Greek followed established guidelines. We invited orthopedic outpatients suffering from chronic hip pain to participate in the study. The validity, reliability, and responsiveness of the CPGQ-Gr were assessed. Results: Factor analysis yielded two factors (subscales), disability score (DS) and characteristic pain intensity (CPI). CPGQ-Gr items, total and subscale scores were highly correlated with the 12-Item Short Form Health Survey (SF-12) physical component summary score, and slightly correlated or not correlated with the SF-12 mental component summary score. Cronbach's alpha correlation coefficients for the CPGQ-Gr total scale, DS, and CPI subscales were 0.90, 0.95, and 0.83 respectively. All measures showed excellent temporal stability (intraclass correlation coefficients of 0.84, 0.92, and 0.91, respectively). Cliff's delta effect sizes ranged from 0.47 to 0.82. The values of the area under the receiver operating characteristic curve were consistent with good to excellent discriminatory ability (range: 0.747-0.902). Conclusion: Our findings suggest that the Greek version of the CPGQ is a valid, reliable, and sensitive to changes, instrument for grading the severity of chronic hip pain. [ABSTRACT FROM AUTHOR]

Background: Nitric oxide (NO) is considered a means of detecting airway hyperresponsiveness, since even non-asthmatic patients experiencing bronchospasm intraoperatively or postoperatively display higher levels of exhaled NO. It can also be used as a non-invasive biomarker of lung inflammation and injury. This prospective, single-blind, randomized study aimed to evaluate the impact of two different anesthesia maintenance techniques on fractional exhaled nitric oxide (FeΝO) in patients without respiratory disease undergoing total thyroidectomy under general anesthesia. Methods: Sixty patients without respiratory disease, atopy or known allergies undergoing total thyroidectomy were randomly allocated to receive either inhalational anesthesia maintenance with sevoflurane at a concentration that maintained Bispectral Index (BIS) values between 40 and 50 intraoperatively or intravenous anesthesia maintenance with propofol 1% targeting the same BIS values. FeΝO was measured immediately preoperatively (baseline), postoperatively in the Postanesthesia Care Unit and at 24 h post-extubation with a portable device. Other variables measured were eosinophil blood count preoperatively and postoperatively and respiratory parameters intraoperatively. Results: Patients in both groups presented lower than baseline values of FeΝO measurements postoperatively, which returned to baseline measurements at 24 h post-extubation. In the peripheral blood, a decrease in the percentage of eosinophils was demonstrated, which was significant only in the propofol group. Respiratory lung mechanics were better maintained in the propofol group as compared to the sevoflurane group. None of the patients suffered intraoperative bronchospasm. Conclusions: Both propofol and sevoflurane lead to the temporary inhibition of NO exhalation. They also seem to attenuate systemic hypersensitivity response by reducing the eosinophil count in the peripheral blood, with propofol displaying a more pronounced effect and ensuring a more favorable mechanical ventilation profile as compared to sevoflurane. The attenuation of NO exhalation by both agents may be one of the underlying mechanisms in the reduction in airway hyperreactivity. The clinical significance of this fluctuation remains to be studied in patients with respiratory disease.

Background: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery., Methods: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations., Results: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92)., Conclusions: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes., Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong., Competing Interests: Competing interests: SGM is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Society of Anesthesia and Sleep Medicine (SASM). He is a one-time consultant for Sandoz and the holder of US Patent Multicatheter Infusion System. US-2017-0361063. He is the owner of SGM Consulting, LLC and Centauros Healthcare Analytics and Consulting. SGM is also a shareholder in Parvizi Surgical Innovations LLC and HATH. None of the above relations influenced the conduct of the present project., (© American Society of Regional Anesthesia & Pain Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction Increasing the duration of regional anesthesia in orthopedic surgery is of vital importance, as it prolongs postoperative analgesia, allowing faster rehabilitation of patients. Dexamethasone has been found to extend the block duration in animal and human studies. The aim of this study is the assessment of the effect of the addition of dexamethasone to ropivacaine on the onset and duration of axillary brachial plexus block, along with the intensity of postoperative pain. Methods Forty patients undergoing below-elbow surgery under ultrasound-guided axillary brachial plexus block were randomly allocated to receive either 30 mL ropivacaine 0.75% with 2 mL of saline (Group A, n = 20) or 30 mL ropivacaine 0.75% with 2 mL of dexamethasone (4 mg) (Group B, n = 20). Sensory and motor blockade were assessed, with the use of the pinprick test and the modified Bromage scale, at five, 10, 15, and 20 min after the block. The duration of analgesia, intensity of postoperative pain, postoperative opioid consumption, overall satisfaction, and perioperative complications were compared between the two groups. Results We found no difference at the mean onset time of the sensory and motor block between the two groups. The mean duration of postoperative analgesia was three hours higher in the dexamethasone group (15.85 ± 4.82 versus 11.75 ± 6.81, p-value = 0.035). Pain intensity was lower in the dexamethasone group, at six and 12 hours after surgery (3.45 ± 1.79 versus 4.65 ± 1.79, p-value = 0.040). Postoperative opioid consumption, patient overall satisfaction, and perioperative complications were not significantly different between groups. Conclusions Dexamethasone prolongs the duration of ropivacaine in an axillary brachial plexus block and decreases postoperative pain in patients subjected to below-elbow surgery., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Chazapi et al.)

