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Purpose This study compared the efficacy and safety of controlled-release pregabalin (GLA5PR GLARS-NF1 tablets) with those of an immediate-release pregabalin capsule after 12 weeks' administration to patients with peripheral neuropathic pain. Methods In this multicenter, randomized, double-blind, active-controlled, parallel-group, Phase III study, the primary outcome was to confirm that a single treatment with the study drug (after the evening meal) is clinically noninferior to the control drug (BID regimen) at improving the mean Daily Pain Rating Scale score for treating peripheral neuropathic pain. Secondary outcomes were the Daily Sleep Interference Scale, Medical Outcomes Study Sleep Scale, Hospital Anxiety and Depression scale, and frequency of rescue medication use. The safety and tolerability of GLA5PR GLARS-NF1 tablets were also evaluated. The total daily dose of pregabalin is 150–600 mg. Findings Of the 352 randomized subjects, 261 (n = 130, study group; n = 131, control group) were analyzed. The difference in adjusted mean Daily Pain Rating Scale scores between the groups was −0.11 (95% confidence interval, −0.05 to 0.30), indicating that the study group is noninferior to the control group. There was no statistically significant difference in Daily Sleep Interference Scale, Medical Outcomes Study Sleep Scale, and Hospital Anxiety and Depression scale scores between the groups at treatment termination. Logistic regression analysis revealed no significant difference in the use of rescue medication between the groups (P = 0.217). The overall adverse event profile of the groups was similar, and no serious adverse drug reactions were observed. Implications GLA5PR GLARS-NF1 tablets can be effectively and safely administered to patients with peripheral neuropathic pain. Furthermore, we found that sleep, anxiety, and depression were improved with pain control. Owing to the once-daily administration, treatment effects can be maximized by improved treatment compliance. ClinicalTrials.gov identifier: NCT03221907.

Although endoscopic ultrasound-guided celiac neurolysis (EUS-CN) and percutaneous celiac neurolysis (PCN) are utilized to manage intractable pain in pancreatic cancer patients, no direct comparison has been made between the two methods. We compared the efficacy and safety of EUS-CN and PCN in managing intractable pain in such patients. Sixty pancreatic cancer patients with intractable pain were randomly assigned to EUS-CN (n = 30) or PCN (n = 30). The primary outcomes were pain reduction in numerical rating scale (NRS) and opioid requirement reduction. Secondary outcomes were: successful pain response (NRS decrease &ge, 50% or &ge, 3-point reduction from baseline), quality of life, patient satisfaction, adverse events, and survival rate at 3 months postintervention. Both groups reported sustained decreases in pain scores up to 3 months postintervention (mean reductions in abdominal pain: 0.9 (95% confidence interval (CI): &minus, 0.8 to 4.2) and 1.7 (95% CI: &minus, 0.3 to 2.1), back pain: 1.3 (95% CI: &minus, 0.9 to 3.4) and 2.5 (95% CI: &minus, 0.2 to 5.2) in EUS-CN, and PCN groups, respectively). The differences in mean pain scores between the two groups at baseline and 3 months were &minus, 0.5 (p = 0.46) and &minus, 1.4 (p = 0.11) for abdominal pain and 0.1 (p = 0.85) and &minus, 0.9 (p = 0.31) for back pain in favor of PCN. No significant differences were noted in opioid requirement reduction and other outcomes. EUS-CN and PCN were similarly effective and safe in managing intractable pain in pancreatic cancer patients. Either methods may be used depending on the resources and expertise of each institution.

High-speed, high-performance electrochromic devices can be designed using unique solid-solid phase changes induced by oxygen flow., Mobile oxygen vacancies offer a substantial potential to broaden the range of optical functionalities of complex transition metal oxides due to their high mobility and the interplay with correlated electrons. Here, we report a large electro-absorptive optical variation induced by a topotactic transition via oxygen vacancy fluidic motion in calcium ferrite with large-scale uniformity. The coloration efficiency reaches ~80 cm2 C−1, which means that a 300-nm-thick layer blocks 99% of transmitted visible light by the electrical switching. By tracking the color propagation, oxygen vacancy mobility can be estimated to be 10−8 cm2 s−1 V−1 near 300°C, which is a giant value attained due to the mosaic pseudomonoclinic film stabilized on LaAlO3 substrate. First-principles calculations reveal that the defect density modulation associated with hole charge injection causes a prominent change in electron correlation, resulting in the light absorption modulation. Our findings will pave the pathway for practical topotactic electrochromic applications.

Oxygen vacancies are ubiquitous in oxides, and taking advantage of their mobility is the cornerstone for a variety of future applications. The visualization and quantification of collective defect flow based on electrochromism is a powerful approach to explore oxygen kinetics and electrochemical reaction even in cases that electronic conduction is considerably mixed, but whether or not the measured kinetic properties harmonize with those obtained by the conventional impedance spectroscopy remains veiled. Here, we identify complementary relationships between the two methods by investigating the oxygen vacancy transport in Ca 30%-doped bismuth ferrite thin films epitaxially grown on SrTiO3 (110) substrates. We find that the activation energy of ionic hopping is 0.78 (or 0.92 eV) for the application of an electric bias along [001] (or [1 1 ¯0]) due to the grain elongation along [001]. We anneal the films in an N2 gas environment at high temperatures to suppress the electronic contribution for access to standard impedance spectroscopy. The oxygen kinetic properties obtained from the two methods are consistent with each other, complementarily revealing the collective phase evolution as well as the ionic impedance of the bulk, grain boundary, and interfacial regions. These comparative works provide useful insights into ionic defect conduction in oxides in an intuitive and quantitative manner.

