Post-herpetic neuralgia / Neuralgia pós-herpética

ABSTRACT BACKGROUND AND OBJECTIVES: Post-herpetic neuralgia is defined as pain persisting for more than three months after the resolution of skin eruptions observed in herpes-zoster. Post-herpetic neuralgia incidence is quite variable, increases with age, being more frequent among patients aged over 60, and is associated to reduced quality of life of affected individuals. The objective of this review is to discuss key aspects of post-herpetic neuralgia, particularly its pathophysiology, clinical signs, diagnosis, prevention and treatment. CONTENTS: Post-herpetic neuralgia pathophysiology is poorly understood and involves peripheral and central nervous system mechanisms. Associated clinical signs are variable and represented mainly by pain with neuropathic features and skin changes in dermatomes previously affected by herpes-zoster. Post-herpetic neuralgia prophylactic vaccination seems to be the best preventive option. Diagnosis of post-herpetic neuralgia is largely clinical and treatment involves an early-stage, multimodal approach. Among techniques described in the literature, there is pharmacological treatment which, when not effective, requires the implementation of interventional techniques. CONCLUSION: Post-herpetic neuralgia is a complex entity and should be treated in a multidisciplinary way aiming at improving patients' quality of life.

RESUMO JUSTIFICATIVA E OBJETIVOS: A neuralgia pós-herpética é conceituada como dor persistente por mais de três meses após a resolução das lesões de pele observadas no herpes-zoster. A incidência de neuralgia pós-herpética é bastante variável e dependente da idade, sendo mais frequente em pacientes acima de 60 anos e associada a redução da qualidade de vida do indivíduo. O objetivo deste estudo foi discutir os principais aspectos da neuralgia pós-herpética, atentando para a sua fisiopatologia, manifestações clínicas, diagnóstico, prevenção e tratamento. CONTEÚDO: A fisiopatologia da neuralgia pós-herpética é pobremente compreendida e envolve mecanismos periféricos e centrais. As manifestações clínicas a ela associadas são variáveis e representadas principalmente por dor com característica neuropática e alterações de pele no dermátomo acometido anteriormente pelo herpes-zoster. A vacinação profilática para a neuralgia pós-herpética parece ser a melhor opção para preveni-la. O seu diagnóstico é eminentemente clinico e o seu tratamento envolve a necessidade de uma abordagem precoce e multi-modal. Dentre as técnicas descritas encontram-se o tratamento farmacológico e, quando este não é efetivo, a implementação de técnicas intervencionistas. CONCLUSÃO: A neuralgia pós-herpética é uma entidade complexa que deve ser tratada de forma multidisciplinar com o intuito de aumentar a qualidade de vida dos pacientes.

Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases.

BACKGROUND AND OBJECTIVE: to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar. METHODS: sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n=30 (intraperitoneal pressure [IPP] 12mmHg) and P20 group: n=37 (IPP of 20mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP=12mmHg in P12 and after 5min with IPP=20mmHg at P20; and at time 3 (TP3) after 10min with IPP=12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes. RESULTS: there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed. CONCLUSIONS: high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient.

Efeitos da pressão do pneumoperitôneo artificial elevada sobre a pressão arterial invasiva e os níveis dos gases sanguíneos / Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases / Efectos de la presión elevada del neumoperitoneo artificial sobre la presión arterial invasiva y los niveles de los gases sanguíneos

Justificativa e objetivo: avaliar as repercussões clínicas, hemodinâmicas, gasométricas e metabólicas das altas pressões transitórias do pneumoperitônio por curto período de tempo que garantem maior segurança para a introdução do primeiro trocarte. Métodos: foram estudados 67 pacientes submetidos a procedimentos videolaparoscópicos e aleatoriamente distribuídos em grupo P12: n = 30 (pressão intraperitoneal [PIP] de 12 mmHg) e grupo P20: n = 37 (PIP de 20 mmHg). Foram avaliados a pressão arterial média (PAM), por cateterismo da artéria radial; e, mediante gasometria, o pH, a pressão parcial de oxigênio arterial (PaO2), a pressão parcial de CO2 arterial (PaCO2), o bicarbonato (HCO3) e a reserva alcalina (BE). Esses parâmetros foram avaliados em ambos os grupos no tempo zero, antes do pneumoperitônio (TP0); no tempo um (TP1), quando a PIP atinge 12 mmHg em ambos os grupos; no tempo dois (TP2), após cinco minutos com PIP de 12 mmHg em P12 e após cinco minutos com PIP de 20 mmHg em P20; e no tempo três (TP3), após 10 minutos com PIP de 12 mmHg em P12 e com PIP retornada de 20 mmHg para 12 mmHg, contados 10 minutos após TP1 em P20. Os valores diferentes dos considerados normais para os parâmetros aquilatados ou o surgimento de fenômenos orgânicos atípicos foram considerados alteracões clínicas. Resultados: ocorreram diferenças estatísticas significantes no grupo P20 na PAM, no pH, no HCO3 e na BE, mas dentro dos limites da normalidade. Não foram evidenciadas alterações clínicas e patológicas. Conclusões: pressão intra-abdominal alta e transitória causa alterações da PAM, do pH, do HCO3 e da BE sem que haja repercussão clínica no paciente. .

