Intervencionismo para el control del dolor por metástasis óseas / Interventionism for pain control due bone metastases

Objetivo: El dolor óseo por cáncer óseo o metástasis es un dolor de difícil manejo asociado a dolor incidental. Hay distintas estrategias quirúrgicas para su tratamiento, sin embargo, no todos los pacientes con metástasis óseas pueden beneficiarse de un tratamiento quirúrgico. La presente revisión bibliográfica tiene como objetivo identificar terapias intervencionales mínimamente invasivas para el control del dolor por metástasis óseas. Métodos: Revisión bibliográfica acerca de terapias intervencionales para el control del dolor por metástasis óseas utilizando la base de datos PubMed (www.pubmed.gov) y el motor de búsqueda Google (www.google.cl). Tipos de participantes: Pacientes con metástasis óseas dolorosas de cualquier tumor primario. Tipos de intervenciones: Bloqueos anestésicos, bloqueos neurolíticos, terapias ablativas, cementoplastías. Resultados: Se obtuvieron 384 resultados que incluyeron revisiones sistemáticas, revisiones bibliográficas, ensayos clínicos controlados, series de casos y reporte de casos. Todos los artículos relevantes en inglés y español se incluyeron para su análisis. Conclusión: Las metástasis óseas son un evento común en los pacientes con cáncer, y el dolor óseo es un dolor de difícil manejo asociado a dolor incidental. Se han desarrollado terapias intervencionales no invasivas o mínimamente invasivas para tratar el dolor, mejorar la calidad de vida y la funcionalidad, disminuir el consumo de fármacos, y reducir el tamaño del tumor. La gran mayoría ha demostrado ser terapias seguras y eficaces, con pocos eventos adversos y de rápida resolución, y que si son combinadas mejoran los resultados.

Objective: Bone pain from bone cancer or metastasis is a pain that is difficult to manage associated with incidental pain. There are different surgical strategies for its treatment, however, not all patients with bone metastases can benefit from a surgical treatment. This literature review aims to identify minimally invasive interventional therapies for the control of pain due to bone metastasis. Methods: Literature review of interventional therapies for the control of pain due to bone metastases was done using the PubMed database (www.pubmed.gov) and the Google search engine (www.google.cl). Types of participants: Patients with painful bone metastases from any primary tumor. Types of interventions: Anesthetic blocks, neurolytic blocks, ablative therapies, cementoplasties. Results: We obtained 384 results that included systematic reviews, literature reviews, controlled clinical trials, case series and case reports. All relevant articles in English and Spanish were included for analysis. Conclusion: Bone metastases are a common event in cancer patients, and bone pain is a difficult-to-manage pain associated with incidental pain. Non-invasive or minimally invasive interventional therapies have been developed to treat pain, improve quality of life and functionality, decrease drug use, and reduce tumor size. The vast majority therapies have been shown to be safe and effective ones, with few adverse events and rapid resolution, and that if combined they improve the outcomes.

Relação entre Norepinefrina Urinária, Fibrose e Arritmias na Cardiopatia Chagásica Crônica com Fração de Ejeção Preservada ou Minimamente Reduzida / Relationship between Urinary Norepinephrine, Fibrosis, and Arrhythmias in Chronic Chagas Heart Disease with Preserved or Mildly Reduced Ejection Fraction

Resumo Fundamento: Na cardiomiopatia chagásica crônica (CCC), impõem-se estudos com a proposta de identificar fatores de risco arritmogênicos em pacientes nos quais a disfunção ventricular de moderada a grave não está presente. Objetivos: Verificar a dependência entre arritmias ventriculares frequentes (ARV), fração de ejeção de ventrículo esquerdo (FEVE), extensão da fibrose pela ressonância magnética cardíaca (RMC) e dosagem de norepinefrina urinária (NOREPI) na CCC com FEVE preservada ou minimamente comprometida. Métodos: Foi analisada no Holter a presença de extrassístoles ventriculares >30/hora. Na RMC, avaliou-se a FEVE e a quantificação de massa fibrosada. Foi realizada a dosagem de NOREPI pelo método de Muskiet. A matriz de correlação foi calculada para aferir a capacidade de as variáveis preverem outra sendo considerado significante p<0,05. Resultados: Foram incluídos no estudo 59 pacientes, com idade média de 57,9±10,94 anos. Arritmia ventricular frequente (ARV) foi detectada em 28 pacientes. A variável fibrose mostrou-se inversamente proporcional à fração de ejeção de ventrículo esquerdo (FEVE) (R de −0,61) e à norepinefrina urinária (NOREPI) (R de −0,68), assim como a variável ARV mostrou-se inversamente proporcional à FEVE (R de −0,33) e à NOREPI (R de −0,27). Já a FEVE mostrou-se diretamente proporcional à NOREPI (R de 0,83). Conclusão: Nesta amostra, em pacientes com CCC com FEVE preservada ou discretamente reduzida, observa-se a integridade do sistema nervoso autonômico em corações com pouca fibrose e FEVE mais elevada, apesar da presença de tradicionais fatores de risco para morte súbita cardíaca. Há dependência entre os níveis de NOREPI, FEVE e fibrose miocárdica, mas não com ARV.