Objective: A cervical epidural steroid injection is one of the most commonly performed interventions to manage chronic neck pain and cervical radiculopathy. Despite its many severe complications, cervical transforaminal epidural steroid injection (CTFESI) is a clinically necessary modality for managing neck pain and cervical radiculopathy. We aimed in this study to find a safer optimal needle entry angle to decrease the chance of an accidental vertebral artery (VA) puncture even with a proper needle entry angle and to visualize the target of the needle tip. Methods: This retrospective study included 312 patients with neck pain or cervical radiculopathy who had undergone magnetic resonance imaging scans for diagnosis and treatment. The first line was drawn from the midpoint of the two articular pillars and passed through the exact midline of the spinous process. The second line was drawn parallel to the ventral lamina line (conventional transforaminal approach line, CTAL). The third line was drawn parallel to the ventral margin at the midpoint of the superior articular process's ventral border (new transforaminal approach line, NTAL). The angle of intersection between the midline and CTAL versus with NTAL were measured from both sides (right and left) at C5-6, C6-7, and C7-T1 levels. Also, the distance of CTAL and NTAL from VA were measured from both sides at each level. We examined whether the CTAL and NTAL would penetrate the ipsilateral VA, internal carotid artery (ICA), and internal jugular vein (IJV). Results: There were significant differences between CTAL and NTAL angles at all levels (P < 0.001). There were significant differences between the distance of CTAL and NTAL from VA at all levels (P < 0.001). There were also significant differences between the observed frequency of CTAL and NTAL that would penetrate the major ipsilateral vessel (VA, ICA, and IJV) on all levels and sides (P < 0.001~0.030). Conclusion: The angle of NTAL (approximately 70°) is safer than the angle of CTAL (approximately 50°) when considering vascular injuries to vessels, such as the VA, ICA, and IJV.

Background: Hypertrophy of the ligamentum flavum (LF) has been considered as a major cause of lumbar central spinal stenosis (LCSS). Previous studies have found that ligamentum flavum thickness (LFT) is correlated with aging, disc degeneration, and lumbar spinal stenosis. However, hypertrophy is different from thickness. Thus, to evaluate hypertrophy of the whole LF, we devised a new morphological parameter, called the ligamentum flavum area (LFA). Objectives: We hypothesized that the LFA is a key morphologic parameter in the diagnosis of LCSS. Study Design: Retrospective observational study. Setting: The single center study in Seoul, Republic of Korea. Methods: LF samples were collected from 166 patients with LCSS, and from 167 controls who underwent lumbar magnetic resonance imaging (MRI) as part of a routine medical examination. T1- weighted axial MR imageswere acquired at the facet joint level from individual patients. We measured the LFA and LFT at the L4-L5 intervertebral level on MRI using a picture archiving and communications system. The LFA was measured as the cross-sectional area of the whole LF at the L4-L5 stenotic level. The LFT was measured by drawing a line along the side of the ligament facing the spinal canal and along the laminar side of the ligament curve and then measuring the thickest point at the L4-L5 level. Results: The average LFA was 96.56 ± 30.74 mm2 in the control group and 132.69 ± 32.68 mm2 in the LCSS group. The average LFT was 3.61 ± 0.72 mm in the control group and 4.24 ± 0.97 mm in the LCSS group. LCSS patients had significantly higher LFA (P < 0.001) and LFT (P < 0.001). Regarding the validity of both LFA and LFT as predictors of LCSS, Receiver Operator Characteristics (ROC) curve analysis showed that the best cut-off point for the LFA was 105.90 mm2 , with 80.1% sensitivity, 76.0% specificity, and area under the curve (AUC) of 0.83 (95% CI, 0.78 – 0.87). The best cut off-point of the LFT was 3.74 mm, with 70.5% sensitivity, 66.5% specificity, and AUC of 0.72 (95% CI, 0.66 – 0.77). Limitations: The principal methodological limitation was the retrospective observational nature. Anatomically, degenerative lumbar spinal stenosis can involve the central canal, foramina, and lateral recess. However, we focused on LCSS only. Conclusions: Although the LFT and LFA were both significantly associated with LCSS, the LFA was a more sensitive measurement parameter. Thus, to evaluate LCSS patients, the treating doctor should more carefully analyze the LFA than LFT. Institutional Review Board (IRB) approval number: S2015-1328-0001 Key words: Ligamentum flavum, ligamentum flavum area, ligamentum flavum thickness, lumbar central spinal stenosis, hypertrophy of the ligamentum flavum, morphological parameter, crosssectional area, optimal cut-off point

