Drug resistance and genomic characteristics of Salmonella enterica serovar London from clinical and food sources in Hangzhou City from 2017 to 2021 / 中华预防医学杂志

Objective: To analyze the drug resistance and genomic characteristics of Salmonella enterica serovar London isolated from clinical and food sources in Hangzhou City from 2017 to 2021. Methods: A total of 91 Salmonella enterica serovar London strains isolated from Hangzhou City from 2017 to 2021 were analyzed for drug susceptibility, pulsed field gel electrophoresis (PFGE) typing and whole genome sequencing. Multilocus sequence typing (MLST), core genome multilocus sequence typing (cgMLST) and detection of drug resistance genes were performed by using the sequencing data. Phylogenetic analysis was conducted to compare the 91 genomes from Hangzhou City with 347 genomes from public databases. Results: No significant difference in the drug resistance rate was observed between clinical strains and food strains to 18 drugs in Hangzhou City(all P>0.05), and the multidrug resistance (MDR) rate was 75.8% (69/91). Most strains were resistant to 7 drug classes simultaneously. One strain was resistant to Polymyxin E as well as positive for mcr-1.1, and 50.5% (46/91) of the strains were resistant to Azithromycin and were positive for mph(A). All 91 Salmonella enterica serovar London strains were ST155, which were subdivided into 44 molecular types by PFGE and 82 types by cgMLST. Phylogenetic analysis showed that most strains from Hangzhou City (83/91) were clustered together, and a small number of human isolates from Europe, North America and pork isolates from Hubei and Shenzhen were mixed in the cluster. Other strains from Hangzhou City (8/91) were closely related to strains from Europe, America and Southeast Asia. Strains isolated from pork were the most closely related to clinical strains. Conclusion: The epidemic of Salmonella enterica serovar London in Hangzhou City is mainly caused by the spread of ST155 strains, which is mainly transmitted locally. At the same time, cross-region transmission to Europe, North America, Southeast Asia, and other provinces and cities in China may also occur. There is no significant difference in the drug resistance rate between clinical strains and food strains, and a high level of MDR is found in the strains. Clinical infection of Salmonella enterica serovar London may be closely related to pork consumption in Hangzhou City.

Dexmedetomidine versus clonidine as an adjuvant to local anaesthetic in brachial plexus blocks: a metaanalysis of randomised controlled trials

Abstract Objective: This meta-analysis aimed to compare the efficacy and safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. Methods: Two investigators independently searched databases to identify all RCTs comparing the efficacy and/or safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. All outcomes were pooled using the inverse variance method with a random-effect model. An I2 test was used to assess heterogeneity. The source of heterogeneity was explored through meta-regression. The quality of the evidence was assessed using the GRADE approach. Results: Out of 123 full texts assessed, 24 studies (1448 patients) were included in the analysis. As compared to Clonidine, dexmedetomidine groups showed significantly longer sensory block duration (MD = 173.31; 95% CI 138.02-208.59; I2 = 99%; GRADE approach evidence: high); motor block duration (MD = 158.35; 95% CI 131.55-185.16; I2 = 98%; GRADE approach evidence: high), duration of analgesia (MD = 203.92; 95% CI 169.25-238.58; I2 = 99%; GRADE approach evidence-high), and provided higher grade quality of block (RR = 1.97; 95% CI 1.60-2.41 ; I2 = 0%; GRADE approach evidence: moderate). The block positioning technique (regression coefficient: 51.45, p = 0.005) was observed as a significant predictor of the heterogeneity in the case of sensory block duration. No significant difference was observed for the risk of hypotension (RR = 2.59; 95% CI 0.63-10.66; I2 = %). Conclusion: Moderate to high-quality evidence suggests dexmedetomidine is a more efficacious adjuvant to local anesthetic in BPBs than Clonidine.

Estudio cuasi experimental: analgesia intratecal Clonidina vs Morfina para manejo del dolor postoperatorio inmediato en cirugías de columna / QUASI-EXPERIMENTAL STUDY: CLONIDINE INTRATHECAL ANESTHESIA VS. MORPHINE FOR IMMEDIATE POSTOPERATIVE PAIN MANAGEMENT IN SPINE SURGERY

Introducción: El manejo inmediato del dolor postoperatorio es esencial para una comodidad y rehabilitación temprana del paciente Este estudio busca evaluar el efecto analgésico postoperatorio inmediato en cirugías de columna lumbosacra por vía posterior, como los efectos adversos con la administración de analgesia intratecal, usando Clonidina contra Morfina. Material y métodos: Es un estudio analítico de intervención, cuasi experimental, prospectivo, longitudinal, comparativo, doble ciego. Para comparar la eficacia de la analgesia intratecal post operatoria inmediata en cirugías de columna lumbosacra primarias por vía posterior y los efectos adversos. Los pacientes se distribuyeron en dos grupos previamente designados, a un grupo se le administro Clonidina 0.5 microgramos/kg/peso y a otro grupo Morfina 5 microgramos/Kg/Peso. intratecal, intraoperatorio. Resultados: Existió diferencia estadísticamente significativa con mejor manejo del dolor postoperatorio en las primeras horas y menor presencia de vómitos en el grupo de pacientes que se utilizó Clonidina intratecal. No existió diferencia estadísticamente significativa de ambas medicaciones intratecales en la valoración de otros efectos adversos. Discusión: El uso de la analgesia intratecal ha ido ganando relevancia en el tiempo y se fueron sumando estudios para ver la eficacia de diferentes medicamentos, diferentes dosis, menor presencia de efectos adversos. El estudio analiza estas variables buscando una mejor opción terapéutica. Tenemos a favor una muestra representativa a pesar de no ser aleatoria, estricto seguimiento, y análisis estadístico adecuado. Conclusión: La Clonidina intratecal es más efectiva para manejo del dolor post operatorio inmediato de cirugías de columna lumbosacra por vía posterior y con menor presencia de efectos adversos