Study Objective: Chronic postsurgical pain (CPSP), i.e. pain persisting >3 months, may appear after any type of surgery. There is a paucity of literature addressing CPSP development after hip fracture repair and the impact of any analgesic intervention on the development of CPSP in patients after hip fracture surgery. This study is the first aiming to examine the impact of ultrasound-guided fascia iliaca compartment block (USG FICB) on the development of CPSP after hip fracture repair., Design: Prospective randomized study., Setting: Operating room., Patients: 182 patients scheduled for hip fracture surgery., Interventions: Patients were randomized to receive a USG FICB (FICB group) or a sham saline injection (sham FICB group), twenty minutes before positioning for spinal anesthesia., Measurements: The hip - related characteristic pain intensity (CPI) at 3- months post-surgery was the primary outcome measure. Presence and severity of hip-related pain at 3- and 6-months post-surgery, numeric rating pain scale (NRS) scores at 6, 24, 36, 48 postoperative hours, total 24-hour tramadol PCA administration and timing of the first tramadol dose, were documented as well., Main Results: FICB group presented with lower CPI scores 3- months postoperatively (p < 0.01), as well as lower percentage of patients with high-grade CPSP, 3 and 6 months postoperatively (p < 0.001). FICB group also showed significantly lower NRS scores in all instances, lower total 24 - hour tramadol consumption and higher mean time to first tramadol dose (p < 0.05). The overall sample of 182 patients reported a considerably high incidence of hip -related CPSP (60% at 3 months, 45% at 6 months)., Conclusions: USG FICB in the perioperative setting may reduce the incidence, intensity and severity of CPSP at 3 and 6 months after hip fracture surgery, providing safe and effective postoperative analgesia., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest and no sources of funding for this manuscript., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes., Methods: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations., Results: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87., Conclusions: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation., Recommendation: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty., Trial Registry Number: PROSPERO CRD42018099935., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objectives: To describe the functional recovery of consecutive inpatients with Critical Illness Polyneuropathy (CIP) at the time-point of the discharge from rehabilitation units according to Barthel Index scores. To examine whether age, gender, pre-ICU admission diagnosis, tracheostomy performance, heterotopic ossification development and duration of neuro-rehabilitation treatment are among the prognostic factors that can predict the functional outcome in studied patients., Methods: A retrospective observational clinical study from January 2010 to December 2014 in three rehabilitation units in Greece., Results: Sixteen subjects (57.1%) had >60 BI discharge scores, showing a prospect in gaining further independence. Females presented a tendency for better functional outcome vs males (73.8 ± 12.6 vs 58.6 ± 23.4, p=0.082). Respiratory, septic and neurologic patients demonstrated better rates of functional improvement after the rehabilitation process vs cardiac patients (p minor than 0.001, p=0.009 and p=0.019, respectively vs p=0,072). Heterotopic ossification development proved to be an adverse independent prognostic factor of functional outcome (47.8 ± 25.7 vs 68.8 ± 17.7, p=0.023)., Conclusions: A proportion of included patients experienced severe disability with poor prospect of further functional development and return to work at the discharge from the rehabilitation units. According to the present study, which is the first that focuses only on CIP and its outcome, specific prognostic factors can be defined. Our results can be used as pilot data for larger studies, so that firmer conclusions can be drawn., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by Aracne Editrice, Roma, Italy.)