Objective To investigate the change in pulse transit time (PTT)—time between the electrocardiographic R wave and the highest point of the corresponding plethysmographic wave—after lumbar sympathetic ganglion block (LSGB) and evaluate PTT as an indicator of successful LSGB. Methods Sixteen cases of sympathetically mediated lower extremity neuropathic pain treated with LSGB were studied. Correlations between the changes in PTT and temperature were used to identify the cutoff point indicating successful LSGB. Results PTT rate of change at 5 min relative to the baseline PTT (dPTT5/PTT0) significantly correlated positively with the temperature change at 20 min (correlation coefficient 0.734). The dPTT5/PTT0 ratios of the Success and Failure groups were 6.46 ± 2.81% and 2.77 ± 1.72%, respectively. The dPTT5/PTT0 cutoff indicating successful LSGB, based on receiver operating characteristic curve analysis, was 4.23%. Conclusion PTT measurement 5 min after local anesthetic injection was an early, objective indicator of successful or failed LSGB.

Background: Chronic neck and upper extremity pain associated with cervical origin is common, and cervical interlaminar epidural steroid injections (CILESIs) are frequently used to manage the symptoms of cervical spinal disorders. However, CILESIs are associated with risks such as dural puncture and cord injury. Objectives: We aimed to determine the optimal needle tip visualization, in order to minimize CILESIs-induced complications. Study Design: Retrospective observational study. Setting: The single center study in Seoul, Republic of Korea. Methods: Participants were 312 adults with neck or upper extremity pain caused by cervical lesion such as cervical herniated nucleus pulposus (HNPs). They underwent magnetic resonance imaging (MRI). Patients with severe cervical spinal stenosis, prior posterior cervical spine surgery, or other anatomical abnormalities of the vertebral laminae were excluded from the study. By using axial T2- weighted spin-echo MRI, we defined the area between the spinous processes as the anterior posterior zone 1 (APZ1), and the area lateral to the spinous processes as the anterior posterior zone 2 (APZ2). Line 1 was drawn along the ventral margin of lamina that confined APZ1, and line 2 was similarly drawn in order to define APZ2. The angles between the midsagittal line and lines 1 and 2 were defined as angle 1 and angle 2, respectively. Angles were measured at the C5-6, C6-7, and C7-T1 levels, on both right and left sides at each level. Results: Angle 1 values (in degrees) at right C5-6, left C5-6, right C6-7, left C6-7, right C7-T1, and left C7-T1 were 62.54 ± 10.52, 64.34 ± 9.86, 62.03 ± 10.27, 62.87 ± 10.64, 61.64 ± 11.0, and 62.58 ± 10.83, respectively. Angle 2 values at right C5-6, left C5-6, right C6-7, left C6-7, right C7- T1, and left C7-T1 were 50.44 ± 6.84, 50.77 ± 7.00, 49.15 ± 6.07, 49.89 ± 6.45, 50.84 ± 6.68, and 50.24 ± 6.60, respectively. There were significant differences between angles 1 and 2 at each level. Limitations: This study is a retrospective review and did not employ controls, blinding, or randomization. Additionally, the optimal CLO angles for CILESIs and cervicothoracic interlaminar epidural steroid injections (CTILESIs) have not been assessed in clinical studies. Another limitation is that we divided lamina into only APZ1 and APZ2. Conclusions: During CILESIs, a contralateral oblique (CLO) view at 60 degrees is superior to other angles for visualizing the epidural space when the needle tip is placed in the interlaminar space and within the spinous processes margin. When the needle tip is placed in the interlaminar space and lateral to the spinous processes, a CLO view at 50 degrees is most appropriate. Institutional Review Board (IRB) approval number: S2016-0390-0001 Key words: Chronic neck pain, chronic upper extremity pain, cervical epidural injections, cervical interlaminar steroid injections, steroid, needle tip position, needle tip visualization, fluoroscopy, complication, contralateral oblique view

Patient-controlled analgesia (PCA) is one of the most popular and effective methods for managing postoperative pain. Various types of continuous infusion pumps are available for the safe and accurate administration of analgesic drugs. Here we report the causes and clinical outcomes of device-related errors in PCA.Clinical records from January 1, 2011 to December 31, 2014 were collected by acute pain service team nurses in a 2715-bed tertiary hospital. Devices for all types of PCA, including intravenous PCA, epidural PCA, and nerve block PCA, were included for analysis. The following 4 types of infusion pumps were used during the study period: elastomeric balloon infusers, carbon dioxide-driven infusers, semielectronic disposable pumps, and electronic programmable pumps. We categorized PCA device-related errors based on the error mechanism and clinical features.Among 82,698 surgical patients using PCA, 610 cases (0.74%) were reported as human error, and 155 cases (0.19%) of device-related errors were noted during the 4-year study period. The most common type of device-related error was underflow, which was observed in 47 cases (30.3%). The electronic programmable pump exhibited the high incidence of errors in PCA (70 of 15,052 patients; 0.47%; 95% confidence interval, 0.36-0.59) among the 4 types of devices, and 96 of 152 (63%) patients experienced some type of adverse outcome, ranging from minor symptoms to respiratory arrest.The incidence of PCA device-related errors was0.2% and significantly differed according to the infusion pump type. A total of 63% of patients with PCA device-related errors suffered from adverse clinical outcomes, with no mortality. Recent technological advances may contribute to reducing the incidence and severity of PCA errors. Nonetheless, the results of this study can be used to improve patient safety and ensure quality care.

