Multilevel local anesthetic nerve blockade for the treatment of generalized vulvodynia: a pilot study.

INTRODUCTION: Vulvodynia is a common pain disorder among women with a major impact on sexual functioning and quality of life. There are few published studies addressing the treatment of the pain of generalized vulvodynia or of generalized vulvodynia accompanying localized pain in the region of the vulvar vestibule. AIM: A prospective, noncontrolled pilot study was conducted to assess the efficacy of a novel treatment using caudal epidural, pudendal nerve block, and vulvar infiltration of local anesthetic agents. MAIN OUTCOME MEASURES: The main outcome measure was vulvar pain as assessed by the McGill Pain Questionnaire (MPQ). The secondary outcome measures were depressed mood evaluated with the Beck Depression Inventory (BDI) and sexual functioning assessed by the Female Sexual Functioning Inventory (FSFI). METHODS: Thirty-two women with vulvodynia met inclusion criteria and 26 women completed the study. The protocol included five treatment sessions with multilevel local anesthetic nerve blockade and a follow-up contact or visit 2-3 months later. RESULTS: There were significant improvements in vulvar pain as determined by both the sensory and affective components of the MPQ and in depression as assessed by the BDI. However, there were no changes in sexual functioning on the FSFI. CONCLUSION: Serial multilevel nerve block administered for the treatment of vulvodynia is a neurophysiologically based modality that may be effective and merits a placebo-controlled study.

Estradiol attenuates the adenosine triphosphate-induced increase of intracellular calcium through group II metabotropic glutamate receptors in rat dorsal root ganglion neurons.

Estradiol attenuates the ATP-induced increase of intracellular calcium concentration ([Ca(2+)](i)) in rat dorsal root ganglion (DRG) neurons by blocking the L-type voltage gated calcium channel (VGCC). Because ATP is a putative nociceptive signal, this action may indicate a site of estradiol regulation of pain. In other neurons, 17ß-estradiol (E(2)) has been shown to modulate L-type VGCC through a membrane estrogen receptor-group II metabotropic glutamate receptor (mGluR(2/3)). The present study investigated whether the rapid estradiol attenuation of the ATP-induced increase in [Ca(2+)](i) requires mGluR(2/3). Previously we showed that DRG (L(1)-S(3)) express ERα, P2X(3), and mGluR(2/3) receptors. DRG were acutely dissociated by enzyme digestion and grown in short-term culture for imaging analysis. DRG neurons were stimulated twice, once with ATP (50 µM) for 5 sec and then again in the presence of E(2) (100 nM) or E(2) (100 nM) + LY341495 (100 nM), an mGluR(2/3) inhibitor. ATP induced a transient increase in [Ca(2+)](i) (216.3 ± 41.2 nM). This transient increase could be evoked several times in the same DRG neurons if separated by a 5-min washout. Treatment with estradiol significantly attenuated the ATP-induced [Ca(2+)](i) increase in 60% of the DRG neurons, to 163.3 ± 20.9 nM (P < 0.001). Coapplication of E(2) and the mGluR(2/3) inhibitor LY341495 blocked the 17ß-estradiol attenuation of the ATP-induced [Ca(2+) ](i) transient (209.1 ± 32.2 nM, P > 0.05). These data indicate that the rapid action of E(2) in DRG neurons is dependent on mGluR(2/3) and demonstrate that membrane estrogen receptor-α-initiated signaling involves interaction with mGluRs.

Monitoring the conjunctiva for carbon dioxide and oxygen tensions and pH during cardiopulmonary bypass.