Background: This prospective double-blind randomized study aimed at evaluating the short- and long-term postoperative analgesic efficacy of the ultrasound-guided tranversus abdominis plane (TAP) block in inguinal hernia repair under general anesthesia., Methods: Sixty patients undergoing inguinal hernia repair were allocated to TAP block with either ropivacaine 0.75% 20 mL or placebo 20 mL. Postoperatively, they had access to a patient-controlled analgesia (PCA) device administering 1 mg doses of morphine as rescue analgesia. Pain was assessed at rest and during movement with the numeric rating scale (NRS) score 3,6 and 24 hs postoperatively. Other variables recorded were intraoperative dose of remifentanil required to maintain systolic arterial pressure within 20% of baseline, mg of morphine used in the Post Anesthesia Care Unit (PACU) and total dose of morphine administered via the PCA device. Six months after surgery, the occurrence of chronic pain was assessed with the NRS score at rest and during movement. Patients were also asked to fill in the DN4 questionnaire to estimate the development of neuropathic pain., Results: Patients who were administered ropivacaine demonstrated significantly less pain at rest and on movement, as expressed by NRS scores in comparison to patients in the placebo group. The former group also required less remifentanil intraoperatively, less morphine during the PACU stay and had lower morphine consumption through the PCA device. Six months after surgery, pain scores at rest and during movement were comparable between the two groups. At the same time DN4 scores were low and comparable between the two groups., Conclusion: Ultrasound-guided TAP block provided better pain control than placebo in the acute setting after inguinal hernia repair. However, the incidence of chronic pain was low and not significantly affected by the performance of the block., (Copyright © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Current evidence regarding the effects of selective cyclooxygenase inhibitors on gastrointestinal anastomoses is controversial. An experimental randomized control study was conducted in our institution to histopathologically evaluate the consequences of parecoxib, on intestinal and abdominal wound healing., Methods: Twenty-four adult Wistar rats underwent laparotomy, ascending colon transection, and hand-sewn anastomosis. They were randomized to receive either parecoxib (0.5 mg/kg twice daily) or 0.9% normal saline by intraperitoneal injection postoperatively. Animals were euthanatized either on the third or the seventh postoperative day. Semiquantitative methods were used to evaluate both intestinal and abdominal wounds for inflammatory cell composition, angiogenesis, fibroblasts, granular tissue, collagen deposition, epithelization, and presence of necrosis, exudate, and abscess formation. Results are presented as (parecoxib: median [IQR] versus control: median [IQR], P-value)., Results: No macroscopic anastomotic leakage or wound dehiscence was observed. Intestinal anastomoses in the parecoxib group, showed significantly decreased epithelization (2 [1] versus 3 [1], [P = 0.004]) and collagen deposition (2 [0] versus 3 [1], [P = 0.041]). No difference was observed in angiogenesis (3 [1] versus 2.5 [1], [P = 0.158]). Abdominal wall specimens appeared to demonstrate decreased epithelization (2 [2] versus 4 [0.5], [P = 0.0004]) in the treatment group. No difference between the two groups was identified regarding collagen deposition (2.5 [1] versus 2 [0.5], [P = 0.280]) and angiogenesis (2.5 [1] versus 2 [1], [P = 0.633]). Necrosis was significantly more present in the parecoxib group in both specimen types, (3.5 [1] versus 2.5 [1], [P = 0.017]) and (3 [1] versus 1 [0.5], [P < 0.0001])., Conclusions: The present study shows that despite the absence of clinical adverse effects, parecoxib can impair anastomotic and abdominal wound healing on a histopathological level., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: While reduction of portal venous (PV) blood flow has been described in animal models of intra-abdominal hypertension, reports on compensatory changes in hepatic arterial (HA) flow, known as the hepatic arterial buffer response are controversial., Materials and Methods: Pneumoperitoneum with helium was induced in 13 piglets. Hemodynamic measurements and pathological assessment were conducted at baseline and during the three subsequent phases: Phase A: 45 minutes with a stable intra-abdominal pressure of 25 mmHg; phase B: 45 minutes with a stable intra-abdominal pressure of 40 mmHg; and phase C during which the abdomen was re-explored and reperfusion of the liver was allowed to take place., Results: Phase B pressure was significantly greater than phase A pressure in both the PV and the inferior vena cava, demonstrating a positive association between escalating intra-abdominal hypertension and the pressure in these two vessels (all p<0.001). In contrast, HA pressure was comparable between baseline and phase A, while it tended to decrease in phase B. Regarding histology, the most notable abnormality was the presence of inflammatory infiltrates and hepatocyte necrosis., Conclusion: Helium-insufflation increased PV pressure with a partial compensatory decrease of HA pressure. Nonetheless, findings consistent with hepatic ischemia were observed on pathology., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The Chronic Pain Grade Questionnaire (CPGQ) was developed to assess the global severity of chronic pain based on pain intensity and pain-related disability. This study aimed to translate, culturally adapt, and validate the Greek version of the CPGQ (CPGQ-Gr).  Methods: Adaptation into Greek followed established guidelines. We invited orthopedic outpatients suffering from chronic hip pain to participate in the study. The validity, reliability, and responsiveness of the CPGQ-Gr were assessed., Results: Factor analysis yielded two factors (subscales), disability score (DS) and characteristic pain intensity (CPI). CPGQ-Gr items, total and subscale scores were highly correlated with the 12-Item Short Form Health Survey (SF-12) physical component summary score, and slightly correlated or not correlated with the SF-12 mental component summary score. Cronbach's alpha correlation coefficients for the CPGQ-Gr total scale, DS, and CPI subscales were 0.90, 0.95, and 0.83 respectively. All measures showed excellent temporal stability (intraclass correlation coefficients of 0.84, 0.92, and 0.91, respectively). Cliff's delta effect sizes ranged from 0.47 to 0.82. The values of the area under the receiver operating characteristic curve were consistent with good to excellent discriminatory ability (range: 0.747-0.902)., Conclusion: Our findings suggest that the Greek version of the CPGQ is a valid, reliable, and sensitive to changes, instrument for grading the severity of chronic hip pain. HIPPOKRATIA 2018, 22(1): 37-42., Competing Interests: The authors declare that they have no conflict of interest.

Background and Aim: The Fibromyalgia Rapid Screening Tool (FiRST) is a brief, simple, and straightforward self-administered questionnaire that was developed by Perrot et al. for the detection of fibromyalgia syndrome in patients with diffuse chronic pain. The aim of our study was to develop and validate the Greek version of FiRST., Methods: The study was set up as a prospective observational study. The original French version of FiRST was adapted into Greek using forward and backward translation. Patients with chronic diffuse pain with a clinical diagnosis of fibromyalgia and osteoarthritis based on the criteria of the American College of Rheumatology were invited to participate to the study., Results: Of the 101 patients who met our inclusion criteria, 42 were diagnosed with fibromyalgia and 59 with osteoarthritis. The 2 groups did not differ significantly regarding gender and pain characteristics (duration, intensity). Cronbach's alpha coefficient was 0.79. Receiver operating characteristic analysis showed an area under the curve of 89% (95% confidence interval = 83 to 95%; SE: 0.032, P < 0.001). At a cutoff score of ≥ 5, FiRST showed a sensitivity of 86%, a specificity of 83%, a positive predictive value of 78%, and a negative predictive value of 89%. The intraclass coefficient for the test-retest reliability was 0.96., Conclusion: The Greek version of FiRST is a valid screening tool for fibromyalgia in daily practice., (© 2016 World Institute of Pain.)