OBJECTIVE There is no well-defined predictor of satisfactory pain relief after celiac plexus block (CPB) at the early stage of treatment. This study evaluated whether measurement of the electrocardiographic R-wave and the arrival time of the pulses at the toe pulse transit time (E-T PTT) can be an early predictor of pain response and success of CPB in patients with chronic intractable visceral pain. METHODS Twelve patients aged between 20 and 80 years who underwent CPB for treatment of chronic intractable cancer-related abdominal pain were included. A successful CPB was determined as a >50% decrease on the numerical rating scale measured 24 hours after the procedure. The E-T PTT at baseline and at 5, 10, 20, and 30 minutes after the injection of local anesthetic was measured as the time between the R-wave on the electrocardiogram and the peak point of the corresponding plethysmogram wave from the ipsilateral great toe. The change in the E-T PTT that was predictive of a successful CPB was analyzed using receiver operating characteristic curve analysis. RESULTS A CPB was successful in 9 of 12 cases; the dE-T PTT5/E-T PTT0 of the success group was 6.84%±5.04% versus 0.72%±0.78% in the failure group (P=0.021). The mean E-T PTTx differed significantly between timepoints (F=9.313, P=0.014) and between the success and failure groups (P

Objectives The objective of this study was to determine the effects of combining pulsed radiofrequency (PRF) treatment and transforaminal epidural injection (TFEI) to treat patients with chronic refractory lumbar radicular pain caused by lumbar spinal stenosis. Study design Randomized control trial. Settings Interventional pain management practice. Method Sixty-two patients were assigned to the study groups (PRF group = 31; control group = 31). Under fluoroscopic guidance, the RF needle was positioned close to the lumbar dorsal root ganglion. The PRF group received 3 cycles of PRF treatment, and sensory stimulation without RF lesioning was applied to the control group. After PRF or sham lesioning, a local anesthetic with steroid was injected. The primary outcome of a successful response was defined as: 1) ≥50% or 4–point pain reduction in the numerical rating scale (NRS) without an increase in the Oswestry disability index (ODI) or medication quantification scale (MQS), or mean score

The relationship between the change of pulse transit time and the presence of clinical signs after stallate ganglion block (SGB) was investigated in patients with disorders mediated by the sympathetic nervous system. SGB is used for the treatment and diagnosis of these disorders; however, a successful objective marker does not exist. Therefore, identifying increased blood flow following SGB and determining whether pulse transit time could be used to verify the success of SBG would be a helpful resource., BACKGROUND: An objective marker of successful stellate ganglion block (SGB) does not exist. Horner syndrome, which is currently used to determine the effect of SGB, is sometimes ambiguous. OBJECTIVE: To investigate the change in pulse transit time (PTT) after SGB, and to evaluate the utility of PTT as an objective measure of successful SGB. METHODS: Eight patients (34 to 62 years of age) underwent SGB for diagnosis or treatment of sympathetically mediated pain of the upper extremities. The success of the SGB was determined according to the presence of Horner syndrome. Electrocardiography, noninvasive blood pressure measurements and pulse oximetry were used to monitor all patients. PTT was measured using data saved on the WinDaq waveform browser. RESULTS: PTT was measured at baseline and 3 min, 5 min and 10 min after the injection of a local anesthetic. At 3 min after SGB, the mean (± SD) PTT was 624.6±20.5 ms. At 5 min after injection, the mean PTT was 630.8±17.5 ms. Prolonged PTT at 5 min was found to return to the baseline value at 10 min (613.6±14.7 ms). According to the Friedman test, the differences from baseline values were significant (P=0.008). CONCLUSION: Measurement of PTT at 5 min after local anesthetic injection can help to objectively determine the success of SGB.