Abstract Background: In Chronic Chagas Cardiomyopathy (CCC), studies are needed to identify arrhythmogenic risk factors in patients in which moderate to severe ventricular dysfunction is not present. Objective: To verify the correlation between frequent ventricular arrhythmias (PVC), left ventricular ejection fraction (LVEF), extension of fibrosis by cardiac magnetic resonance (CMR), and urinary norepinephrine measurement (NOREPI) in CCC with preserved or mildly compromised LVEF. Methods: The presence of ventricular extrasystoles > 30/h was analyzed on Holter. At CMR, LVEF and quantification of fibrosis mass were evaluated. The dosage of NOREPI was performed using the Muskiet method. The correlation coefficient matrix was calculated to measure the predictive ability of the variables to predict another variable, with p < 0.05 being considered significant. Results: A total of 59 patients were included. The mean age was 57.9 + 10.94 years. PVC was detected in 28 patients. The fibrosis variable was inversely proportional to LVEF (R of −0.61) and NOREPI (R of −0.68). Also, the variable PVC was inversely proportional to LVEF (R of −0.33) and NOREPI (R of −0.27). On the other hand, LVEF was directly proportional to NOREPI (R of 0.83). Conclusion: In this sample, in patients with CCC with preserved or slightly reduced LVEF, integrity of the autonomic nervous system is observed in hearts with little fibrosis and higher LVEF despite the presence of traditional risk factors for sudden cardiac death. There is correlation between the levels of NOREPI, LVEF, and myocardial fibrosis, but not with PVC.

Estratificação de Risco e Avaliação da Atividade Simpática Cardíaca Utilizando Imagem Miocárdica com [123I] MIBG na Denervação Renal / Risk Stratification and Cardiac Sympathetic Activity Assessment Using Myocardial [123I] MIBG Imaging in Renal Denervation

Resumo A hiperativação do sistema nervoso simpático desempenha um papel central na fisiopatologia da hipertensão. O objetivo deste estudo foi avaliar a atividade simpática cardíaca e investigar o papel da cintigrafia miocárdica com metaiodobenzilguanidina com 123I ([123I] MIBG) na estratificação de risco cardiovascular de pacientes com hipertensão resistente tratados com denervação renal (DR). Dezoito pacientes foram incluídos neste estudo prospectivo (média de idade de 56 ± 10 anos, 27,8% mulheres). Ecocardiograma transtorácico, análise geral do sangue e cintilografia miocárdica com [(123I) MIBG] foram realizados antes e seis meses após a DR. Um paciente era considerado respondedor (R) se uma diminuição ≥ 5 mmHg na pressão arterial sistólica (PAS) média ambulatorial fosse observada no seguimento de seis meses. 66,7% dos pacientes foram R (diminuição na PAS de 20,6 ± 14,5 mmHg, vs. menos 8 ± 11,6 mmHg em não-respondedores (NR), p = 0,001). A relação coração-mediastino (RCM) inicial foi significativamente menor na linha basal no grupo R (1,6 ± 0,1 vs. 1,72 ± 0,1, p <0,02), mas semelhante em seis meses. Considerando os dois momentos no tempo, o grupo R teve valores iniciais de RCM mais baixos do que o grupo NR (p <0,05). Tanto o RCM tardio quanto a taxa de washout foram idênticos e nenhuma correlação significativa entre a resposta à DR ou qualquer índice de imagem com MIBG foi encontrada. A denervação renal efetivamente reduziu a pressão arterial na maioria dos pacientes, mas a imagem com [123I] MIBG não foi útil na previsão da resposta. Entretanto, houve evidência de overdrive do sistema nervoso simpático e, tanto a RCM inicial quanto tardia estavam reduzidas em geral, provavelmente colocando essa população em um risco maior de eventos adversos.