Introduction and Aim. With the implementation of multimodal analgesia regimens, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are often administered for optimal pain control and reduction of opioid use. The aim of the study was to examine the effects of lornoxicam, a NSAID, on anastomotic healing employing an animal model. Materials and Methods. A total of 28 Wistar rats were randomly assigned in two groups. All animals underwent ascending colonic transection followed by an end-to-end hand sewn anastomosis. Group 1 received intraperitoneally lornoxicam before and daily after surgery. Group 2 received intraperitoneally an equal volume of placebo. Half of the animals in each group were euthanized on the 3rd pod and the remaining on the 7th pod. Macro- and microscopic indicators of anastomotic healing were compared using a two-tailed Fisher exact test. Results. The lornoxicam group significantly decreased fibroblast in growth and reepithelization of the mucosa at the anastomotic site on the 3rd pod and significantly increased occurrence of deep reaching defects, necrosis, and microabscess on the 7th pod. Conclusion. Lornoxicam administration during the perioperative period adversely affects histologic parameters of intestinal anastomotic healing. These effects of lornoxicam administration were not found to induce significant increase of anastomotic dehiscence in the rat model.

Background: The Douleur Neuropathique 4 questionnaire (DN4) was developed by the French Neuropathic Pain Group and is a simple and objective tool, primarily designed to screen for neuropathic pain. The aim of our study is to validate the DN4 in the Greek language., Methods: The study was set up as a prospective observational study. Two pain specialists independently examined patients and diagnosed them with neuropathic, nociceptive, or mixed pain, according to the International Association for the Study of Pain (IASP) definitions. A third and a fourth physician administered the DN4 questionnaire to the patients., Results: Out of the 237 patients who met our inclusion criteria and had identical diagnoses regarding the type of pain, 123 were diagnosed with neuropathic, 59 with nociceptive, and 55 with mixed pain. Among patients with identical diagnoses of neuropathic or nociceptive pain, using a receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.92. A cutoff point of equal or greater than 4 resulted in a sensitivity of 93% and a specificity of 78%. Among patients suffering from pain with neuropathic element (neuropathic or mixed pain) or pain with no neuropathic element (nociceptive pain), using a ROC curve analysis, the AUC was 0.89. A cutoff point of equal or greater than 4 resulted in a sensitivity of 89% and a specificity of 78%., Conclusion: The Greek version of DN4 is a valid tool for discriminating between neuropathic and nociceptive pain conditions in daily practice., (© 2014 World Institute of Pain.)

This paper reports a rare iatrogenic complication of acupuncture-induced haemothorax and comments on the importance and need for special education of physicians and physiotherapists in order to apply safe and effective acupuncture treatment. A 37-year-old healthy woman had a session of acupuncture treatments for neck and right upper thoracic non-specific musculoskeletal pain, after which she gradually developed dyspnoea and chest discomfort. After some delay while trying other treatment, she was eventually transferred to the emergency department where a chest X-ray revealed a right pneumothorax and fluid collection. She was admitted to hospital and a chest tube inserted into the right hemithorax (under ultrasound guidance) drained 800 mL of bloody fluid (haematocrit (Hct) 17.8%) in 24 h and 1200 mL over the following 3 days. Her blood Hct fell from 39.0% to 30.8% and haemoglobin from 12.7 to 10.3 g/dL. The patient recovered completely and was discharged after 9 days of hospitalisation. When dyspnoea, chest pain and discomfort occur during or after an acupuncture treatment, the possibility of secondary (traumatic) pneumo- or haemopneumothorax should be considered and the patient should remain under careful observation (watchful waiting) for at least 48 h. To maximise the safety of acupuncture, specific training should be given for the safe use of acupuncture points of the anterior and posterior thoracic wall using dry needling, trigger point acupuncture or other advanced acupuncture techniques., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Pain is one of the most undertreated medical complaints, with barriers to effective pain management lying in poor education of health professionals and misconceptions regarding patients in pain. The aim of this study was to assess whether an elective undergraduate course on chronic pain offered in Greek medical schools influences knowledge and attitudes of medical undergraduates about chronic pain and helps them clarify pain-related concepts., Methods: An electronic questionnaire with 6 demographic and 21 pain-related items was uploaded on SurveyMonkey. The questionnaire was open to medical students in every Greek medical school for 1 month. Students were asked to respond to questions regarding various aspects of pain taught in the aforementioned course. In specific, they were asked to respond to questions regarding the definition, types, and adequacy of treatment of chronic cancer and non-cancer pain. They were queried about their knowledge of pain clinics, health practitioners who run them, and types of treatment available there. There were also questions about opioid use in cancer and non-cancer chronic pain patients and regarding the likelihood of opioid addiction., Results: According to their responses, medical students had good knowledge about the definition and consequences of pain, and those who attended the pain course had greater knowledge regarding the adequacy of treatment of chronic pain and were more familiar with the recent classification of types of pain. Students who did not have exposure to the undergraduate pain course had little information regarding pain clinics and had poor knowledge regarding the use of opioids in cancer and in nonmalignant chronic pain. All students expressed concerns regarding addiction to opioids., Conclusions: Although students enter medical school with little knowledge about pain issues, pain awareness can be positively influenced by education. A curriculum about pain should not only teach the basic science of pain but also present treatment strategies available and address the socio-emotional dimensions of pain. Additionally, if misconceptions about opioid use and addiction are properly elucidated early in medical education, the future health practitioners will be one step forward in achieving the goal of alleviating suffering patients' pain., (Wiley Periodicals, Inc.)