Background and objective: to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar. Methods: sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n = 30 (intraperitoneal pressure [IPP] 12 mmHg) and P20 group: n = 37 (IPP of 20 mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP = 12mmHg in P12 and after 5 min with IPP = 20mmHg at P20; and at time 3 (TP3) after 10 min with IPP = 12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes. Results: there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed. Conclusions: high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient. .

Justificación y objetivo: evaluar las repercusiones clínicas, hemodinámicas, gasométricas y metabólicas de las altas presiones transitorias del neumoperitoneo durante un corto período de tiempo para garantizar una mayor seguridad en la introducción del primer trocar. Métodos: fueron estudiados 67 pacientes sometidos a procedimientos videolaparoscópicos y distribuidos aleatoriamente en grupo P12: n = 30 (presión intraperitoneal [PIP] de 12 mmHg), y grupo P20: n = 37 (PIP de 20 mmHg). Se evaluó la presión arterial media por cateterismo de la arteria radial; y mediante gasometría, el pH, la presión parcial de oxígeno arterial, la presión parcial de CO2 arterial, el bicarbonato y la reserva alcalina. Esos parámetros fueron evaluados en ambos grupos en el tiempo cero, antes del neumoperitoneo (TP0); en el tiempo uno (TP1), cuando la PIP alcanza 12 mmHg en ambos grupos; en el tiempo 2 (TP2), después de 5 min con PIP de 12 mmHg en P12 y después de 5 min con PIP de 20 mmHg en P20; y en el tiempo 3 (TP3), después de 10 min con PIP de 12 mmHg en P12 y con PIP de retorno desde 20 mmHg a 12 mmHg, contados 10 min después de TP1 en P20. Los valores diferentes de los considerados normales para los parámetros medidos o el surgimiento de fenómenos orgánicos atípicos fueron considerados alteraciones clínicas. Resultados: hubo diferencias estadísticas significativas en el grupo P20 en la presión arterial media, en el pH, en el bicarbonato y en la reserva alcalina, pero dentro de los límites de la normalidad. No se evidenciaron alteraciones clínicas ni patológicas. Conclusiones: la presión intraabdominal alta y transitoria causa alteraciones de la presión arterial media, del pH, del bicarbonato y de la reserva alcalina sin repercusiones clínicas para el paciente. .

Fuzzy obesity index (MAFOI) for obesity evaluation and bariatric surgery indication.

BACKGROUND: The Miyahira-Araujo Fuzzy Obesity Index (MAFOI) for being used as an alternative in bariatric surgery indication (BSI) is validated in this paper. The search for a more accurate method to evaluate obesity and to indicate a better treatment is important in the world health context. Body mass index (BMI) is considered the main criteria for obesity treatment and BSI. Nevertheless, the fat excess related to the percentage of Body Fat (%BF) is actually the principal harmful factor in obesity disease that is usually neglected. The aim of this research is to validate a previous fuzzy mechanism by associating BMI with %BF that yields the Miyahira-Araujo Fuzzy Obesity Index (MAFOI) for obesity evaluation, classification, analysis, treatment, as well for better indication of surgical treatment. METHODS: Seventy-two patients were evaluated for both BMI and %BF. The BMI and %BF classes are aggregated yielding a new index (MAFOI). The input linguistic variables are the BMI and %BF, and the output linguistic variable is employed an obesity classification with entirely new types of obesity in the fuzzy context, being used for BSI, as well. RESULTS: There is gradual and smooth obesity classification and BSI criteria when using the Miyahira-Araujo Fuzzy Obesity Index (MAFOI), mainly if compared to BMI or %BF alone for dealing with obesity assessment, analysis, and treatment. CONCLUSION: The resulting fuzzy decision support system (MAFOI) becomes a feasible alternative for obesity classification and bariatric surgery indication.