Hypertrophy of the ligamentum flavum (LF) has been considered as a major cause of lumbar central spinal stenosis (LCSS). Previous studies have found that ligamentum flavum thickness (LFT) is correlated with aging, disc degeneration, and lumbar spinal stenosis. However, hypertrophy is different from thickness. Thus, to evaluate hypertrophy of the whole LF, we devised a new morphological parameter, called the ligamentum flavum area (LFA).We hypothesized that the LFA is a key morphologic parameter in the diagnosis of LCSS.Retrospective observational study.The single center study in Seoul, Republic of Korea.LF samples were collected from 166 patients with LCSS, and from 167 controls who underwent lumbar magnetic resonance imaging (MRI) as part of a routine medical examination. T1-weighted axial MR imageswere acquired at the facet joint level from individual patients. We measured the LFA and LFT at the L4-L5 intervertebral level on MRI using a picture archiving and communications system. The LFA was measured as the cross-sectional area of the whole LF at the L4-L5 stenotic level. The LFT was measured by drawing a line along the side of the ligament facing the spinal canal and along the laminar side of the ligament curve and then measuring the thickest point at the L4-L5 level.The average LFA was 96.56 ± 30.74 mm2 in the control group and 132.69 ± 32.68 mm2 in the LCSS group. The average LFT was 3.61 ± 0.72 mm in the control group and 4.24 ± 0.97 mm in the LCSS group. LCSS patients had significantly higher LFA (P0.001) and LFT (P0.001). Regarding the validity of both LFA and LFT as predictors of LCSS, Receiver Operator Characteristics (ROC) curve analysis showed that the best cut-off point for the LFA was 105.90 mm2, with 80.1% sensitivity, 76.0% specificity, and area under the curve (AUC) of 0.83 (95% CI, 0.78 - 0.87). The best cut off-point of the LFT was 3.74 mm, with 70.5% sensitivity, 66.5% specificity, and AUC of 0.72 (95% CI, 0.66 - 0.77).The principal methodological limitation was the retrospective observational nature. Anatomically, degenerative lumbar spinal stenosis can involve the central canal, foramina, and lateral recess. However, we focused on LCSS only.Although the LFT and LFA were both significantly associated with LCSS, the LFA was a more sensitive measurement parameter. Thus, to evaluate LCSS patients, the treating doctor should more carefully analyze the LFA than LFT.Institutional Review Board (IRB) approval number: S2015-1328-0001Key words: Ligamentum flavum, ligamentum flavum area, ligamentum flavum thickness, lumbar central spinal stenosis, hypertrophy of the ligamentum flavum, morphological parameter, cross-sectional area, optimal cut-off point.

Epidural adhesions cause pain by interfering with the free movement of the spinal nerves and increasing neural sensitivity as a consequence of neural compression. To remove adhesions and deliver injected drugs to target sites, percutaneous epidural adhesiolysis (PEA) is performed in patients who are unresponsive to conservative treatments. We describe four patients who were treated with a newly developed inflatable balloon catheter for more effective PEA and relief of stenosis. In the present patients, treatments with repetitive epidural steroid injection and/or PEA with the Racz catheter or the NaviCath did not yield long-lasting effects or functional improvements. However, PEA and decompression with the inflatable balloon catheter led to maintenance of pain relief for more than seven months and improvements in the functional status with increases in the walking distance. The present case series suggests that the inflatable balloon catheter may be an effective alternative to performing PEA when conventional methods fail to remove adhesions or sufficiently relieve stenosis.

Ionic migration is a key ingredient for applications such as oxide electrolytes and resistive switching memories. We investigate the evolution of ionic conduction pathways based on optical contrast in an epitaxial Bi0.7Ca0.3FeO3−δ thin film where oxygen vacancies are spontaneously produced. We visualize electroforming processes in the hundred-micrometer-scale material channels between coplanar electrodes with a constant electric bias at an elevated temperature, systematically varying the channel orientation with respect to the crystal axis. At the initial stage of electroforming, conducting filaments are created and propagate nearly along the crystal axes ⟨100⟩. The local density of conducting filament regions increases with the elapsed time of bias application and also exhibits a linear dependence on the spatial position at a given time. We also find that the filament-type ionic conduction is abruptly transformed to the bulk conduction when the filament density reaches ∼30%. These results offer useful insight into collective ionic migration in crystalline solids.

The aim of this study was to determine the association between radiologic spinal pathology and the response to medial branches block (MBB). This retrospective observational study compared 165 patients. A successful response was defined as &ge, 30% or a 2-point reduction in the numeric rating scale (NRS) compared with the baseline at the 1-month follow-up. The facet angle, facet angle difference, facet joint degeneration, disc height and spondylolisthesis grade were analyzed from an MRI at the L3 to S1 levels. Univariate and multivariate logistic regression analyses were used to evaluate independent factors associated with a successful response of MBB. In the univariate analysis, the disc height at L5&ndash, S1 and facet angle difference at L3&ndash, 4 were lower in the positive responders (p = 0.022 and p = 0.087, respectively). In the multivariate analysis, the facet angle difference at L3&ndash, 4 and disc height at L5&ndash, S1 were independent factors associated with a successful response (odds ratio = 0.948, p = 0.038 and odds ratio = 0.864, p = 0.038, respectively). In patients with a degenerative disc at L5&ndash, S1, MBB can lead to a good response for at least one month. In patients with facet tropism at L3&ndash, 4 level, the response to MBB after one month is likely to be poor.

Conventional transcrural CPB via the "walking off" the vertebra technique may injure vital organs while attempting to proximally spread injectate around the celiac plexus. Therefore, we attempted the CT-simulated fluoroscopy-guided transdiscal approach to carry out transcrural CPB in a safer manner, spreading the injectate more completely and closely within the celiac plexus area. A 54-year-old male patient with pancreatic cancer suffered from severe epigastric pain. The conventional transcrural approach was simulated, but the needle pathway was impeded by the kidney on the right side and by the aorta on the left side. After simulating the transdiscal pathway through the T11-12 intervertebral disc, we predetermined the optimal insertion point (3.6 cm from the midline), insertion angle (18 degrees), and advancement plane, as well as the proper depth. With the transdiscal approach, we successfully performed transcrural CPB within a narrow angle, and the bilateral approach was not necessary as we were able to achieve the bilateral spread of the injectate with the single approach.