Background and Aims: Regional anesthesia (RA) techniques (central neuraxial and peripheral nerve blocks [CNBs and PNBs]) are well-established anesthesia/analgesia modalities. However, information on their nationwide use is sparse. The aim of the survey was to assess the utility of RA techniques in Greece, during 2011., Materials and Methods: A nationwide, cross-sectional descriptive survey was conducted (March to June, 2012), using a structured questionnaire that was sent to 128 Greek Anesthesia Departments., Results: Sixty-six completed questionnaires (response rate 51.56%) were analyzed. The data corresponded to 187,703 operations and represented all hospital categories and geographical regions of Greece. On the whole, RA was used in 45.5% of performed surgical procedures (85,386/187,703). Spinal anesthesia was the technique of choice (51.9% of all RA techniques), mostly preferred in orthopedics (44.8%). Epidural anesthesia/analgesia (application rate of 23.2%), was mostly used in obstetrics and gynecology (50.4%). Combined spinal-epidural and PNBs were less commonly instituted (11.24% and 13.64% of all RA techniques, respectively). Most PNBs (78.5%) were performed with a neurostimulator, while elicitation of paresthesia was used in 16% of the cases. Conversely, ultrasound guidance was quite limited (5%). The vast majority of consultant anesthesologists (94.49%) were familiar with CNBs, whereas only 46.4% were familiar with PNBs. The main reported limitations to RA application were lack of equipment (58.23%) and inadequate education/training (49.29%)., Conclusion: Regional modalities were routinely used by Greek anesthesiologists during 2011. Neuraxial blocks, especially spinal anesthesia, were preferred over PNBs. The underutilization of certain RA techniques was attributed to lack of equipment and inadequate training.

Purpose: Increased intra-abdominal pressure, as used in laparoscopic surgery or seen in intraabdominal hypertension (IAH), is associated with tissue ischemia and oxidative stress. Ischemic preconditioning (IP) is a method successfully used in liver and transplant surgery, in order to attenuate the detrimental effects of ischemia and reperfusion. In this experimental study, we tested the ability of IP to modify oxidative stress induced by extremely high intraabdominal pressures., Methods: Twenty-five female pigs were studied and divided in three groups: a control group, a pneumoperitoneum group (with pressure of 30 mmHg), and an ischemic preconditioning group (initially subjected to preconditioning with pressure of 25 mmHg for 15 min and desufflation for 15 min and then to pneumoperitoneum as in pneumoperitoneum group). Blood samples were obtained at identical time intervals in the three groups. Total oxidative capacity, total antioxidative capacity and total nitric oxide (NO), nitrite and nitrate concentrations were measured and compared between groups., Results: IP increased total antioxidative capacity (p = .045) and protective mediators like nitrite (p = .022). It was also associated with a trend toward lower levels of total oxidative capacity at the end of the abdominal desufflation period but statistical significance was not met., Conclusions: IP attenuated oxidative stress induced by IAH, mainly by increasing antioxidative capacity and the levels of protective mediators. The fact that IP was effective, even when used at extremely high levels of intraabdominal pressure, reinforces the interest on this method but further studies are needed to clarify its mechanism of action and potential clinical applications.

Background: We compared the effects of intravenous lidocaine (IVL) with lumbar epidural lidocaine analgesia (LEA) on pain and ileus after open colonic surgery., Methods: Between December 2011 and February 2013, 60 patients were randomly allocated to IVL, LEA, or control group. The IVL group received intraoperatively lidocaine 2 % intravenously (1.5 mg/kg bolus, 2 mg/kg/h infusion) and normal saline (NS) epidurally. The LEA group received lidocaine epidurally (1.5 mg/kg bolus, 2 mg/kg/h infusion) and NS intravenously. The control group received NS both intravenously and epidurally, as bolus and infusion. All NS volumes were calculated as if containing lidocaine 2 % at the aforementioned doses. We assessed pain intensity at rest/cough at 1, 2, 4, 12, 24, and 48 h postoperatively (numerical rating scale 0-10), 48-h analgesic consumption, and time to first flatus passage., Results: Data from 60 patients (20 per group) were analyzed. The IVL group had significantly lower pain scores at rest and cough compared to LEA or control group only at 1, 2, and 4 h postoperatively (P < 0.005 for all comparisons). The 48-h analgesic requirements and time to first flatus passage did not differ significantly between IVL group and LEA or control group (P > 0.05)., Conclusions: Compared with LEA-lidocaine or placebo, intravenous lidocaine offered no clinically significant benefit in terms of analgesia and bowel function.

Trigeminal neuralgia is the most common neuralgia. Its therapeutic approach is challenging as the first line treatment often does not help, or even causes intolerable side effects. The aim of our randomized double blind, placebo controlled, crossover study was to investigate in a prospective way the effect of lidocaine in patients with trigeminal neuralgia. Twenty patients met our inclusion criteria and completed the study. Each patient underwent four weekly sessions, two of which were with lidocaine (5 mgs/kg) and two with placebo infusions administered over 60 minutes. Intravenous lidocaine was superior regarding the reduction of the intensity of pain, the allodynia, and the hyperalgesia compared to placebo. Moreover, contrary to placebo, lidocaine managed to maintain its therapeutic results for the first 24 hours after intravenous infusion. Although, intravenous lidocaine is not a first line treatment, when first line medications fail to help, pain specialists may try it as an add-on treatment. This trial is registered with NCT01955967.