Veress needle insertion into the left hypochondrium for creation of pneumoperitoneum: diagnostic value of tests to determine the position of the needle in unselected patients.

OBJECTIVE: To assess the effectiveness of the Veress needle puncture in the left hypochondrium and the accuracy of the tests described for the intraperitoneal correct positioning of the tip of the Veress needle in an unselected population. METHODS: Ninetyone patients consecutively scheduled for Videolaparoscopy had the abdominal wall punctured in the left hypochondrium. There were no exclusion criteria. The patients received general anesthesia and mechanical ventilation according to the protocol. After puncturing five tests were used to confirm the positioning of the needle tip within the peritoneal cavity: aspiration test--AT; resistance to infusion--Pres; recovery of the infused fluid--Prec, dripping test--DT, and test of initial intraperitoneal pressure--IIPP. The test results were compared with results from literature for groups with defined exclusion criteria. The results were used for calculating sensitivity (S) specificity (E), positive predictive value (PPV) and negative predictive value (NPV). Inferential statistical methods were used to analyze the findings. RESULTS: There were 13 failures. AT had E = 100% and NPV 100%. Pres had S = 100%, E = 0; PPV = 85.71%; NPV does not apply. Prec: S = 100%, E = 53.84%, PPV = 92.85%, NPV = 100%. DT: S = 100%, E = 61.53%, PPV = 93.97% NPV 100%. In IIPP, S, E, PPV and NPV were 100%. CONCLUSION: The puncture in the left hypochondrium is effective and the performed tests guide the surgeon regardless of sex, BMI, or previous laparotomy.

Punção com agulha de Veress no hipocôndrio esquerdo para a criação do pneumoperitônio: valor diagnóstico das provas de posicionamento da agulha em pacientes não selecionados / Veress needle insertion into the left hypochondrium for creation of pneumoperitoneum: diagnostic value of tests to determine the position of the needle in unselected patients

OBJETIVO: Verificar a eficiência da punção com agulha de Veress no hipocôndrio esquerdo, a acurácia dos testes descritos para o correto posicionamento intraperitoneal da ponta da agulha de Veress em população não selecionada. MÉTODOS: Noventa e um pacientes, sem quaisquer critérios de exclusão, consecutivamente agendados para procedimentos videolaparoscópicos, tiveram a parede abdominal puncionada no hipocôndrio esquerdo. Os pacientes receberam anestesia geral e ventilação controlada mecânica segundo o protocolo. Após a punção foram utilizadas cinco provas para testar o posicionamento da ponta da agulha no interior da cavidade peritoneal: prova da aspiração - PA, da resistência à infusão - Pres, da recuperação do líquido infundido - Prec, prova do gotejamento - PG, e a prova da pressão intraperitoneal inicial - PPII. Os resultados foram considerados para cálculo da sensibilidade (S) e da especificidade (E) e valores preditivos positivos (VPP) e valores preditivos negativos (VPN). Métodos inferenciais estatísticos foram utilizados na análise dos achados. RESULTADOS: Ocorreram 13 fracassos. A PA teve E=100 por cento e VPN=100 por cento. Pres teve S=100 por cento; E=0; VPP=85,71 por cento VPN= não se aplica. Prec: S=100 por cento; E= 53,84 por cento; VPP= 92,85 por cento; VPN= 100 por cento. PG: S=100 por cento; E= 61,53 por cento; VPP= 93,97 por cento VPN= 100 por cento. Na PPII, a S, E, VPP e VPN foram de 100 por cento. CONCLUSÃO: A punção no hipocôndrio esquerdo é eficiente, as provas realizadas orientam o cirurgião a despeito do gênero, IMC ou operações prévias.

Objective: To assess the effectiveness of the Veress needle puncture in the left hypochondrium and the accuracy of the tests described for the intraperitoneal correct positioning of the tip of the Veress needle in an unselected population. Methods: Ninetyone patients consecutively scheduled for Videolaparoscopy had the abdominal wall punctured in the left hypochondrium. There were no exclusion criteria. The patients received general anesthesia and mechanical ventilation according to the protocol. After puncturing five tests were used to confirm the positioning of the needle tip within the peritoneal cavity: aspiration test - AT; resistance to infusion - Pres; recovery of the infused fluid - Prec, dripping test - DT, and test of initial intraperitoneal pressure - IIPP. The test results were compared with results from literature for groups with defined exclusion criteria. The results were used for calculating sensitivity (S) specificity (E), positive predictive value (PPV) and negative predictive value (NPV). Inferential statistical methods were used to analyze the findings. Results: There were 13 failures. AT had E = 100 percent and NPV 100 percent. Pres had S = 100 percent, E = 0; PPV = 85.71 percent; NPV does not apply. Prec: S = 100 percent, E = 53.84 percent, PPV = 92.85 percent, NPV = 100 percent. DT: S = 100 percent, E = 61.53 percent, PPV = 93.97 percent NPV 100 percent. In IIPP, S, E, PPV and NPV were 100 percent. Conclusion: The puncture in the left hypochondrium is effective and the performed tests guide the surgeon regardless of sex, BMI, or previous laparotomy.