Introduction: Immediate postoperative pain management is essential for the patient's greater comfort and early rehabilitation. Te goal of this study is to evaluate the immediate analgesic postoperative effect in posterior lumbosacral spine surgery, as well as the adverse effects of the administration of intrathecal analgesia, using Clonidine versus Morphine. Material and methods: An analytical, quasi-experimental, prospective, longitudinal, comparative, double-blinded intervention study was conducted to compare the efficacy of immediate postoperative intrathecal analgesia in primary posterior lumbosacral spine surgery, and the adverse effects. Te patients were divided into two previously designated groups. One group received Clonidine 0.5 microgramos/kg and the other group received Morphine 5 microgramos/kg. Intrathecal, intraoperative. Results: Tere was a statistically significant difference with better postoperative pain management in the first hours and less vomiting in the group of patients who received intrathecal Clonidine. Tere was no statistically significant difference between both intrathecal medications in the evaluation of other adverse effects. Discussion: Te use of intrathecal analgesia, has been on the rise over time and more studies have been conducted to see the efficacy of different drugs, different doses, with fewer adverse effects. Tis study to analyze these variables with a view to finding a better therapeutic option. Te advantage is having a representative if not random sample, strict follow-up, and appropriate statistical analysis Conclusion: Intrathecal Clonidine proved to be more effective in immediate postoperative pain management after posterior lumbosacral spine surgery and with fewer adverse effects

Quadratus Lumborum Block for Upper Tract Urological Surgery in Pediatric Patients / Bloqueo del cuadrado lumbar para cirugía urológica del tracto superior en pacientes pediátricos

Objective Among regional blocks, the quadratus lumborum fascial plane block (QLB) has been well described, but the description of its use and efficacy for pediatric patients undergoing upper abdominal urologic surgery is limited. We present a case series examining the use of the QLB for postoperative pain management in children undergoing upper tract surgery. Methods From August 2019 to August 2020, through a chart review, we identified 5 patients who had undergone a QLB for upper urinary tract surgery via a flank incision. Posterior QLB was performed after induction of general anesthesia. A single injection of 0.5mL/kg of either 0.25% or 0.5% ropivacaine with 1mcg/kg of clonidine was administered. Patients received fentanyl IV (1 mcg/kg), and acetaminophen IV (15mg/kg) as adjuvants during the operation. Postoperative pain was managed with oral acetaminophen and ibuprofen. Results The average postoperative pain score during the entire admission was 1, with the lowest being 0 and highest, 3. No administration of rescue narcotics was required in the postanesthesia care unit or on the floor. The average length of stay ranged from 0 to 1 day. No complications associated with the regional QLB were identified. Conclusions Our series suggests the QLB may be considered as a regional anesthetic option to minimize narcotic requirements for children undergoing upper abdominal urological surgery via flank incision. Additional studies are needed to compare the efficacy of the QLB versus alternate regional anesthetic blocks for upper tract urological surgery via flank incision in children and to determine effective dosing and use of adjuvants

Objetivo Entre los bloqueos regionales, el bloqueo del plano fascial del cuadrado lumbar (BCL) ha sido bien descrito; sin embargo, tiene una descripción limitada de su uso y eficacia en pacientes pediátricos sometidos a cirugía urológica abdominal superior. Presentamos una serie de casos que examinan el uso del BCL en el manejo del dolor posoperatorio en niños sometidos a cirugía urológica del tracto superior. Métodos De agosto de 2019 a agosto de 2020, mediante revisión de historias clínicas, se identificaron 5 pacientes sometidos al BCL para cirugía del tracto urinario superior por incisión en el flanco. El BCL posterior se realizó después de la inducción de la anestesia general. Solo se administró una inyección de 0,5 ml/kg de ropivacaína al 0,25% o al 0,5% con 1 mcg/kg de clonidina. Los pacientes recibieron fentanilo IV (1 mcg/kg) y acetaminofén IV (15 mg/kg) como adyuvantes durante la operación. El dolor posoperatorio se manejó con acetaminofén e ibuprofeno oral. Resultados El puntaje promedio de dolor posoperatorio para todo el ingreso fue de 1, siendo el más bajo 0 y el más alto, 3. No se requirieron administraciones de narcóticos de rescate en la unidad de recuperación posanestésica ni en la planta de hospitalización. La estancia media fue de 0 a 1 día. No se identificaron complicaciones asociadas con el BCL regional. Conclusiones Nuestra revisión sugiere que el BCL puede ser considerado una opción anestésica regional para minimizar los requerimientos de narcóticos en niños sometidos a cirugía urológica abdominal superior por incisión en el flanco. Se necesitan estudios adicionales para comparar la eficacia de BCL en comparación con la de los bloqueos anestésicos regionales alternativos para la cirugía urológica del tracto superior por incisión en el flanco en niños y para determinar la efectividad de la dosificación y del uso de adyuvantes.

Como a dexmedetomidina e a clonidina devem ser prescritas no ambiente de terapia intensiva? / How should dexmedetomidine and clonidine be prescribed in the critical care setting?

RESUMO O manejo cardíaco, ventilatório e renal no ambiente de terapia intensiva tem melhorado nas últimas décadas. Cognição e sedação representam dois dos últimos desafios a vencer. Como a sedação convencional não é ideal, e a sedação evocada por agonistas adrenérgicos alfa-2 (sedação "cooperativa" com dexmedetomidina, clonidina ou guanfacina) representa uma alternativa valiosa, este artigo abrange três tópicos práticos para os quais há lacunas na medicina baseada em evidência. O primeiro deles é a mudança de sedação convencional para sedação cooperativa ("mudança"): a resposta curta consiste em retirada abrupta de sedação convencional, implantação imediata de infusão de um agonista alfa-2 e uso de "sedação de resgate" (bolos de midazolam) ou "sedação agressiva" (haloperidol em bolos) para estabilizar a sedação cooperativa. O segundo tópico é a mudança de sedação convencional para sedação cooperativa em pacientes instáveis (por exemplo: delirium tremens refratário, choque séptico, síndrome do desconforto respiratório agudo etc.), pois, para evitar a hipotensão e a bradicardia provocadas por desativadores simpáticos, a resposta curta é manter o volume sistólico por administração de volume, vasopressores e inotrópicos. Por fim, para evitar essas mudanças e dificuldades associadas, os agonistas alfa-2 podem ser sedativos de primeira linha. A resposta curta é administrar agonistas alfa-2 lentamente desde a admissão ou intubação endotraqueal, até estabilização da sedação cooperativa. Dessa forma, conclui-se que os agonistas alfa-2 são, ao mesmo tempo, agentes desativadores simpáticos e sedativos, bem como a desativação simpática implica na manutenção do volume sistólico e na avaliação persistente da volemia. A medicina baseada em evidência deve documentar esta proposta.