Objectives: Neuropathic cancer pain (NCP) is a common manifestation of cancer and/or its treatment. Treatment following the WHO analgesic ladder provides relief for the majority of cancer pain patients; however, concern remains that opioids may be less efficacious for neuropathic pain (NP) compared with nociceptive pain, often necessitating the use of higher doses. Adjuvants, such as pregabalin, have shown to be efficacious for the treatment of NP, although data come mostly from noncancer studies. The comparative efficacy and safety of opioids versus adjuvants has not been studied for NCP. The aim of this study was to directly compare pregabalin versus a strong opioid for the treatment of NCP., Methods: A total of 120 patients, diagnosed with "definite" NCP, were randomized into two groups and received increasing doses of either oral pregabalin or transdermal fentanyl for 28 days. VAS score, patient satisfaction, need for opioid rescue, and adverse events (AEs) were recorded., Results: In the pregabalin group, a significantly higher proportion of patients achieved at least 30% reduction in VAS compared with the fentanyl group (73.3%, 95% CI: 60.3%-83.93 vs. 36.7%, 95% CI: 24.5%-50.1%, P < 0.0001, respectively), while the percentage mean change from baseline was also significantly different [46% (95% CI: 39.5%-52.8%) for pregabalin and 22% (95% CI: 14.9%-29.5%) for fentanyl (P < 0.0001)]. Patient-reported satisfaction was more frequent with pregabalin, while AEs and treatment discontinuations were more frequent in the fentanyl group., Discussion: Prompt use of a neuropathic pain-specific adjuvant, such as pregabalin, in NCP may lead to better control of the neuropathic component, with opioid-sparing effects., (© 2013 The Authors Pain Practice © 2013 World Institute of Pain.)

Background: Intra-abdominal hypertension (IAH) can have a profound impact on the cardiovascular system. We hypothesized that natriuretic peptides (Nt-pro-ANP and Nt-pro-BNP) are produced in response to the cardiovascular changes observed in an experimental model of IAH., Materials and Methods: Eleven female pigs were enrolled in this study. Four experimental phases were created: a baseline phase for instrumentation (T1); two subsequent phases (T2 and T3), in which helium pneumoperitoneum was established at 20 and 35 mm Hg, respectively; and the final phase (T4), in which abdominal desufflation took place. Hemodynamic parameters and concentrations of Nt-pro-ANP and Nt-pro-BNP were measured., Results: Central venous pressure and pulmonary capillary wedge pressure increased significantly during the elevation of intra-abdominal pressure (IAP) and returned to baseline after abdominal desufflation. Right and left transmural pressures remained unaffected by the elevation of IAP. Cardiac output decreased in phases T2 and T3 and was restored to baseline levels after abdominal desufflation. Systemic and pulmonary vascular resistances increased significantly with IAH and decreased after abdominal desufflation. Nt-pro-ANP did not change significantly in comparison to baseline. Nt-pro-BNP increased significantly in comparison to baseline at T3 and T4. Peak Nt-pro-BNP levels at T3 (peak IAP) correlated positively with indices of afterload at this time point, that is, systemic vascular resistance and pulmonary vascular resistance (r(2) = 0.38, P = 0.042 and r(2) = 0.55, P = 0.009, respectively). A strong negative correlation between Nt-pro-BNP and cardiac output at T3 was also demonstrated (r(2) = 0.58, P = 0.006)., Conclusions: IAH resulted in cardiovascular compromise. The unchanged Nt-pro-ANP concentrations might reflect unaltered atrial stretch with IAH, despite the elevation of right atrial filling pressure. The significant increase of Nt-pro-BNP in response to high levels of IAP may reflect left ventricular strain and dysfunction due to the severe IAH and provide an alternative marker in the monitoring of IAH., (Copyright © 2013 Elsevier Inc. All rights reserved.)

There are numerous studies in the literature of anesthesia administered during colonoscopy including various methods, drugs, and monitoring systems; however, none of them has studied whether a university-degreed nurse anesthesia provider (known as a certified registered nurse anesthetist in the United States) is skillful enough to provide safe anesthesia in patients undergoing endoscopic procedures. The aim of our study was to determine whether anesthesia provided by a university-degreed nurse anesthesia provider during an endoscopic procedure is comparable in terms of safety and efficacy with routine sedation practice. This randomized, double-blind study included 100 adult patients who underwent colonoscopy conducted in the Evgenidion University Hospital during a single year. Subjects were divided into 2 groups: the first group received the usual scheme of intravenous sedation with midazolam and fentanyl administered by a member of the endoscopic team that was blind to Bispectral Index (BIS) values recordings (Group 0). The second group received intravenous bolus injection of propofol bolus by a university-degreed anesthesia registered nurse based on the BIS values (Group 1). The average of the mean BIS values of Group 0 was 85.07 (SD = 8.01) and for Group 1 was 76.1 (SD = 10.88; p = .04). The parameters of "patient memory during procedure" and the satisfaction scores (as self-assessed by the patients as well as 2 gastroenterologists) were also significantly different between the patients of the 2 groups (p = .000). Comparison between the 2 groups showed that the sedation offered by a university-degreed nurse anesthesia provider was absolutely safe and effective, offering particular comfort to the patient during the intervention and contributing significantly to its successful results.