Background: Degenerative lumbar spinal stenosis is one of the most common causes of chronic lower back pain and radiculopathy. Spinal stenosis is anatomically classified as central and lateral spinal canal stenosis. Many treatment modalities and techniques, including surgery and epidural injection, have been used to manage the pain. However, the effect of hypertonic saline injection via the transforaminal approach has not yet been studied. Objectives: The aim of this study is to determine the effect of adding hypertonic saline to conventional transforaminal epidural steroid injections (TFEI) to provide pain relief for chronic radiculopathy patients secondary to lateral canal spinal stenosis. Study Design: A double-blind, randomized, active-control trial. Setting: An interventional pain management practice in a hospital, Republic of Korea. Methods: Two groups: the hypertonic group received hypertonic saline combined with triamcinolone and the control group received normal saline combined with triamcinolone. A total of 68 patients were randomly allocated into either 2 groups by a computergenerated randomization program. Twenty-seven patients in the hypertonic group and 26 patients in the control group were assessed. A total of 53 patients were included in this analysis. Outcome measures were taken at baseline, one, 2, 3, 4, and 6 months postprocedure. The primary outcome measures included the numerical rating scale (NRS) and the proportion of substantial responders. The secondary outcome measures included the Oswestry disability index (ODI), the proportion of substantial and moderate responders, and patient satisfaction. Results: Transforaminal epidural injection of steroids, with or without the addition of 10% hypertonic saline, was effective and provided significant pain relief with the improvement of functional outcome within 4 months. The addition of hypertonic saline was superior in efficacy compared with conventional TFEI at 3 months follow-up. The differences in the absolute pain scores did not demonstrate statistical significance between the 2 groups. The reduction in pain intensity from the baseline was greater in the hypertonic group and demonstrated higher rates of satisfaction. The use of hypertonic saline also extended the duration of significant pain relief to 6 months compared with baseline. Limitations: The lack of placebo group and small sample size. Conclusion: Superior short-term pain relieving efficacy, but limited long-term effects of hypertonic saline, when added to TFEIs. Key words: Chronic pain, lumbar radiculopathy, lateral canal, spinal stenosis, transforaminal, epidural steroid injections, hypertonic saline, local anesthetic

Background: Lumbar spinal stenosis is a common condition in the elderly. Although balloon treatment is a well-known therapeutic method in specific pain conditions, applying the balloon treatment in patients with lumbar spinal stenosis is not yet well established. Objectives: We tested the therapeutic effect of transforaminal balloon treatment with a Fogarty balloon catheter on body pain and functional performance in patients with severe lumbar spinal stenosis. Study Design: Prospective, randomized, double-blinded, active control trial. Setting: A tertiary, interventional pain management practice, specialty referral center. Methods: Sixty-two patients with refractory unilateral radiculopathy aggravated by walking were enrolled and randomly assigned to receive transforaminal steroid injection after transforaminal balloon treatment using a 3 Fr balloon catheter (n = 32) or the same procedure without balloon treatment (n = 30). The patients were prohibited from making any alterations to their medications during the 12 weeks of their follow-up period. After the first 12 weeks, the patients who had persistent symptoms or unbearable pain were allowed to increase the dose of analgesics or to receive additional interventional treatment. Outcome Assessment: Visual analogue scale (VAS) pain scores for the leg and lower back, Oswestry disability index (ODI), and claudication distance were measured at 2, 4, 8, and 12 weeks post procedure. During the 52 weeks of the overall follow-up period, the patients achieving ≥ 50% leg pain relief without additional treatment or increasing the dose of analgesics were evaluated. Results: Significant improvement occurred compared to baseline in VAS (P < 0.001), ODI (P < 0.001), and claudication distance (P < 0.001) in the balloon group during the overall follow-up period, whereas the improvement in ODI (P < 0.05) and claudication distance (P < 0.05) in the control group persisted for 8 weeks. The balloon group showed better improvement in leg VAS (P < 0.05), ODI (P < 0.05), and claudication distance (P < 0.05) than the control group at all post-procedure assessment points. Kaplan-Meier analysis of the duration of the patients achieving ≥ 50% leg pain relief without additional treatment or increasing the dose of analgesics showed a significant intergroup difference between the balloon and control (P = 0.003) groups. Six patients (18.8%) in balloon group maintained > 50% pain relief for 52 weeks whereas no patient (0%) did in control group. Limitations: Our study is an active-controlled randomized design with a relatively small number of patients. Conclusion: Transforaminal balloon treatment leads to both significant pain relief and functional improvement in a subset of patients with refractory spinal stenosis. Institutional Review: This study was approved by the Institutional Review Board of the Asan Medical Center. Key words: Neurogenic claudication, lumbar foraminal stenosis, transforaminal balloon treatment, Fogarty catheter

Spontaneous intracranial hypotension (SIH) is characterized by postural headache because of low cerebrospinal fluid (CSF) pressure. Brain magnetic resonance imaging (MRI) and radioisotope (RI) cisternography can be used to identify the site of a CSF leakage. Although autologous epidural blood patch (EBP) is a very effective treatment modality, some patients require a repeat autologous EBP. We investigated whether autologous EBP responses correlate with surrogate markers of quantitative findings. All cases of autologous EBP for SIH from January 2006 to December 2014 were enrolled. The demographic variables, number of EBPs, pain scores, RI cisternography (early visualization of bladder activity), and MRI findings (subdural fluid collections, pachymeningeal enhancement, engorgement of venous structures, pituitary hyperemia, and sagging of the brain) were reviewed. Patients with early bladder activity on RI cisternography had a tendency to need a higher number of autologous EBPs. Only sagging of the brain and no other variables showed a statistically significant negative correlation with the number of autologous EBPs. The response to autologous EBP may be related to the radiologic findings of early bladder activity on RI cisternography and sagging of the brain on MRI.

Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs).Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt.Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded.Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P=0.012).Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.

BACKGROUND It has been demonstrated that the expression of tumor necrosis factor-α (TNF-α) and apoptotic cell death in the dorsal root ganglion (DRG) following spinal nerve constriction injury play a role in the initiation and continuation of hyperalgesia and allodynia. The present study was designed to investigate the effects of ethyl pyruvate (EP) on mechanical and cold allodynia, TNF-α expression, and apoptosis in DRG after spinal nerve ligation injury. METHODS Rats were divided into 3 groups: control, pre-EP, and post-EP. EP (50 mg/kg) was intraperitoneally injected 30 minutes before (pre-EP) or after (post-EP) surgery. Behavioral tests to determine mechanical and cold allodynia were conducted before surgery and 4 and 7 days after surgery. Seven days after surgery, TNF-α protein levels in DRG were evaluated by enzyme-linked immunosorbent assay, and DRG apoptosis was determined by immunohistochemical detection of activated caspase-3. RESULTS Treatment with EP significantly reduced mechanical and cold allodynia following spinal nerve ligation injury. TNF-α protein levels in the pre-EP (4.7 ± 1.2 pg/200 µg; P < 0.001) and post-EP (6.4 ± 1.8 pg/200 µg; P < 0.001) groups were 2-3 times lower than the control group (14.4 ± 1.2 pg/200 µg). The percentages of neurons and satellite cells that co-localized with caspase-3 were also significantly lower in the pre-EP and post-EP groups than the control group. CONCLUSIONS These results demonstrate that EP has a strong anti-allodynic effect that acts through the inhibition of TNF-α expression and apoptosis in DRG after spinal nerve ligation injury.

Lumbar spinal stenosis is a commonly treated with epidural injections of local anesthetics and corticosteroids, however, these therapies may relieve leg pain for weeks to months but do not influence functional status. Furthermore, the majority of patients report no substantial symptom change over the repeated treatment. Utilizing balloon catheters, we successfully treated with three patients who complained persistent symptoms despite repeated conventional steroid injections. Our results suggest that transforaminal decompression using a balloon catheter may have potential in the nonsurgical treatment of spinal stenosis by modifying the underlying pathophysiology.

Background Spinal nerve ligation (SNL) injury in rats produces a pain syndrome that includes mechanical and thermal allodynia. Previous studies have indicated that proinflammatory cytokines such as tumor necrosis factor-α (TNF-α) play an important role in peripheral mediation of neuropathic pain, and that altered dorsal root ganglion (DRG) function and degree of DRG neuronal apoptosis are associated with spinal nerve injury. The present study was conducted to evaluate the expression of TNF-α and the extent of apoptosis in the dorsal root ganglion after SNL in rats. Methods Sprague-Dawley rats were subjected to SNL of the left L5 and L6 spinal nerves distal to the DRG and proximal to the formation of the sciatic nerve. At postoperative day 8, TNF-α protein levels in the L5-6 DRG were compared between SNL and naive groups using ELISA. In addition, we compared the percentage of neurons injured in the DRG using immunostaining for apoptosis and localization of activated caspase-3. Results SNL injury produced significant mechanical and cold allodynia throughout the 7-day experimental period. TNF-α protein levels were increased in the DRG in rats that had undergone SNL (12.7 ± 3.2 pg/100 µg, P < 0.001) when compared with naïve rats (4.1 ± 1.4 pg/100 µg). The percentage of neurons or satellite cells co-localized with activated caspase-3 were also significantly higher in rats with SNL than in naïve rats (P < 0.001, P < 0.05, respectively). Conclusions SNL injury produces mechanical and cold allodynia, as well as TNF-α elevation and apoptosis in the DRG.