ABSTRACT Cardiac, ventilatory and kidney management in the critical care setting has been optimized over the past decades. Cognition and sedation represent one of the last remaning challenges. As conventional sedation is suboptimal and as the sedation evoked by alpha-2 adrenergic agonists ("cooperative" sedation with dexmedetomidine, clonidine or guanfacine) represents a valuable alternative, this manuscript covers three practical topics for which evidence-based medicine is lacking: a) Switching from conventional to cooperative sedation ("switching"): the short answer is the abrupt withdrawal of conventional sedation, immediate implementation of alpha-2 agonist infusion and the use of "rescue sedation" (midazolam bolus[es]) or "breakthrough sedation" (haloperidol bolus[es]) to stabilize cooperative sedation. b) Switching from conventional to cooperative sedation in unstable patients (e.g., refractory delirium tremens, septic shock, acute respiratory distress syndrome, etc.): to avoid hypotension and bradycardia evoked by sympathetic deactivation, the short answer is to maintain the stroke volume through volume loading, vasopressors and inotropes. c) To avoid these switches and associated difficulties, alpha-2 agonists may be considered first-line sedatives. The short answer is to administer alpha-2 agonists slowly from admission or endotracheal intubation up to stabilized cooperative sedation. The "take home" message is as follows: a) alpha-2 agonists are jointly sympathetic deactivators and sedative agents; b) sympathetic deactivation implies maintaining the stroke volume and iterative assessment of volemia. Evidence-based medicine should document our propositions.

Efecto del manejo farmacológico del sistema nervioso autónomo en la pancreatitis aguda inducida por el veneno de escorpión Tityus zulianus en un modelo ex vivo / Effect of the pharmacological management of the autonomic nervous system in the acute pancreatitis induced by the venom of Tityus zulianus scorpion in an ex vivo model

La pancreatitis es una de las consecuencias principales del envenenamiento escorpiónico producido por el género Tityus. El manejo farmacológico mediante el uso de agonistas y antagonistas α adrenérgicos en modelos experimentales in vivo e in vitro, permiten establecer una aproximación del papel del Sistema Nervioso Simpático (SNS) en el desarrollo de la pancreatitis. Objetivo: determinar el papel del SNS en el desarrollo de la pancreatitis aguda inducida por el veneno de escorpión Tityus zulianus (TzV), por medio del uso de simpaticolíticos como la clonidina y el prazosin. Métodos: La Extravasación de Proteínas Plasmáticas (EPP) en el páncreas se evaluó mediante el método de Azul de Evans (AE), modificado de Saria y Lundberg (1983) a 620 nm; n=3 ratones NIH en cada grupo experimental. Las comparaciones se hicieron por ANOVA de una vía y las pruebas post HOC por Tukey-Kramer. Resultados: Ambos fármacos (1mg/Kg), disminuyeron significativamente p< 0,01 (**) la EPP en el páncreas inducida por el TzV, en comparación con los animales inoculados solo con TzV. No hubo diferencias significativas entre los animales del grupo control y los grupos tratados con los fármacos más el TzV. Conclusiones: El efecto pancreatotóxico del TzV en ratones podría tener un componente autonómico dado que drogas simpaticolíticas al disminuir la actividad noradrenérgica reducen la magnitud del edema. Esto sugiere que ambos fármacos pueden usarse como estrategia terapéutica en estos casos(AU)

Pancreatitis is one of the main consequences of scorpionic poisoning produced by the genus Tityus. The pharmacological management through the use of agonists and α adrenergic antagonists in experimental models in vivo and in vitro, allow us to establish an approximation of the role of the Sympathetic Nervous System (SNS) in the development of pancreatitis. Objective: to determine the role of SNS in the development of acute pancreatitis induced by the scorpion venom Tityus zulianus (TzV), through the use of sympatholytics such as clonidine and prazosin. Methods: Plasma Protein Extravasation (PPE) in the pancreas was evaluated by the method of Evans Blue (EA), modified by Saria and Lundberg (1983) at 620 nm; n = 3 NIH mice in each experimental group. Comparisons were made by one-way ANOVA and post-HOC tests by Tukey-Kramer. Results: Both drugs (1mg / Kg) significantly decreased p <0.01 (**) the EPP in the pancreas induced by TzV, compared to animals inoculated only with TzV. There were no significant differences between the animals in the control group and the groups treated with drugs plus TzV. Conclusions: The pancreatotoxic effect of TzV in mice could have an autonomic component since sympatholytic drugs by decreasing noradrenergic activity reduce the magnitude of edema. This suggests that both drugs can be used as a therapeutic strategy in these cases(AU)

Seguridad y efectividad de la preparación magistral de clonidina como ansiolítico en pacientes pediátricos sometidos a cirugía ambulatoria / Safety and effectiveness of the magistral preparation of clonidine as an ansiolytic in pediatric patients undergoing ambulatory surgery

Objetivo: evaluar la seguridad y efectividad de la preparación magistral de clonidina a una concentración de 15 µg/mL utilizada para premedicación oral en niños entre uno y siete años de edad a una dosis de 4 µg/kg de peso sometidos a cirugía ambulatoria entre febrero y octubre de 2019 en la Clínica San Marcel. Materiales y métodos: se realizó un estudio observacional descriptivo retrospectivo de corte transversal, con muestreo consecutivo durante el periodo del estudio. Los datos de 202 pacientes fueron obtenidos de la historia clínica para luego realizar el análisis univariado y bivariado con estadística descriptiva. Un valor de P > 0,05 se consideró significativa. Resultados: hubo una incidencia de ansiedad preoperatoria del 2,5%, hipotensión arterial de 30,69% y de bradicardia de 23,26%. No se dieron casos de vómito, escalofrío o depresión respiratoria posoperatorios. La edad estuvo asociada con ansiedad preoperatoria (P=0,03) y bradicardia (P=0,049) pero no con hipotensión arterial (P=0,066). Conclusiones: la preparación magistral de clonidina se asocia con baja incidencia de ansiedad preoperatoria en niños y ausencia de vómito, escalofrío y depresión respiratorias posoperatorias. Sin embargo, preocupa la alta frecuencia de hipotensión arterial y bradicardia encontrados sin que pueda plantearse ninguna asociación..Au