The occurrence of an enteric fistula in the middle of an open abdomen is called an enteroatmospheric fistula, which is the most challenging and feared complication for a surgeon to deal with. It is in fact not a true fistula because it neither has a fistula tract nor is covered by a well-vascularized tissue. The mortality of enteroatmospheric fistulae was as high as 70% in past decades but is currently approximately 40% due to advanced modern intensive care and improved surgical techniques. Management of patients with an open abdomen and an enteroatmospheric fistula is very challenging. Intensive care support of organs and systems is vital in order to manage the severely septic patient and the associated multiple organ failure syndrome. Many of the principles applied to classic enterocutaneous fistulae are used as well. Control of enteric spillage, attempts to seal the fistula, and techniques of peritoneal access for excision of the involved loop are reviewed in this report. Additionally, we describe our recent proposal of a lateral surgical approach via the circumference of the open abdomen in order to avoid the hostile and granulated surface of the abdominal trauma, which is adhered to the intraperitoneal organs.

Purpose: Intra-abdominal hypertension (IAH) has several pathophysiologic implications on human organs and systems. The aim of this experimental study was to investigate whether ischemic preconditioning (IP), namely the application of IAH for a small period of time prior to establish pneumoperitoneum, can attenuate the hemodynamic, biochemical and inflammatory alterations observed during IAH., Methods: Twenty-four pigs were divided into three groups: group A (control group), group B (pneumoperitoneum of 30 mmHg) and group C (ischemic preconditioning, consisting of pneumoperitoneum of 25 mmHg for 15 min and subsequent pneumoperitoneum of 30 mmHg). Hemodynamic (central venous pressure, cardiac index, mean arterial pressure, heart rate, stroke volume index, systemic vascular resistance index, global end-diastolic index, intrathoracic blood index and extravascular lung water index), biochemical (serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), alkaline phosphatase (ALP), γ-glutamyl transpeptidase (γ-GT), urea and creatinine) and inflammatory (tumour necrosis factor-α, interleukin (IL)-6, IL-10 and C-reactive protein) parameters were measured., Results: (a) Hemodynamics: The increase of central venous pressure monitoring and heart rate and the decrease of cardiac index, mean arterial pressure, stroke volume index, global end-diastolic volume index and intrathoracic blood volume index with the establishment of pneumoperitoneum were attenuated by IP. Systemic vascular resistance index and extravascular lung water were not affected. (b) Urea significantly increased with the pneumoperitoneum. IP, however, attenuated this effect. Οther biochemical parameters (SGOT, SGPT, ALP, γ-GT and creatinine) had a similar upward trend during IAH, which was reversed with IP. (c) Inflammatory parameters: CRP was increased with pneumoperitoneum, an effect that was attenuated with the application of IP. Νo significant differences were observed for interleukins., Conclusions: Ischemic preconditioning seems to attenuate the pathophysiologic alterations of several hemodynamic, biochemical and inflammatory parameters observed during IAH.

The efficacy of acupuncture as an adjunctive therapy to pharmacological treatment of chronic pain due to knee osteoarthritis was studied with a 3-armed, single-blind, randomized, sham-controlled trial; it compared acupuncture combined with pharmacological treatment, sham acupuncture including pharmacological treatment, and pharmacological treatment alone. A total of 120 patients with knee osteoarthritis were randomly allocated to 3 groups: group I was treated with acupuncture and etoricoxib, group II with sham acupuncture and etoricoxib, and group III with etoricoxib. The primary efficacy variable was the Western Ontario and McMaster Universities (WOMAC) index and its subscales at the end of treatment at week 8. Secondary efficacy variables included the WOMAC index at the end of weeks 4 and 12, a visual analogue scale (VAS) at the end of weeks 4, 8, and 12, and the Short Form 36 version 2 (SF-36v2) health survey at the end of week 8. An algometer was used to determine changes in a predetermined unique fixed trigger point for every patient at the end of weeks 4, 8, and 12. Group I exhibited statistically significant improvements in primary and secondary outcome measures, except for Short Form mental component, compared with the other treatment groups. We conclude that acupuncture with etoricoxib is more effective than sham acupuncture with etoricoxib, or etoricoxib alone for the treatment of knee osteoarthritis., (Copyright © 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Introduction: The aims of our study were to evaluate the impact of increased intra-abdominal pressure (IAP) on central nervous system (CNS) cytokines (Interleukin 6 and tumor necrosis factor), lactate and perfusion pressures, testing the hypothesis that intra-abdominal hypertension (IAH) may possibly lead to CNS ischemia., Methods: Fifteen pigs were studied. Helium pneumoperitoneum was established and IAP was increased initially at 20 mmHg and subsequently at 45 mmHg, which was finally followed by abdominal desufflation. Interleukin 6 (IL-6), tumor necrosis factor alpha (TNFa) and lactate were measured in the cerebrospinal fluid (CSF) and intracranial (ICP), intraspinal (ISP), cerebral perfusion (CPP) and spinal perfusion (SPP) pressures recorded., Results: Increased IAP (20 mmHg) was followed by a statistically significant increase in IL-6 (p = 0.028), lactate (p = 0.017), ICP (p < 0.001) and ISP (p = 0.001) and a significant decrease in CPP (p = 0.013) and SPP (p = 0.002). However, further increase of IAP (45 mmHg) was accompanied by an increase in mean arterial pressure due to compensatory tachycardia, followed by an increase in CPP and SPP and a decrease of cytokines and lactate., Conclusions: IAH resulted in a decrease of CPP and SPP lower than 60 mmHg and an increase of all ischemic mediators, indicating CNS ischemia; on the other hand, restoration of perfusion pressures above this threshold decreased all ischemic indicators, irrespective of the level of IAH.