Abstract Hyperactivation of the sympathetic nervous system plays a central role in the pathophysiology of hypertension. The aim of this study was to assess cardiac sympathetic activity and investigate the role of myocardial123I-labelled meta-iodo benzyl guanidine ([123I] MIBG) scintigraphy in cardiovascular risk stratification of patients with resistant hypertension treated with renal denervation (RDN). Eighteen patients were included in this prospective study (mean age 56 ± 10 years old, 27.8% females). Transthoracic echocardiogram, general blood analysis and myocardial ([123I] MIBG scintigraphy were performed before and six-months after RDN. A patient was considered a responder (R) if a drop ≥ 5mmHg on mean systolic ambulatory blood pressure (BP) monitoring was observed at the six-month follow-up. 66.7% of patients were R (drop in systolic BP of 20.6 ± 14.5mmHg, vs minus 8 ± 11.6mmHg in non-responders (NR), p=0.001). Early heart-mediastinum ratio (HMR) was significantly lower at baseline in the R group (1.6 ± 0.1 vs 1.72 ± 0.1, p<0.02) but similar at six months. Considering both instants in time, the R group had lower early HMR values than the NR group (p<0.05). Both the late HMR and the washout rate were identical and no significant correlation between response to RDN or any MIBG imaging index was found. Renal denervation effectively lowered blood pressure in the majority of patients but [123I] MIBG was not useful in predicting the response. However, there was evidence of sympathetic overdrive and, both early and late HMR were overall reduced, probably putting this population at a higher risk of adverse events.

Denervação de artéria renal em paciente com hipertensão arterial refratária / Renal denervation in patient with refrataryarterial hypertension

Caso clínico de uma paciente com quadro de hipertensão arterial refratária, sendo inicialmente atribuída como etiologia a displasia de artéria renal. Os níveis pressóricos mantiveram elevados após a angioplastia de artéria renal, mantendo descontrole pressórico apesar do uso de 10 classes de anti-hipertensivos. Foi indicada a denervação de artéria renal e após tal, foi possível redução das medicações e êxito no controle de seus níveis tensionais. Destaca-se a importância do adequado diagnóstico de hipertensão arterial refratária, a exclusão de hipertensão secundária, somado à otimização terapêutica e indicação de procedimentos quando necessário, tendo como objetivo o melhor controle pressórico e consequente redução de lesões de órgãos-alvo e eventos cardiovasculares graves (AU).

It will be explained the patient clinical case of with refractory hypertension, which was initially attributed to renal artery dysplasia, but after the renal artery angioplasty, remained with high blood pressure levels despite adequate anti-hypertensive drugs administration. Renal denervation was indicated and after medications was reduced, with adequate blood pressure level control. It emphasizes the importance of secondary hypertension diagnosis, therapeutic optimization and specific therapies, if necessary, with the aim to take blood pressure control and the consequent reduction of target-organ damage and severe vascular events (AU).

Denervação simpática renal no tratamento da hipertensão arterial resistente: relato de caso / Renal sympathetic denervation in the treatment of resistant arterial hypertension: case report

Introdução: A hipertensão arterial sistêmica (HAS) pode levar a consequências cardiovasculares graves quando não tratadas adequadamente. No entanto, alguns indivíduos, mesmo realizando tratamento recomendado, a pressão arterial (PA) se mantém elevada, passando a ser chamada de hipertensão arterial refratária (HAR). A denervação simpática renal (DSR) é uma terapia amplamente estuda e com resultados promissores que surgiu como alternativa para controlar a PA em pacientes resistentes ao tratamento convencional. Relato de caso: Participante da pesquisa, sexo masculino, 67 anos, com queixa de cefaleia e elevação dos níveis pressóricos. Avaliação cardíaca com alteração apenas da PA (182x113 mmHg), demais sistemas sem variações. Diagnosticado com HAS estágio 3, realizou todas as etapas do tratamento medicamentoso, porém resistente as terapias propostas. Diante do caso, foi diagnosticado com HAR. Sendo realizado DSR que mostrou resultados satisfatórios de redução progressiva da pressão arterial central e periférica. Conclusão: A DSR mostrou-se eficaz no controle gradual e sustentado da PA do participante da pesquisa. Contudo, somente através de estudos clínicos mais amplos e rigorosos será capaz de comprovar a eficácia da DSR no tratamento da PA alta persistente (AU).

Introduction: Systemic arterial hypertension (SHT) can lead to severe cardiovascular outcomes when not properly treated. However, in some individuals, even with recommended treatment, blood pressure (BP) remains high, and is now referred to as Resistant hypertension (RHTN). Renal sympathetic denervation (RDn) is a widely studied and promising therapy that has emerged as an alternative to control BP in patients resistant to conventional treatment. Case report: Research participant, male, 67 years old, complaining of headache and elevated blood pressure. Cardiac assessment with only BP alteration (182x113 mmHg), other systems without variations. Diagnosed with stage 3 hypertension, performed all stages of drug treatment, but resistant to the proposed therapies. Given the case, was diagnosed with RHTN. Being performed RDn that showed satisfactory results of progressive reduction of central and peripheral blood pressure. Discussion: Sympathetic hyperactivity of the renal nervous system releases catecholamines that raise BP. Based on this, the RDn uses a catheter connected to the radiofrequency device that through the femoral artery goes to the two renal arteries and emits energy in the sympathetic fibers attached to the walls of these arteries, destroying them. RDn has been the target of several clinical studies, the best-known being Simplicity HTN-1, 2 and 3 which brought significant and questionable results regarding the efficacy of the procedure. Conclusion: RDn proved to be effective in gradually and sustained BP control of the research participant. However, only through broader and more rigorous clinical studies will it be able to prove the efficacy of RDn in combating persistent high BP (AU).