Objectives: to evaluate the safety and effectiveness of the clonidine preparation at a concentration of 15 µg / mL used for oral premedication in children between one and seven years old at a dose of 4 µg / kg of weight undergoing ambulatory surgery between February and October 2019 at the San Marcel Clinic. Materials and methods: a restrospective, descriptive observational cross-sectional study was carried out, with consecutive sampling during the study period. The data of 202 patients were obtained from the medical history to then perform the univariate and bivariate analysis with descriptive statistics. P value > 0,05 was considered significant. Results: there was an incidence of preoperative anxiety of 2,5%, arterial hypotension of 30,69% and bradycardia of 23,26%. There were no cases of postoperative vomiting, chills, or respiratory depression. Age was associated with preoperative anxiety (P = 0,03) and bradycardia (P= 0,049) but not with arterial hypotension (P = 0,066). Conclusions: master clonidine preparation is associated with low incidence of preoperative anxiety in children and absence postoperative respiratory vomiting, chills, and depression. However, there is concern about the high frequency of low blood pressure and bradycardia found without any association being raised..Au

Prevalence of delirium in intensive care patients and association with sedoanalgesia, severity and mortality / Prevalencia de delirio en pacientes de cuidados intensivos y asociación con la sedoanalgesia, gravedad y mortalidad / Prevalência de delirium em pacientes de terapia intensiva e associação com sedoanalgesia, gravidade e mortalidade

ABSTRACT Objective: To establish the prevalence of delirium and its subsyndrome in intensive care and to associate it with the use of sedative and analgesia, severity and mortality. Method: Carried out in two intensive care units of adult patients, this is a quantitative and transversal study, with 157 patients, using the Richmond Agitation-Sedation Scale to assess the level of sedation and the Intensive Care Delirium Screening Checklist for delirium. The T test and Chi-square test were applied for statistical analysis. Results: The prevalence of delirium was 22.3%, and 49.7% of the subsyndrome. Associations of the use of midazolam with the presence of delirium (p=0.05) and subsyndromal delirium (p<0.01), use of clonidine with the appearance of delirium (p<0.01) and of fentanyl with subsyndromal delirium (p=0.09). There were no significant differences between the mortality of patients with delirium (p=0.40) and subsyndromal delirium (p=0.86), as well as association with the mortality score. Conclusion: The use of sedoanalgesia is associated with the presence of delirium and subsyndromal delirium. No significant statistical associations were found between the severity and mortality scores.

RESUMEN Objetivo: Establecer la prevalencia del delirio y su subsíndrome en pacientes de cuidados intensivos y asociarlos con el uso de la sedoanalgesia, con la gravedad y con la mortalidad. Método: Realizado en dos unidades de cuidados intensivos de pacientes adultos, se trata de un estudio cuantitativo y transversal, con 157 pacientes, utilizando las escalas Richmond Agitation-Sedation Scale (Escala de agitación-sedación de Richmond) para evaluar el nivel de sedación y la de la Intensive Care Delirium Screening Checklist (Lista de verificación para la detección del delirio en cuidados intensivos) para el delirio. Se aplicaron las pruebas de T y Chi-cuadrado para el análisis estadístico. Resultados: La prevalencia del delirio fue del 22,3%, y la del subsíndrome fue del 49,7%. Se han encontrado asociaciones del uso de midazolan con la presencia de delirio (p = 0,05) y del deilirio subsindromático (p < 0,01), del uso de clonidina con la aparición de delirio (p < 0,01) y de fentanil con el delirio subsindromático (p = 0,09). No se registraron diferencias significativas entre la mortalidad de los pacientes con delirio (p = 0,40) y el delirio. Conclusión: El uso de sedoanalgesia se asocia con la presencia de delirio y delirio subsindromático. No se encontraron asociaciones estadísticas significativas entre la gravedad y las puntuaciones de mortalidad.

RESUMO Objetivo: Estabelecer a prevalência do delirium e sua subsíndrome em pacientes de terapia intensiva e associar com uso de sedoanalgesia, gravidade e mortalidade. Método: Realizado em duas Unidades de Terapia Intensiva de pacientes adultos, trata-se de estudo quantitativo e transversal, com 157 pacientes, utilizando as escalas Richmond Agitation-Sedation Scale para avaliação do nível de sedação e Intensive Care Delirium Screening Checklist para delirium. Foi aplicado o teste t e qui-quadrado para análise estatística. Resultados: A prevalência de delirium foi 22,3% e da subsíndrome 49,7%. Foram encontradas associações do uso de midazolan com a presença de delirium (p=0,05) e delirium subsindromático (p<0,01), uso de clonidina com o aparecimento de delirium (p<0,01) e de fentanil com o delirium subsindromático (p=0,09). Não houve diferenças significativas entre mortalidade de paciente com delirium (p=0,40) e delirium subsindromático (p= 0,86), bem como associação com o escore de mortalidade. Conclusão: O uso de sedoanalgesia está associado à presenta de delirium e delirium subsindromático. Não foram encontradas associações estatísticas significativas entre os escores de gravidade e mortalidade.

Prevalence of delirium in intensive care patients and association with sedoanalgesia, severity and mortality / Prevalencia de delirio en pacientes de cuidados intensivos y asociación con la sedoanalgesia, gravedad y mortalidad / Prevalência de delirium em pacientes de terapia intensiva e associação com sedoanalgesia, gravidade e mortalidade

ABSTRACT Objective: To establish the prevalence of delirium and its subsyndrome in intensive care and to associate it with the use of sedative and analgesia, severity and mortality. Method: Carried out in two intensive care units of adult patients, this is a quantitative and transversal study, with 157 patients, using the Richmond Agitation-Sedation Scale to assess the level of sedation and the Intensive Care Delirium Screening Checklist for delirium. The T test and Chi-square test were applied for statistical analysis. Results: The prevalence of delirium was 22.3%, and 49.7% of the subsyndrome. Associations of the use of midazolam with the presence of delirium (p=0.05) and subsyndromal delirium (p<0.01), use of clonidine with the appearance of delirium (p<0.01) and of fentanyl with subsyndromal delirium (p=0.09). There were no significant differences between the mortality of patients with delirium (p=0.40) and subsyndromal delirium (p=0.86), as well as association with the mortality score. Conclusion: The use of sedoanalgesia is associated with the presence of delirium and subsyndromal delirium. No significant statistical associations were found between the severity and mortality scores.