Background: Leakage from pancreatojejunal anastomosis continues to be a major source of morbidity in pancreatic surgery. In the present study, we test the hypothesis that a safe, sutureless pancreatojejunal anastomosis can be constructed using a synthetic surgical sealant., Materials and Methods: Ten pigs weighing 20 to 25 kg underwent distal pancreatectomy and anastomosis of the pancreatic remnant with a jejunal limb with the use of an absorbable surgical sealant. Integrity of the anastomosis was checked on the 10th postoperative d by means of an autopsy study and histological examination., Results: One animal died on the 3rd postoperative d of peritonitis. The remaining 9 animals had an uneventful postoperative course. Gross and microscopic pathological examination revealed intact pancreatojejunal anastomosis in all surviving animals., Conclusions: Following distal pancreatectomy in pigs, pancreatojejunal anastomoses with the use of sealant are technically feasible. During a 10-d observation period, the sealant appeared to prevent anastomotic dehiscence and allow normal anastomotic healing.

Background: The effect of parecoxib, when used perioperatively or during interventional techniques, is well demonstrated in the literature. Little is known about its effects on anxiety levels before the analgesic technique application. The aim of this prospective, randomized, double-blind, placebo-controlled, clinical study is to investigate whether parecoxib, preemptively administrated, has an effect on anxiety levels reported prior to an epidural puncture, and if it influences the reported pain of the interventional technique itself., Material and Methods: The study protocol involved 110 patients, scheduled for epidural catheter placement for chronic pain therapy--Group I, as well as 112 patients scheduled for orthopedic operations under epidural anesthesia--Group II. Patients in each group were randomly allocated into two subgroups in relation to parecoxib/placebo administration before epidural catheter placement: Group Ia, parecoxib 40 mg i.v. (n = 54), Group Ib, placebo (n = 56), Group IIa, parecoxib 40 mg i.v. (n = 57), Group IIb, placebo (n = 55). Patients were given a self-administered inventory to measure the anxiety level of the presurgical/preprocedural state (State-Trait Spielberger Anxiety Inventory) and anxiety levels were recorded 1 hour before epidural puncture, 20 minutes postdosing, and 1 hour after epidural catheter placement. Anxiety levels were also measured and recorded using visual analog scale (VAS). One hour after epidural puncture, reported procedural pain was recorded (VAS). One hour and 6 hours postepidural, patients' satisfaction was also recorded, on a 4-point scale., Results: All four subgroups were similar regarding demographic, operative/procedural data, and coexisting diseases. Preprocedural anxiety levels were significantly decreased with parecoxib administration in comparison with placebo in both groups (P < 0.05). Reported VAS regarding pain from epidural puncture was lower in Groups IA and Ib. Patients' satisfaction was greater with parecoxib in comparison with placebo., Conclusion: The levels of anxiety have been investigated in several medical procedures and early, in the study of pain. The higher the expectation of pain and the anxiety are, the higher the intensity of the pain. Parecoxib seems to exert positive influence on pain and anxiety levels of interventional procedure. Further studies are needed to elucidate the actual mechanisms that are involved.

Purpose: To evaluate the prevalence of bacteremia after mask ventilation, laryngoscopy, and endotracheal intubation before induction of general anesthesia and to discover any correlation between traumatic manipulations and bacteremia. The specific bacteria responsible, knowledge of which may guide the prophylactic use of antibiotics, also were investigated., Methods: Fifty patients were enrolled. Three 10-mL blood samples were collected from a peripheral vein 10 min before induction of anesthesia, 10 min after mask ventilation, and 10 min after intubation. All samples were placed in aerobic and anaerobic bottles for culture and bacterial identification., Results: Cultures received 10 min after intubation were positive in 12% of patients. The following strains were isolated: Escherichia coli in two cases, Staphylococcus aureus in three cases, and Peptostreptococcus anaerobius in one case. A strong positive correlation was found between difficult intubation and bacteremia. No correlation between bacteremia and easy intubation or between bacteremia and face mask ventilation was identified., Conclusion: Traumatic manipulations during difficult laryngoscopy and endotracheal intubation could cause bacteremia. This finding may justify and guide prophylactic use of antibiotics.

Cancer is a public health problem worldwide and a major cause of death or disability. Pain is one of the most common and feared symptoms in patients with cancer with marked impact on quality of life. According to the WHO analgesic ladder, opioids are the mainstay of cancer pain management, if well-accepted guidelines are systematically applied. Oral morphine has been widely used in treating cancer pain of moderate to severe intensity and remains the preferred first choice to many clinicians for its familiarity/availability/costs. However, a significant proportion of patients under oral morphine do not have successful outcomes, often switched to alternative strong opioids. Opioid rotation is a therapeutic maneuver aiming in improving analgesic response and/or reducing adverse effects, including change to different medication using the same administration route, maintaining the current medication but altering administration route, or both. In this review, a detailed presentation of the available literature, regarding opioid rotation strategy, up to now is performed. Indications, principles, opioid dose-conversion recommendations, and guidelines in oncology patients are presented. An outline of the evidence supporting the use of this therapeutic modality on clinical benefit/outcome is attempted. Mechanisms contributing to patients' variable opioid response are underlined. Since 1/3 of population will die from cancer (80 percent with severe pain in their final year of life) effective pain control remains an ongoing challenge. Opioid rotation may be useful in opening the therapeutic window and establishing a more advantageous analgesia/toxicity relationship. However, too much work is to be done to further individualize analgesic therapy for patients with cancer.