Visualized analysis of researches on denervated muscle atrophy in the past five years / 中国康复理论与实践

@#Objective To perform a visualized analysis of the current status, hotspots and frontiers of research on denervated muscle atrophy in the past five years.Methods The Web of Science core database was used to retrieve relevant documents in the field of denervated muscle atrophy, and visualized analysis was performed on CiteSpace 5.8.R3 in terms of annual number of published papers, frequency of citations, countries, institutions, authors, keywords and references.Results A total of 516 articles were retrieved from 2017 to 2021. The annual number of published papers was on the rise, and the number of citations was increasing year by year. The United States, Canada and England were high-influence countries, the University of Padua in Italy was the leading institution. The author SUN Hualin published the most articles. The authors Bodine S C and Sandri M were the main influencers. Physiological and pathological mechanisms based on cytology, molecular biology and tissue morphology, as well as prevention and treatment measures based on physical factor therapy, drugs and exercise were the research hotspots in this field. It might be coming that taking reactive oxygen species as the target and looking for multi-targeted proteolytic system drugs as the goal for prevention and treatment.Conclusion This visualized analysis has comprehensively summarized the trends and development of denervated muscle atrophy research, and identified the potential research frontiers and hot directions in the near future.

Manejo terapéutico kinésico en pacientes pediátricos con parálisis facial sometidos a cirugía reconstructiva / Kinesic therapeutic management in pediatric patients with facial palsy undergoing reconstructive surgery

La Parálisis Facial (PF) es una condición infrecuente en pacientes pediátricos, representa un problema clínico relevante y conlleva diversas implicaciones. Tanto el curso natural como el tratamiento y pronóstico no se encuentran bien documentados en la literatura, más aún en sujetos sometidos a cirugía. Se presentan 2 casos de PF sometidos a cirugía reconstructiva, niño de 9 años y niña de 8, ambos casos revisados de forma retrospectiva. Se planteó un bordaje y evaluación kinésica estructurado como tratamiento para estos pacientes. El sistema de graduación facial Sunnybrook (SGFS) fue usado para evaluar resultados funcionales. Durante el seguimiento los sujetos mostraron mejoras continuas con una ganancia promedio de 30 puntos en el SGFS. En nuestra experiencia, la rehabilitación kinésica estructurada con el enfoque presentado, parece ser un coadyuvante efectivo en potenciar el proceso de recuperación de la función muscular y simetría facial en sujetos con PF sometidos a cirugía reconstructiva.

Facial Palsy (FP) is an uncommon condition in pediatric patients, it represents a serious linical problem and carries various implications. Both the natural course, as well as the treatment and prognosis are not well documented in the literature especially in subjects undergoing surgery. Two cases of FP undergoing reconstructive surgery are presented, a 9-year-old boy and an 8-year-old girl, both cases reviewed retrospectively. A structured kinesic approach and valuation was proposed as a treatment for these patients. The Sunnybrook Facial Grading System (SGFS) was applied to evaluate functional outcomes. During follow-up the subjects showed continuous improvement with an average increment of 30 points in the SGFS. In our experience, structured kinesic rehabilitation with the approach presented, seems to be an effective adjunct in enhancing the process of recovery of muscle function and facial symmetry in subjects with FP undergoing reconstructive surgery.

Autonomic Innervation Evaluation in Cardiac Disease

Abstract Cardiovascular diseases are among the leading causes of mortality and morbidity in the world. In different cardiac diseases, the neuronal function of the heart is impaired. Nevertheless, the development of a simple method to assess the autonomic effects on the heart and/or autonomic dysfunction is a challenge. The evaluation of autonomic innervation in cardiac diseases has helped to improve the knowledge of the pathophysiology of these conditions, as well as to provide information on their prognosis. Single photon emission computed tomography (SPECT) and positron emission tomography (PET) are currently the only imaging methods that allow in vivo assessment of cardiac innervation. The majority of SPECT and PET radiotracers evaluate sympathetic neuronal integrity using presynaptic imaging agents that are either labeled as endogenous transmitters or analogues. Postsynaptic imaging agents have also been developed to study sympathetic neuronal integrity, as well as tracers to investigate the parasympathetic nervous system. These methods may be used to analyze the innervation of the heart and allow for early detection of abnormalities caused by, for example, ischemia, heart failure, cardiomyopathies, cardiotoxicity, and arrhythmogenic disorders. This review provides an overview of cardiac innervation evaluation and their application in the assessment of heart disease.