RESUMEN Objetivo: Establecer la prevalencia del delirio y su subsíndrome en pacientes de cuidados intensivos y asociarlos con el uso de la sedoanalgesia, con la gravedad y con la mortalidad. Método: Realizado en dos unidades de cuidados intensivos de pacientes adultos, se trata de un estudio cuantitativo y transversal, con 157 pacientes, utilizando las escalas Richmond Agitation-Sedation Scale (Escala de agitación-sedación de Richmond) para evaluar el nivel de sedación y la de la Intensive Care Delirium Screening Checklist (Lista de verificación para la detección del delirio en cuidados intensivos) para el delirio. Se aplicaron las pruebas de T y Chi-cuadrado para el análisis estadístico. Resultados: La prevalencia del delirio fue del 22,3%, y la del subsíndrome fue del 49,7%. Se han encontrado asociaciones del uso de midazolan con la presencia de delirio (p = 0,05) y del deilirio subsindromático (p < 0,01), del uso de clonidina con la aparición de delirio (p < 0,01) y de fentanil con el delirio subsindromático (p = 0,09). No se registraron diferencias significativas entre la mortalidad de los pacientes con delirio (p = 0,40) y el delirio. Conclusión: El uso de sedoanalgesia se asocia con la presencia de delirio y delirio subsindromático. No se encontraron asociaciones estadísticas significativas entre la gravedad y las puntuaciones de mortalidad.

RESUMO Objetivo: Estabelecer a prevalência do delirium e sua subsíndrome em pacientes de terapia intensiva e associar com uso de sedoanalgesia, gravidade e mortalidade. Método: Realizado em duas Unidades de Terapia Intensiva de pacientes adultos, trata-se de estudo quantitativo e transversal, com 157 pacientes, utilizando as escalas Richmond Agitation-Sedation Scale para avaliação do nível de sedação e Intensive Care Delirium Screening Checklist para delirium. Foi aplicado o teste t e qui-quadrado para análise estatística. Resultados: A prevalência de delirium foi 22,3% e da subsíndrome 49,7%. Foram encontradas associações do uso de midazolan com a presença de delirium (p=0,05) e delirium subsindromático (p<0,01), uso de clonidina com o aparecimento de delirium (p<0,01) e de fentanil com o delirium subsindromático (p=0,09). Não houve diferenças significativas entre mortalidade de paciente com delirium (p=0,40) e delirium subsindromático (p= 0,86), bem como associação com o escore de mortalidade. Conclusão: O uso de sedoanalgesia está associado à presenta de delirium e delirium subsindromático. Não foram encontradas associações estatísticas significativas entre os escores de gravidade e mortalidade.

Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine / Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina

Abstract Background and objectives: Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. Methods: A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30 mL saline, Group R - ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 µg.kg-1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. Results: The mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. Conclusion: Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Resumo Justificativa e objetivos: O alívio inadequado da dor após a reconstrução do ligamento cruzado anterior afeta a mobilidade, leva ao desenvolvimento de aderências, inserção do ligamento enfraquecido e atrofia muscular. O bloqueio do canal adutor para analgesia pós-operatória preserva a força do quadríceps. O presente estudo foi feito para comparar o período sem dor em pacientes de reconstrução artroscópica do ligamento cruzado anterior, submetidos ao bloqueio do canal adutor guiado por ultrassom com ropivacaína isolada e ropivacaína + clonidina. Métodos: Um estudo prospectivo, randômico e duplo-cego foi conduzido com 63 pacientes adultos, estado físico ASA I-II, submetidos à reconstrução do ligamento cruzado anterior. Os pacientes foram randomizados em três grupos: Grupo S, que recebeu bloqueio do canal adutor com 30 mL de solução salina para controle; Grupo R, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375%; Grupo RC, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375% e 1 µg.kg-1 de clonidina. O desfecho primário do estudo foi comparar o período sem dor nos pacientes que receberam bloqueio do canal adutor com ropivacaína isolada ou ropivacina + clonidina. Os desfechos secundários foram escores de dor em repouso e movimento, necessidade total de analgésicos, escore de sedação, além de náusea e vômito no pós-operatório. Resultados: Os períodos médios sem dor foram 20 min, 384,76 min e 558,09 min para os grupos S, R e RC, respectivamente, e essa diferença foi estatisticamente significativa (p < 0,001). Não houve diferença significativa entre os grupos R e RC em termos de escores de dor em repouso e movimento e a necessidade total de analgésicos. Conclusão: A adição de clonidina à ropivacaína em bloqueio do canal adutor guiado por ultrassom levou a um prolongamento significativo do período sem dor, embora os escores de dor em repouso e movimento, e a necessidade de analgésico de resgate, não tenham diferido.

Combination of clonidine-bupivacaine in caudal epidural anesthesia for hypospadias surgery in children: prospective, randomized, blind study / Associação clonidina-bupivacaína na anestesia peridural caudal para cirurgia de hipospádia em crianças: estudo prospectivo, randomizado, encoberto

Abstract Background and objectives: The combination of clonidine with local anesthetic administered for epidural anesthesia via caudal route seems to improve the quality of postoperative analgesia, but with conflicting results. This study compared the postoperative analgesia of three different doses of clonidine combined with bupivacaine in caudal epidural anesthesia in children undergoing hypospadias repair. Methods: Eighty children aged 1-10 years, candidates for surgical repair of hypospadias, were randomly divided into four groups of 20 patients to receive general anesthesia combined with caudal epidural anesthesia with bupivacaine 0.165% alone or in combination with 1, 2 or 3 µg.kg- 1 of clonidine. The primary outcome was morphine consumption in the first 24 h postoperatively. Mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, time to awakening, pain severity (FLACC scale), level of sedation (RAMSAY), duration of analgesia, and occurrence of adverse effects were also compared. Results: Intraoperatively, there was no difference between groups regarding mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, and time to awakening. Postoperative morphine consumption and pain severity were similar between groups, but the group receiving clonidine (3 µg.kg-1) had lower heart rate and higher sedation level than the group receiving bupivacaine alone. Conclusions: The combination of clonidine at doses of 1, 2 or 3 µg.kg-1 with bupivacaine 0.16% via caudal epidural route did not alter the consumption of morphine in the early postoperative period of children undergoing hypospadias repair.