Creation of pneumoperitoneum: noninvasive monitoring of clinical effects of elevated intraperitoneal pressure for the insertion of the first trocar.

AIM: The aim of this work is to analyze, by means of noninvasive monitoring, the clinical effects of high intraperitoneal pressure for enough time to insert the first trocar. METHODS: Sixty-seven patients without significant lung problems were randomly divided into groups P12 (n = 30, maximum intraperitoneal pressure 12 mmHg) and P20 (n = 37, maximum intraperitoneal pressure 20 mmHg). A Veress needle was inserted into the left hypochondrium for creation of pneumoperitoneum. The parameters evaluated were heart rate (HR, in bpm), arterial oxygen saturation (SaO(2), expressed as percentage of hemoglobin saturated with oxygen), end-tidal CO(2) (ETCO(2), in mmHg), mean arterial pressure (MAP, in mmHg), and intratracheal pressure (ITP, in cmH(2)O). Clinical parameters were evaluated in both groups at time point 0 (TP0, before CO(2) insufflation), time point 1 (TP1, when intraperitoneal pressure of 12 mmHg was reached in both groups), time point 2 (TP2, 5 min after reaching intraperitoneal pressure of 12 mmHg in group P12 and of 20 mmHg in group P20), and time point 3 (TP3, 10 min after reaching intraperitoneal pressure of 12 mmHg in group P12 and 10 min after TP1 in group P20, when intraperitoneal pressure decreased from 20 to 12 mmHg). Values outside of the normal range or occurrence of atypical phenomena suggestive of organic disease indicated clinical changes. RESULTS: Statistically significant differences were observed between the two groups regarding HR, MAP, ETCO(2), and ITP. No significant clinical changes were observed. CONCLUSIONS: Transitory, high intraperitoneal pressure (20 mmHg for 5 min) for insertion of the first trocar resulted in changes in HR, MAP, ETCO(2), and ITP that were within the normal range, and no adverse clinical effects were observed. Therefore, the use of transitory, high intraperitoneal pressure is recommended to prevent iatrogenic injury during blind insertion of the first trocar. Nevertheless, it is not clear that this method would be safe in patients with moderate to severe chronic obstructive pulmonary disease.

Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review.

BACKGROUND: The aim of this study was to assess the prevalence, risks, and outcomes of injuries caused by the Veress needle described in the literature. METHODS: Iatrogenic injuries caused by Veress needle insertion during diagnostic or therapeutic laparoscopies in humans were researched, with no language restriction, in the Medline, Lilacs, Embase, Scielo, and Cochrane Library databases. The following words were combined: "Veress" or "insufflation needle" or "pneumoperitoneum needle," and "complications" or "injuries" or "lesions." The bibliographic references of the selected articles were also analyzed. We considered the following: (1) number of injuries described in the literature, (2) relationship between number of injuries and number of patients who underwent Veress needle insertion in the studies that reported Veress needle injury, (3) organs and structures injured (retroperitoneal vessels, digestive tract, and self-limited, minor injuries), and (4) outcome (death, conversion to laparotomy, laparoscopic repair, spontaneous resolution). RESULTS: Thirty-eight selected articles included 696,502 laparoscopies, with 1,575 injuries (0.23%), 126 (8%) of which involved blood vessels or hollow viscera (0.018% of all laparoscopies). Of the 98 vascular injuries, 8 (8.1%) were injuries to major retroperitoneal vessels. There were 34 other reported retroperitoneal injuries, but the authors were not specific as to which vessel was injured. Of the 28 injuries to hollow viscera, 17 were considered major injuries, i.e., 60.7% (0.0024% of the total cases assessed). CONCLUSION: The insertion of the Veress needle in the abdominal midline, at the umbilicus, poses serious risk to the life of patients. Therefore, further studies should be conducted to investigate alternative sites for Veress needle insertion.