White matter hyperintensities: repercussion on grey matter structures of the brain / Hiperintensidades da substância branca: repercussão em estruturas da substância cinzenta do cérebro

The extensive white matter of the brain, which comprises about one half of its volume, is constituted by an intricate and interwoven assemble of nerve fibers. The WMH (leukoaraiosis) represent the most frequent ischemic type of lesion of SVD, affecting the white matter. These lesions may be apparent or normal appearing on neuroimaging. In both cases such lesions may interrupt the affected white matter fibers, with consequent disconnection syndromes, and atrophy of the denervated grey matter structures. These conditions affect the structural neural networks (connectome), with functional repercussion on the cognitive and behavioral domains.

A extensa substância branca do cérebro, que compreende cerca da metade do seu volume, é constituída por um intricado e entrelaçado conjunto de fibras nervosas. As HSB (hiperintensidades da substância branca) (leucoaraiose) representam o mais frequente tipo de lesão isquêmica da DPV (doença dos pequenos vasos) que afeta a substância branca. Essas lesões podem ser aparentes ou de aparência normal na neuroimagem. Em ambos os casos tais lesões podem interromper essas fibras da substância branca, com consequente síndromes por desconexão e atrofia de estruturas de substância cinzenta desnervadas. Essas condições afetam as redes neurais estruturais (conectoma), com repercussão funcional nos domínios cognitivo e do comportamento.

The use of dexmedetomidine in puncture techniques for degenerative diseases of the lumbar spine / Uso de dexmedetomidina em técnicas de punção para doenças degenerativas da coluna lombar / Uso de dexmedetomidina en técnicas de punción para enfermedades degenerativas de la columna lumbar

ABSTRACT Objective To analyze the results of the use of dexmedetomidine (D) in the treatment of patients with degenerative diseases of the lumbar spine using puncture techniques. Methods The study included 77 patients who underwent surgical puncture for degenerative diseases of the lumbar spine with the use of alpha-2-adrenomimetic D: percutaneous laser denervation of the facet joints (n = 46) and posterolateral transforaminal endoscopic discectomy (n = 31). We assessed: the level of sedation using the Ramsay Sedation Scale (RSS) and the Richmond Agitation Sedation Scale (RASS); intraoperative dynamics of the cardiovascular and respiratory system parameters; the level of pain syndrome according to VAS. Results A high intraoperative level of sedation was determined, with RASS -2, -3 and Ramsay III, IV; when transferring a patient to a department (in 90 minutes) this parameter was RASS 0 and Ramsay II. There were no significant changes in central hemodynamics and respiratory depression. The minimum level of pain was determined immediately after surgery, at 30 and 60 minutes after surgery, and before transfer to the department (90 minutes): 6 (4;9); 10 (8;12); 12 (9;13); 16 (13;19) respectively. The absence of the need for additional analgesia on the first postoperative day was verified. Conclusion The use of D significantly reduces the level of pain, while maintaining the necessary verbal contact with the patient, and provides the necessary neurovegetative protection without respiratory depression or lowered hemodynamic parameters during the perioperative period. Level of evidence II; Prognostic Studies - Investigating the Effect of a Patient Characteristic on Disease Outcome. Case series, retrospective study.

RESUMO Objetivo Analisar os resultados do uso de dexmedetomidina (D) no tratamento de pacientes com doenças degenerativas da coluna lombar com técnicas de punção. Métodos O estudo incluiu 77 pacientes submetidos à punção cirúrgica em doenças degenerativas da coluna lombar com o uso de um agonista alfa-2 adrenérgico: denervação percutânea das articulações facetárias com laser (n = 46) e discectomia endoscópica transforaminal posterolateral (n = 31). Foram avaliados o nível de sedação usando a Escala de Sedação de Ramsay (RSS) e a Escala de Sedação e Agitação de Richmond (RASS); a dinâmica intraoperatória dos parâmetros dos sistemas cardiovascular e respiratório; o nível de síndrome de dor de acordo com a EVA. Resultados Determinou-se um alto nível intraoperatório de sedação pela RASS (-2, -3) e pela Ramsay (III, IV). Ao transferir um paciente para outro setor (depois de 90 minutos), esse parâmetro era 0 em RASS e II em Ramsay. Não houve alterações significativas na hemodinâmica central e na depressão respiratória. O nível mínimo de dor foi determinado imediatamente após a cirurgia, 30 e 60 minutos depois da cirurgia e antes da transferência para o outro setor (90 minutos depois): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Constatou-se que não era necessária analgesia adicional no primeiro dia pós-operatório. Conclusões O uso de D reduz significativamente o nível de dor mantendo a comunicação verbal necessária com o paciente e fornece a proteção neurovegetativa necessária sem depressão respiratória e os parâmetros hemodinâmicos reduzidos durante o período perioperatório. Nível de evidência II; Estudos prognósticos - Investigação do efeito de característica de um paciente sobre o desfecho da doença. Série de casos, Estudo retrospectivo.