Resumo Justificativa e objetivos: A associação de clonidina ao anestésico local administrado por via peridural caudal parece melhorar a qualidade da analgesia pós-operatória, mas com resultados conflitantes. Este estudo comparou a analgesia pós-operatória de três diferentes doses de clonidina associada à bupivacaína na anestesia peridural caudal em crianças submetidas à correção de hipospádia. Método: Oitenta crianças entre um e dez anos, candidatas à correção cirúrgica de hipospádia, foram divididas, aleatoriamente, em quatro grupos de 20 pacientes para receber anestesia geral associada à anestesia peridural caudal com bupivacaína 0,166% isolada ou associada a 1, 2 ou 3 µg.Kg-1 de clonidina. Como desfecho principal avaliou-se o consumo de morfina nas primeiras 24 horas de pós-operatório. Compararam-se também pressão arterial média, frequência cardíaca, concentração expirada de sevoflurano, tempo de despertar da anestesia, intensidade da dor pela escala FLACC, nível de sedação (Ramsay), tempo de duração da analgesia e ocorrência de efeitos adversos. Resultados: No transoperatório, não houve diferença entre os grupos quanto à pressão arterial média, frequência cardíaca, concentração expirada de sevoflurano e ao tempo de despertar. No pós-operatório, o consumo de morfina e a intensidade da dor foram similares entre os grupos, mas o grupo que recebeu 3 µg.Kg-1 de clonidina apresentou menor frequência cardíaca e maior sedação do que o grupo que recebeu somente bupivacaína. Conclusões: A associação de clonidina nas doses de 1, 2 ou 3 µg.Kg-1 à bupivacaína 0,166% por via peridural caudal não alterou o consumo de morfina no pós-operatório imediato de crianças submetidas à correção de hipospádia.

Comparative Evaluation of Pregabalin and Clonidine as Preemptive Analgesics for the Attenuation of Postoperative Pain Following Thoracolumbar Spine Surgery

STUDY DESIGN: Prospective, randomized, double blind, placebo-controlled study.PURPOSE: To compare clonidine and pregabalin with placebo for the attenuation of postoperative pain after thoracolumbar spinal surgery and instrumentationOVERVIEW OF LITERATURE: Spine surgery is associated with moderate to severe postoperative pain that needs to be controlled to improve patient’s outcome. Alpha 2 agonists (e.g., clonidine) and gabapentenoids (e.g., pregabalin) are successfully used as part of a multimodal analgesic regimen.METHODS: Total 75 patients were enrolled and randomly allocated into three groups. Group P received pregabalin (150 mg), group C received clonidine (150 mcg), and group N received placebo 90 minutes preoperatively. A standard anesthesia protocol comprising fentanyl, thiopentone, vecuronium, nitrous oxide, and oxygen in isoflurane was used for all patients. Postoperative recovery profile, pain, time for first analgesic, 24-hour analgesic requirement, sedation, and hemodynamic parameters were noted.RESULTS: Recovery profile was similar in all three groups; however, the patients in group P and C were more sedated (p<0.05). Group N patients had a higher Visual Analog Scale (VAS) score (p<0.05) and the time for first analgesic was also lower (p=0.02). Postoperative (24-hour) analgesic requirement was maximum in group N, followed by that in group C and group P. The VAS score was highest in the control group; however, after 12 hours, it was similar in all groups.CONCLUSIONS: Postoperative pain and analgesic requirement is significantly attenuated by preoperative administration of a single dose of clonidine (150 mcg) or pregabalin (150 mg); pregabalin was more effective. Thus, their use offers a reasonable strategy for pain management in patients undergoing spine surgery.

Bilateral sphenopalatine ganglion block versus intravenous clonidine premedication for surgical field improvement and postoperative pain relief in endoscopic sino-nasal surgery

ackground: Bilateral sphenopalatine ganglion block (SPGB) and IV clonidine premedication could provide better hemodynamic parameters, surgical field, postoperative pain control during endoscopic sino-nasal surgery. Design: prospectiverandomized controlled comparative study. Methods: A total of 69 patients of ASA grade I or II scheduled for endoscopic sino-nasal surgery were equally divided into three groups (23 patients each): control group; block group; and clonidine group. The sphenopalatine ganglion block technique done by lateral infra-zygomatic approach guided by x-ray fluoroscopy. Iv clonidine premedication was given 15 min before general anesthesia induction with dose 2 µg/kg as singe bolus. Surgical field quality assessment done by average category scale (ACS), hemodynamic profile and consumption of anesthetics were recorded. Postoperative pain evaluated by VAS. The time to first request for analgesia, analgesic requirement for 24 h postoperatively and any complications were recorded. Results: MAP and HR readings at most of intra and postoperative times, Average category scale score, intraoperative blood loss, average consumption of fentanyl and propofol and hypotensive agent (labetalol) were significantly high in control group when compared with block and clonidine groups and were significantly low in block group when compared with clonidine group except for postoperative HR.VASscore postoperatively, Time of first request of analgesia, Total pethidine consumption was significantly high in control group C when compared with block and clonidine groups. Conclusion: SPGB is effective for better hemodynamic control, surgical field and postoperative analgesia in endoscopic sino-nasal surgery when compared with IV clonidine premedication

Crises hipertensivas: definindo a gravidade e o tratamento / Hipertensive crises: defining he severity and treatment

As situações clínicas de aumento súbito da pressão arterial (PA) que caracterizam as crises hipertensivas são comuns na prática clínica, principalmente nas consultas realiza-das no pronto atendimento, portanto, o diagnóstico adequado é essencial para o melhor tratamento e desfecho clínico. A crise hipertensiva é definida pelo aumento súbito na PA (≥180 /120 mmHg) e a necessidade da redução agressiva da PA depende da gravidade da situação clinica associada. A presença de lesões novas ou progressivas em órgãos-alvo e risco iminente de morte definem as emergências hipertensivas que requerem tratamento imediato visando a rápida redução da pressão arterial, porém, não, necessariamente, a níveis normais. Na maioria dos casos, a velocidade do aumento da PA é mais importante que o nível real da PA, portanto, é fundamental que haja avaliação clínica para o diagnóstico preciso dessas condições clínicas, as quais incluem encefalopatia hipertensiva, síndromes coronarianas agudas, edema agudo dos pulmões, acidente vascular cerebral, dissecção de aorta e eclampsia. As metas para diminuição da PA para as emergências hipertensivas, de acordo com o órgão-alvo envolvido, são revisadas pelas atuais diretrizes brasileiras e ame-ricanas de hipertensão. O tratamento das emergências hipertensivas inclui vasodilatadores de ação direta e bloqueadores adrenérgicos já consagrados, entretanto, evidências recentes mostram o benefício do uso de novos fármacos ainda não disponíveis em nosso meio