The purpose of this study was to measure, for the first time, multiple physiologic parameters of perfusion (pH, PCO2, PO2, and temperature) from the conjunctiva of adult patients during cardiopulmonary bypass while undergoing cardiothoracic surgery. Ten patients who underwent either intracardiac valve repair, atrial septal defect repair, or coronary artery bypass graft surgery had placement of a sensor which directly measured pH, PCO2, PO2, and temperature from the conjunctiva. Data were stratified into seven phases (0-5 minutes prior to bypass; 0-5, 6-10, and 11-15 minutes after initiation of bypass; 0-5 minutes prior to conclusion of bypass; and 0-5 and 6-10 minutes after bypass) and analyzed using a mixed model analysis.The change in conjunctival pH over the course of measurement was not statistically significant (p = .56). The PCO2 level followed a quadratic pattern, decreasing from a mean pre-bypass level of 37.7 mmHg at baseline prior to the initiation of cardiopulmonary bypass to a nadir of 33.2 mmHg, then increasing to a high of 39.4 mmHg at 6-10 minutes post bypass (p < .01). The PO2 declined from a mean pre-bypass level of 79.5 mmHg to 31.3 mmHg by 6-10 minutes post bypass and even post-bypass, it never returned to baseline values (p < .01). Temperature followed a pattern similar to PCO2 by returning to baseline levels as the patient was re-warmed following bypass (p < .01). There was no evidence of any eye injury or inflammation following the removal of the sensor. In the subjects studied, the conjunctival sensor yielded reproducible measurements during the various phases of cardiopulmonary bypass without ocular injury. Further study is necessary to determine the role of conjunctival measurements in critical settings.

Multilevel local anesthetic nerve blockade for the treatment of vulvar vestibulitis syndrome.

OBJECTIVE: Vulvar vestibulitis syndrome is a major cause of dyspareunia. This pilot study was designed to evaluate a novel treatment approach. STUDY DESIGN: This is a prospective study of 27 women with vulvar vestibulitis. The protocol included 5 treatment sessions with caudal epidural, pudendal nerve block, and vestibular infiltration of local anesthetic agents. RESULTS: There were significant improvements in vestibular pain as determined by the vulvalgesiometer, McGill pain questionnaire, self-report, and the Female Sexual Functioning Inventory. CONCLUSION: Serial multilevel nerve blocks administered for the treatment of vulvar vestibulitis is a conceptually neurophysiologically based modality that may be effective and merits a placebo-controlled study.

The burning mouth.

Burning in the mouth in and of itself is not all that uncommon. It may result from a variety of local or generalized oral mucosal disorders, or may be secondary to referred phenomena from other locations. Primary burning mouth syndrome, on the other hand, is relatively uncommon. Burning mouth syndrome is an idiopathic pain disorder, which appears to be neuropathic in origin. Thoughts on management of secondary and particularly primary burning mouth syndrome are discussed.

Anesthesiology Point of Care project.

We are developing a dynamic prototype visual communication system for the operating room environs. This has classically been viewed as an isolated and impenetrable workplace. All medical experiences and all teaching remain in a one to one closed loop with no recall or subsequent sharing for the training and education of other colleagues. The "Anesthesia Point of Care" (APOC) concept embraces the sharing of, recording of, and presentation of various physiological and pharmacological events so that real time memory can be shared at a later time for the edification of other colleagues who were not present at the time of the primary learning event. In addition it also provides a remarkably rapid tool for fellow faculty to respond to obvious stress and crisis events that can be broadcast instantly at the time of happening. Finally, it also serves as an efficient and effective means of paging and general communication throughout the daily routines among various healthcare providers in anesthesiology who work as a team unit; these include the staff, residents, CRNAs, physician assistants, and technicians. This system offers a unique opportunity to eventually develop future advanced ideas that can include training exercises, presurgical evaluations, surgical scheduling and improvements in efficiency based upon earlier than expected case completion or conversely later than expected case completion and even as a unique window to development of improved billing itemization and coordination.

Immunohistochemical Expression of N-ras Oncogene is a Late Event in Head and Neck Carcinomas.

This study investigated the expression of the N-ras oncogene in routinely processed tissue sections from 133 patients with squamous cell carcinoma of the head and neck (SCCHN) by immunohistochemistry using anti-N-ras monoclonal antibody. N-ras expression was present in 67 of 133 (49.6%) cases. There was a highly significant correlation between N-ras expression and clinical stage of disease (P=0.003). This study confirmed that overexpression of the N-ras oncogene is common in SCCHN and that it may be an important event in the late stage of disease.

nm23-H1 Expression in Squamous Cell Carcinoma of the Head and Neck.

Archival material from 47 patients with primary squamous cell carcinoma of the head and neck (SCCHN) was studied immunohistochemically for the presence of nm23-H1 protein. Our data indicate that nm23-H1 protein expression is a common event in SCCHN and that there is a trend toward correlation of increased expression of nm23-H1 with increasing tumor size (p = 0.072). The results also show that when adjusting for age and cause of death, there tended to be an inverse relationship between overall survival and the expression of nm23-H1 gene in the primary tumor (p = 0.088).