RESUMEN Objetivo Analizar los resultados del uso de dexmedetomidina (D) en el tratamiento de pacientes con enfermedades degenerativas de la columna lumbar con técnicas de punción. Métodos El estudio incluyó a 77 pacientes con enfermedades degenerativas de la columna lumbar que se sometieron a punción quirúrgica mediante el uso de un agonista adrenérgico alfa-2: denervación percutánea de las articulaciones facetarias con láser (n = 46) y discectomía endoscópica transforaminal posterolateral (n = 31). Fueron evaluados el nivel de sedación mediante la Escala de Sedación de Ramsay (RSS) y la Escala de Sedación y Agitación de Richmond (RASS); la dinámica intraoperatoria de los parámetros de los sistemas cardiovascular y respiratorio; el nivel del síndrome de dolor según la EVA. Resultados Se determinó un alto nivel de sedación intraoperatoria en RASS (-2, -3) y por Ramsay (III, IV)Al transferir un paciente a otro sector (después de 90 minutos), este parámetro fue 0 en RASS y II en Ramsay. No hubo cambios significativos en la hemodinámica central y la depresión respiratoria.El nivel mínimo de dolor se determinó después de la cirugía, 30 y 60 minutos después de la cirugía y antes del traslado al otro sector (90 minutos después): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Se verificó que no era necesaria analgesia adicional el primer día postoperatorio. Conclusiones El uso de D reduce significativamente el nivel de dolor al mismo tiempo que se mantiene la necesaria comunicación verbal con el paciente y brinda la protección neurovegetativa necesaria sin depresión respiratoria y parámetros hemodinámico reducidos durante el período perioperatorio. Nivel de evidencia II; Estudios de pronóstico: Investigación del efecto de la característica de un paciente sobre el desenlace de la enfermedad. Serie de casos, Estudio retrospectivo.

A morphological study of denervation and reinnervation of neuromuscular junction and muscle spindle after sciatic nerve crush in mice / 中华显微外科杂志

Objective:To observe the denervation and reinnervation of the neuromuscular junction (NMJ) and muscle spindle after sciatic nerve crush in mice.Methods:From January, 2019 to October, 2019, 18 C57BL/6 mice were randomly and evenly divided into injured groups (sciatic nerve crush group, 12 mice) and control groups (sham group, 6 mice). Mice in the injured group were sacrificed at day-1, day-2, day-3 and 4 weeks after the sciatic nerve injury. Mice in the control group were sacrificed at day-3 and 4 weeks from the day of experiment. The tibialis anterior muscles with crushed nerve were collected for immunohistochemistry staining by neurofilament (NF), synaptophysin (Syn) and α-bungarotoxin (α-BTX). Data were analysed by unpaired t-test. P<0.05 was considered significant difference. Results:The completely denervation of NMJ reached (92.4±8.85)% at day-3 after the nerve crush, compared with (5.19±1.32)% in the control group ( P<0.05). However, the muscle spindle lost γ-motor neuron innervation at day-2 after the nerve crush and completely denervated at day-3 after the surgery. For the reinnervation, no difference of no reinnervation of NMJ [(3.02±0.78)% vs. (4.22±2.08)%], partial reinnervation of NMJ [(6.44±1.91)% vs. (7.94±2.12)%] and completely reinnervation of NMJ [(90.54±10.44)% vs. (87.84±13.89)%] were observed between the control group and the injured group 4 weeks after the injury. While, for the muscle spindle, only the acetylcholine receptors at each end were partly reinnervated. The innervation of the middle part of the muscle spindle was thin and discontinued without typical spiral winding structure. Conclusion:The denervation speed of NMJ and muscle spindle was comparable after the peripheral nerve injury. The γ-motor neuron lost innervation ahead of the sensory neuron in the muscle spindle. The reinnervation of NMJ is earlier than that of the muscle spindle, and the re-innervation of the γ-motor neuron is prior to the sensory neuron in the muscle spindle.

Wide Pulse Width Electroacupuncture Ameliorates Denervation-Induced Skeletal Muscle Atrophy in Rats via IGF-1/PI3K/Akt Pathway / 中国结合医学杂志