The clinical conditions of an acute rise in blood pressure (BP) that characterize hyperten-sive crises are common in clinical practice, particularly in consultations that take place in the emergency room. Therefore the correct diagnosis is important for the best treatment and clinical outcome. Hypertensive crisis is defined as a sudden rise in BP (≥ 180/120 mmHg), and the need for aggressive reduction of BP depends on the severity of the associated clinical situation. The presence of new or progressive target organ injury and imminent risk of death define hypertensive emergencies requiring immediate treatment aimed at rapid reduction of blood pressure, not ne-cessarily to normal levels. In most cases, the speed of the rise in BP is more important than the actual level of BP, and clinical evaluation is essential for the accurate diagnosis of these clinical conditions, which include hypertensive encephalopathy, acute coronary syndromes, pulmonary edema, stroke, aortic dissection, and eclampsia. The goals of BP reduction for hypertensive emergencies, according to the target organ involved, have been reviewed by the current Brazi-lian and American guidelines on hypertension. Treatment of hypertensive emergencies includes direct action vasodilators and adrenergic blockers, which are already well established, but recent evidence shows the benefit of the use of new drugs, not yet available in Brazil

A prospective, randomized, double-blinded control study on comparison of tramadol, clonidine and dexmedetomidine for post spinal anesthesia shivering / Estudo prospectivo randômico, duplo-cego e controlado comparando tramadol, clonidina e dexmedetomidina para tremores pós-raquianestesia

Abstract Introduction Shivering, a common intraoperative problem under spinal anesthesia increases the oxygen consumption considerably and is uncomfortable and distressing to the patient, anesthesiologist as well as surgeon. The present study was designed to explore the effectiveness of tramadol, clonidine and dexmedetomidine in the treatment of post spinal anesthesia shivering and to look for their adverse effects. Methods This prospective, randomized, double blinded control study was done on 90 patients who developed shivering under spinal anesthesia. They were randomly allocated into three groups with Group T receiving tramadol 1 mg.kg-1, Group C getting clonidine 1 mcg.kg-1 and Group D patients receiving dexmedetomidine 0.5 mcg.kg-1. The time taken to control shivering, recurrence rate, hemodynamic variables, sedation score and adverse effects were observed. Results Dexmedetomidine was faster in the control of shivering in 5.7 ± 0.79 minutes (min) whereas tramadol took 6.76 ± 0.93 min and clonidine was slower with 9.43 ± 0.93 min. The recurrence rate was much lower in the dexmedetomidine group with 3.3% than for clonidine (10%) and tramadol (23.3%) group. The sedation achieved with dexmedetomidine was better than clonidine and tramadol. The tramadol group had more cases of vomiting (four) and dexmedetomidine group had six cases of hypotension and two cases of bradycardia. Two of the clonidine patients encountered bradycardia and hypotension. Conclusion Dexmedetomidine is better than tramadol and clonidine in the control of shivering because of its faster onset and less recurrence rate. Though complications are encountered in the dexmedetomidine group, they are treatable.

Resumo Introdução O tremor, problema comum no período intraoperatório sob raquianestesia, aumenta consideravelmente o consumo de oxigênio, além de ser desconfortável e angustiante para o paciente, o anestesiologista e o cirurgião. O presente estudo foi concebido para explorar a eficácia de tramadol, clonidina e dexmedetomidina no tratamento de tremores pós-raquianestesia e observar seus efeitos adversos. Métodos Este estudo prospectivo, randômico, controlado e duplo-cego foi feito com 90 pacientes que desenvolveram tremores sob raquianestesia. Os pacientes foram randomicamente alocados em três grupos para receber 1 mg.kg-1 de tramadol (Grupo T), 1 mcg.kg-1 de clonidina (Grupo C) e 0,5 mcg.kg-1 de dexmedetomidina (Grupo D). O tempo necessário para controlar os tremores, a taxa de recorrência, as variáveis hemodinâmicas, os níveis de sedação e os efeitos adversos foram registrados. Resultados Dexmedetomidina foi mais rápida para controlar os tremores, com tempo de 5,7 ± 0,79 minutos (min); o tempo de tramadol foi de 6,76 ± 0,93 min; clonidina foi mais lenta, com tempo de 9,43 ± 0,93 min. A taxa de recorrência foi muito menor no grupo dexmedetomidina (3,3%) do que nos grupos clonidina (10%) e tramadol (23,3%). A sedação obtida com dexmedetomidina foi melhor do que a obtida com clonidina e tramadol. O grupo tramadol teve mais casos de vômito (quatro); o grupo dexmedetomidina teve seis casos de hipotensão e dois casos de bradicardia. Dois pacientes do grupo clonidina apresentaram bradicardia e hipotensão. Conclusão Dexmedetomidina foi melhor do que tramadol e clonidina para o controle de tremores devido ao seu início de ação mais rápido e à taxa de recorrência mais baixa. Embora complicações tenham sido observadas no grupo dexmedetomidina, elas foram tratáveis.

A hipertensão e a medicina translacional / Hypertension in translacional cardiology

A nova fase de aceleração da transferência de conhecimento para a aplicação foi, simbolicamente, iniciada na década de 40, com o desenvolvimento da bomba atômica por um grupo notável de físicos. Na mesma época, o conhecimento transferido na Universidade de Stanford cria o Vale do Silício, onde se desenvolveu a indústria eletrônica com aplicação dos transistors. Logo, importantes universidades criam incubadoras e parques tecnológicos para acelerar a transferência do conhecimento para a aplicação, inaugurando-se a assim chamada Pesquisa Translacional. Na Medicina, só a partir do ano 2000, e com importante financiamento do National Institute of Health dos Estados Unidos, é que se inicia o movimento, sistematizando a transferência e criando-se a Medicina Translacional. Nessa revisão, apresentaremos dois exemplos de Medicina Translacional (Cardiologia Translacional) provenientes de pesquisas do nosso grupo de Hipertensão do Instituto do Coração (InCor). O primeiro ilustra a retroalimentação entre a pesquisa básica e a clínica, estudando a influência da hiperatividade da enzima conversora da angiotensina no desenvolvimento da hipertrofia cardíaca clínica (polimorfismo do gene da ECA) e em camundongos com uma, duas, três e quatro cópias do gene da enzima conversora, submetidos a natação ou coarctação da aorta. O segundo ilustra a transferência do conhecimento obtido na investigação clínica para a prática médica, com um estudo multicêntrico (25 centros do Brasil) sobre a prevalência da hipertensão resistente na população brasileira e a comparação da clonidina e espirolactona como quarta droga a ser administrada nos pacientes resistentes: Estudo Multicêntrico de Pacientes com Hipertensão Arterial para Identificação de Pacientes Resistentes e Padronização de Esquema Terapêutico. Os dois exemplos ilustram a importância das instituições (no caso, o InCor) propiciarem condições e ambientes favoráveis para que os profissionais de diferentes disciplinas (clínicos, fisiologistas, biologistas moleculares, bioengenheiros, enfermeiros, nutricionistas, fisioterapeutas, educadores físicos etc) trabalhem integrados e pratiquem a Cardiologia Translacional

The acceleration of the transfer of knowledge to application began symbolically in the 1940s, with the development of the atomic bomb by a notable group of physicists. In that same period, the knowledge transferred from Stanford University led to the creation of Silicon Valley, where the electronic industry was developed with the application of transistors. Soon afterwards, major universities created incubators and technology parks in order to accelerate the transfer of knowledge to application, inaugurating the concept of Translational Research. In the field of Medicine, the transfer systematization process began in 2000, with important funding from the US National Institute of Health, creating Translational Medicine. In this review, two examples of Translational Medicine (Translational Cardiology) from research by our Hypertension team of the Heart Institute (InCor) are presented. The first illustrates the feedback between basic and clinical research, studying the influence of the hyperactivity of the angiotensin converting enzyme in the development of clinical cardiac hypertrophy (polymorphism of the ACE gene) and in mice with one, two, three and four copies of the converting enzyme gene, submitted to swimming or aortic coarctation. The second illustrates the transfer of knowledge obtained in the clinical investigation to clinic practice with a multicenter trial (25 centers in Brazil) on the prevalence of resistant hypertension in the Brazilian population, and the comparison of clonidine and spirolactone as a forth drug to be administrated in resistant patients: Multicenter Study of Patients with Arterial Hypertension for Identification of Resistant Patients and Standardization of the Therapeutic Regimen. Both examples illustrate the importance of institutions (in this case, InCor) in providing a favorable environment and conditions for professionals from different disciplines (clinicians, physiologists, molecular biologists, bioengineers, nurses, nutritionists, physiotherapists, physical educators, etc.) to work in an integrated way and practice Translational Cardiology

Therapeutic alternatives in painful diabetic neuropathy: a meta-analysis of randomized controlled trials

BACKGROUND: One of the most frequent problems caused by diabetes is the so called painful diabetic neuropathy. This condition can be treated through numerous types of therapy. The purpose of this study was to analyze, as a meta-analysis, different treatments used to alleviate painful diabetic neuropathy, with the aim of generating results that help making decisions when applying such treatments to tackle this pathology. METHODS: A search was conducted in the main databases for Health Sciences, such as PUBMED, Web of Science (WOS), and IME biomedicina (Spanish Medical Reports in Biomedicine), to gather randomized controlled trials about treatments used for painful diabetic neuropathy. The analyzed studies were required to meet the inclusion criteria selected, especially those results related to pain intensity. RESULTS: Nine randomized controlled trials were chosen. The meta-analysis shows significant positive effects for those treatments based on tapentadol [g: −1.333, 95% CI (−1.594; −1.072), P < 0.05], duloxetine [g: −1.622, 95 % CI (−1.650; −1.594), P < 0.05], pregabalin [g: −0.607, 95% CI (−0.980; −0.325), P < 0.05], and clonidine [g: −0.242, 95 % CI (−0.543; −0.058), P < 0.05]. CONCLUSIONS: This meta-analysis indicates the effectiveness of the treatments based on duloxetine, gabapentin and pregabalin, as well as other drugs, such as tapentadol and topic clonidine, whose use is better prescribed in more specific situations. The results provided can help increase the knowledge about the treatment of painful diabetic neuropathy and also in the making of clinical practice guidelines for healthcare professionals.

Chronic postsurgical pain: current evidence for prevention and management

Chronic postsurgical pain (CPSP) is an unwanted adverse event in any operation. It leads to functional limitations and psychological trauma for patients, and leaves the operative team with feelings of failure and humiliation. Therefore, it is crucial that preventive strategies for CPSP are considered in high-risk operations. Various techniques have been implemented to reduce the risk with variable success. Identifying the risk factors for each patient and applying a timely preventive strategy may help patients avoid the distress of chronic pain. The preventive strategies include modification of the surgical technique, good pain control throughout the perioperative period, and preoperative psychological intervention focusing on the psychosocial and cognitive risk factors. Appropriate management of CPSP patients is also necessary to reduce their suffering. CPSP usually has a neuropathic pain component; therefore, the current recommendations are based on data on chronic neuropathic pain. Hence, voltage-dependent calcium channel antagonists, antidepressants, topical lidocaine and topical capsaicin are the main pharmacological treatments. Paracetamol, NSAIDs and weak opioids can be used according to symptom severity, but strong opioids should be used with great caution and are not recommended. Other drugs that may be helpful are ketamine, clonidine, and intravenous lidocaine infusion. For patients with failed pharmacological treatment, consideration should be given to pain interventions; examples include transcutaneous electrical nerve stimulation, botulinum toxin injections, pulsed radiofrequency, nerve blocks, nerve ablation, neuromodulation and surgical management. Physical therapy, cognitive behavioral therapy and lifestyle modifications are also useful for relieving the pain and distress experienced by CPSP patients.

Treatment of Children and Adolescents with Attention Deficit Hyperactivity Disorder and/or Tourette's Disorder with Clonidine Extended Release

We aimed to assess the effectiveness and safety of clonidine extended release (ER) treatment in Korean youth with ADHD and/or Tourette's disorder. We retrospectively reviewed the medical records of 29 children and adolescents treated with clonidine ER. The effectiveness were retrospectively measured at baseline and after 4 and 12 weeks based on the Clinical Global Impression-Severity (CGI-S) and Clinical Global Impression-Improvement (CGI-I) scores. Safety was evaluated at each visit based on spontaneous reports from the subjects or from their parents/guardians. Significant decreases in the CGI-S scores for both ADHD (F=23.478, p < 0.001, partial η2=0.540) and tic symptoms (F=15.137, p < 0.001, partial η2=0.443) were noted over 12 weeks. The most common adverse event was somnolence (n=9, 31.0%) and life-threatening adverse effects were not observed. Our results provide preliminary evidence for the effectiveness and safety of clonidine ER.