OBJECTIVE@#To evaluate the effect of the pulse width of electroacupuncture (EA) in the treatment of denervation-induced skeletal muscle atrophy in rats and examine the role of insulin-like growth factor 1 (IGF-1)/phosphatidylinositol 3-kinase (PI3K)/Akt signaling pathway during EA.@*METHODS@#Sciatic nerve functional index (SFI), muscle wet weight and the cross-sectional area (CSA) of the gastrocnemius muscle were analyzed after treatment in model rats with EA of various pulse widths (0.5, 50, 100 and 200 ms). The apoptosis index (AI) and paired box (PAX)3 and PAX7 protein expression were also determined. Further, the mRNA and protein expressions of components of IGF-1/PI3K/Akt pathway and their downstream targets were determined, along with the inhibiting effect of the pathway with a PI3-specific inhibitor.@*RESULTS@#EA with a pulse width of 200 ms was found to have the best effect with regard to increasing SFI, CSA and muscle weight, decreasing AI, and increasing the expression of PAX3 and PAX7. The IGF-1/PI3K/Akt pathway was found to be activated by denervation, although the downstream forkhead box O (FoxO) pathway was not suppressed by its activation. The PI3K/Akt pathway and its downstream molecule mammalian target of rapamycin (mTOR) were up-regulated further by EA to promote muscle protein synthesis. Meanwhile, the expressions of downstream FoxO and F-box protein 32 (ATROGIN-1) were down-regulated to reduce protein degradation.@*CONCLUSIONS@#EA with 200-ms pulse width was found to have a more significant effect than 0.5-ms EA. The positive effects of EA disappeared after inhibition of the PI3K/Akt pathway.

Terminology and Legislation referring to Percutaneous Facet Procedures to Treat Low Back Pain in Brazil ­ Current Status

Incongruities in the terminology and in the Brazilian legislation about percutaneous facet procedures (PFPs) for the treatment of chronic lower back pain are frequently the subject of litigations between health professionals and supplementary healthcare providers. The Brazilian Hierarchical Classification of Medical Procedures (CBHPM, in the Portuguese acronym) describes four types of PFPs, while the Brazilian Unified Supplementary Health Terminology (TUSS, in the Portuguese acronym) describes five distinct lumbar PFPs, which correlate with the ones described on the List of Procedures and Events in Health, created by the Brazilian National Agency of Supplementary Health (ANS, in the Portuguese acronym). In the present paper, we review the terminology of the procedures, proposing the unification of the terminology and the abolition of redundancies in the tables. Finally, we developed a single terminology proposal for the PFPs based on their complexity and objectives to be used for the treatment of lower back pain.

Renal sympathetic denervation for resistant hypertension: where do we stand after more than a decade / Denervação simpática renal para hipertensão resistente: situação depois de mais de uma década

Abstract Despite the current availability of safe and efficient drugs for treating hypertension, a substantial number of patients are drug-resistant hypertensives. Aiming this condition, a relatively new approach named catheter-based renal denervation was developed. We have now a clinically relevant time window to review the efficacy of renal denervation for treating this form of hypertension. This short review addresses the physiological contribution of renal sympathetic nerves for blood pressure control and discusses the pros and cons of renal denervation procedure for the treatment of resistant hypertension.

Resumo Em que pese a atual disponibilidade de medicamentos seguros e eficientes para o tratamento da hipertensão, um número significativo de pacientes sofre de hipertensão arterial resistente a tratamento medicamentoso. Em vista dessa condição, foi desenvolvida uma abordagem relativamente nova, denominada denervação renal por cateter. Dispomos atualmente de uma janela de tempo clinicamente relevante para analisar a eficácia da denervação renal no tratamento dessa modalidade de hipertensão. A presente revisão aborda a contribuição fisiológica dos nervos renais simpáticos no controle da pressão arterial e discute os prós e contras do procedimento de denervação renal no tratamento da hipertensão resistente.

Fibroblast growth factor receptor 3 regulation and mechanism in callus formation / 中国组织工程研究

BACKGROUND: In clinical treatment, patients with traumatic nerve injury and fractures show accelerated fracturehealing and excessive osteophyte growth, and even heterotopic ossification in the muscle, all of which seriously affect the therapeutic efficacy on such fractures. The specific causes and mechanisms for the acceleration of fracture healing after denervation are currently unclear. OBJECTIVE: To investigate the role and expression of fibroblast growth factor receptors 3 (FGFR3) inhibitor in the process of fracture healing. METHODS: The study protocol was approved by the Animal Ethics Committee of Second Hospital of Lanzhou University. Sixty female Sprague-Dawley rats were used to make a transverse humeral fracture model of sciatic nerve injury. They were randomly divided into two groups, experimental group and control group. The experimental group received intraperitoneal injection of FGFR3 blocker; the control group received an equal dose of normal saline. The X-ray films were taken at 4, 7, 10, 14 and 21 days after surgery, and tibia specimens for six animals were subsequently taken at each time point, followed by histological observations using hematoxylin-eosin staining and Masson’s trichrome staining. Osteocyte density and trabecular bone density of the rat tibia were calculated; and the fiber rate of the tibia was determined. RESULTS AND CONCLUSION: There were no significant differences in the X-ray findings of the tibia between the two groups. The experimental group had better bone repair than the control group, shown by hematoxylin-eosin staining and Masson’s trichrome staining. Osteocyte density, trabecular bone density, and fiber rate of the rat tibia were significantly higher in the experimental group than the control group at 7-14 days after treatment. Inhibition of FGFR3 can accelerate fracture healing and promote the shaping of callus in the case of peripheral nerve denervation. FGFR3 is most active at 7-14 days after fracture.

Effects of Tuina on Muscle-specific microRNA and Factors Related with Proliferation and Differentiation of Muscle Satellite Cells in Denervation-induced Atrophy in Rats / 中国康复理论与实践

Objective:To investigate the effects and mechanism of Tuina on denervation-induced atrophy. Methods:A total of 42 Sprague-Dawley rats were randomly divided into sham group (n = 6), model group (n = 18) and Tuina group (n = 18). The model group and Tuina group freed and excised right tibia nerve about one centimeter, while the sham group freed the right tibia nerve only. From the second day after operation, Tuina group accepted Tuina on the injured area, while the sham group and the model group were only fixed without any intervention. Six rats were sacrificed on the 14th, 21st and 28th day after operation in the model and Tuina groups, and the sham group was sacrificed on the 28th day after operation. The gastrocnemius muscles were measured wet weight ratio. The diameter and area of muscle cells were measured under HE staining. The expression of Pax7, MyoD, MyoG, microRNA-1, microRNA-133a and microRNA-206 in the gastrocnemius muscles were detected with reverse transcription real-time quantitative polymerase chain reaction. Results:Compared with the sham group, the wet weight ratio, the area of muscle cells (except the 14-day-Tuina group) and the diameter of muscle cells decreased at each time point in the model group and Tuina group (P < 0.05); compared with the model group, the wet weight ratio, muscle cell diameter and muscle cell area increased at each time point in Tuina group (P < 0.05). Compared with the sham group, the expression of Pax7 increased in the 14-day-model group (P < 0.05) and decreased in the 28-day-model group (P < 0.05), and it increased at each time point (except 28-day) in Tuina group (P < 0.05); compared with the model group, the expression of Pax7 increased at each time point in Tuina group (P < 0.05). Compared with the sham group, the expression of MyoD and MyoG increased at each time point in the model group and Tuina group (P < 0.05); compared with the model group, the expression of MyoD and MyoG increased at each time point (except 14-day) in Tuina group (P < 0.05). Compared with the sham group, the expression of microRNA-1 and microRNA-133a decreased, and microRNA-206 increased in the model group and Tuina group at 21-day (P < 0.05); compared with the model group, the expression of microRNA-1, microRNA-133a and microRNA-206 increased in Tuina group (P < 0.05). Conclusion:Tuina may activate the Pax7/MyoD/MyoG pathway by increasing the expression of muscle-specific microRNA, to promote the proliferation and differentiation of muscle satellite cells, and delay denervation-induced atrophy.

Autonomic nervous intervention in treatment of heart failure: Recent progress / 第二军医大学学报

Heart failure is a complicated pathophysiological syndrome. Balancing autonomic nervous activity and inhibiting myocardial remodeling are important methods for improving long-term efficacy in patients with heart failure. Pharmacologic management has been greatly developed, for example, the use of β-blockers is intended to inhibit the toxic effect of sympathetic activation on the heart and has become a classic treatment for heart failure. However, the incidence of heart failure is still on the rise and survivability is persistently reduced. In recent years, surgical treatments for inhibiting excessive activation of the sympathetic nervous system have emerged, such as vagus nerve stimulation, baroreceptor activation therapy. Some methods have obtained significant benefits in animal experiments and preliminary clinical study. It is essential to further verify the role of the above treatments in patients with heart failure in clinical trials.

Effect of Renal Denervation on Suppression of PVC and QT Prolongation in a Porcine Model of Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Antiarrhythmic effect of renal denervation (RDN) after acute myocardial infarction (AMI) remains unclear. The goal of this study was to evaluate the effect of RDN on ventricular arrhythmia (VA) after AMI in a porcine model.METHODS: Twenty pigs were randomly divided into 2 groups based on RDN (RDN, n=10; Sham, n=10). After implanting a loop recorder, AMI was induced by occlusion of the middle left anterior descending coronary artery. Catheter-based RDN was performed for each renal artery immediately after creating AMI. Sham procedure used the same method, but a radiofrequency current was not delivered. Electrocardiography was monitored for 1 hour to observe VA. One week later, the animals were euthanized and the loop recorder data were analyzed.RESULTS: Ventricular fibrillation event rate and the interval from AMI creation to first VA in acute phase were not different between the 2 groups. However, the incidence of premature ventricular complex (PVC) was lower in the RDN than in the Sham. Additionally, RDN inhibited prolongation of the corrected QT (QTc) interval after AMI. The frequency of non-sustained or sustained ventricular tachycardia, arrhythmic death was lower in the RDN group in the early period.CONCLUSIONS: RDN reduced the incidence of PVC, inhibited prolongation of the QTc interval, and reduced VA in the early period following an AMI. These results suggest that RDN might be a therapeutic option in patients with electrical instability after AMI.