Background: Facet joint disease plays a major role in axial low-back pain. Few diagnostic tests and imaging methods for identifying this condition exist. Single photon emission computed tomography (SPECT) is reported that it has a high sensitivity and specificity in diagnosing facet disease. We prospectively evaluated the use of bone scintigraphy with SPECT for the identification of patients with low back pain who would benefit from medial branch block. Methods: SPECT was performed on 33 patients clinically suspected of facet joint disease. After SPECT, an ultrasound guided medial branch block was performed on all patients. On 28 SPECT-positive patients, medial branch block was performed based on the SPECT findings. On 5 negative patients, medial branch block was performed based on clinical findings. For one month, we evaluated the patients using the visual analogue scale (VAS) and Oswestry disability index. SigmaStat and paired t-tests were used to analyze patient data and compare results. Results: Of the 33 patients, the ones who showed more than 50% reduction in VAS score were assigned ‘responders’. SPECT positive patients showed a better response to medial branch blocks than negative patients, but no changes in the Oswestry disability index were seen. Conclusions: SPECT is a sensitive tool for the identification of facet joint disease and predicting the response to medial branch block. (Korean J Pain 2011; 24: 81-86)

Objective Monitoring of cardiac output is required during anesthesia for off-pump coronary artery bypass (OPCAB) surgery. Recently, FloTrac, a new device for arterial pressure waveform analysis for cardiac output (APCO) monitoring without external calibration, was developed. The authors have compared APCO with STAT-mode continuous cardiac output (SCCO) in patients undergoing OPCAB surgery. Design A clinical study. Setting A university hospital (single institution). Participants Thirty consecutive patients undergoing elective OPCAB surgery. Interventions Arterial pressure measurement with FloTrac, pulmonary arterial catheter insertion. Measurements and Main Results APCO and SCCO measurements were recorded after pulmonary artery catheter insertion (T1), after sternotomy (T2), after heart positioning for left anterior descending artery anastomosis (T3, T4), after heart positioning for obtuse marginal artery anastomosis (T5, T6), after heart positioning for posterior descending artery anastomosis (T7, T8), and after sternal closure (T9). APCO and SCCO were compared using the Bland-Altman method and the percentage error by Critchley's criteria. SCCO and APCO ranged from 2.1 to 6.9 L/min and 1.2 to 7.4 L/min, respectively, and showed low correlation (r = 0.29). The overall bias by the Bland-Altman method between SCCO and APCO was −0.23 L/min, with a precision of −1.4 to 0.9 L/min, and the overall limits of agreement were −2.5 to 2.0 L/min. The overall mean CO was 4.0 ± 0.95 L/min. The overall percentage error between SCCO and APCO measurements was 57%. Conclusions Uncalibrated APCO values do not agree with thermodilution SCCO and significantly overestimated the SCCO in patients undergoing OPCAB surgery. Further evaluation is required to verify the clinical acceptance of FloTrac APCO in OPCAB surgery.

Background: Neuropathic pain resulting from diverse causes is a chronic condition for which effective treatment is lacking. The goal of this study was to test whether dexamethasone exerts a preemptive analgesic effect with bupivacaine when injected perineurally in the spared nerve injury model. Methods: Fifty rats were randomly divided into five groups. Group 1 (control) was ligated but received no drugs. Group 2 was perineurally infiltrated (tibial and common peroneal nerves) with 0.4% bupivacaine (0.2 ml) and dexamethasone (0.8 mg) 10 minutes before surgery. Group 3 was infiltrated with 0.4% bupivacaine (0.2 ml) and dexamethasone (0.8 mg) after surgery. Group 4 was infiltrated with normal saline (0.2 ml) and dexamethasone (0.8 mg) 10 minutes before surgery. Group 5 was infiltrated with only 0.4% bupivacaine (0.2 ml) before surgery. Rat paw withdrawal thresholds were measured using the von Frey hair test before surgery as a baseline measurement and on postoperative days 3, 6, 9, 12, 15, 18 and 21. Results: In the group injected preoperatively with dexamethasone and bupivacaine, mechanical allodynia did not develop and mechanical threshold forces were significantly different compared with other groups, especially between postoperative days 3 and 9 (P ＜ 0.05). Conclusions: In conclusion, preoperative infiltration of both dexamethasone and bupivacaine showed a significantly better analgesic effect than did infiltration of bupivacaine or dexamethasone alone in the spared nerve injury model, especially early on after surgery. (Korean J Pain 2010; 23: 166-171)

Persistent and intractable hiccups (with respective durations of more than 48 hours and 1 month) can result in depression, fatigue, impaired sleep, dehydration, weight loss, malnutrition, and aspiration syndromes. The conventional treatments for hiccups are either non-pharmacological, pharmacological or a nerve block treatment. Pulsed radiofrequency lesioning (PRFL) has been proposed for the modulation of the excited nervous system pathway of pain as a safe and nondestructive treatment method. As placement of the electrode in close proximity to the targeted nerve is very important for the success of PRFL, ultrasound appears to be well suited for this technique. A 74-year-old man suffering from intractable hiccups that had developed after a coronary artery bypass graft and had continued for 7 years was referred to our pain clinic. He had not been treated with conventional methods or medications. We performed PRFL of the phrenic nerve guided by ultrasound and the hiccups disappeared.

Coronary artery bypass graft (CABG) patients often have cerebrovascular disease and pre-operative brain magnetic resonance angiography (MRA) frequently reveals cerebral vasculature stenosis. This study was designed to investigate whether pre-operative MRA findings correlated with regional cerebral oxygen saturation (ScO2) in 120 patients undergoing on-pump or off-pump CABG. Following MRA examination, patients were divided into six groups of 20 patients each based on MRA findings (no stenosis, mild stenosis or severe stenosis) and procedure (on-pump or off-pump CABG). Mean ScO2 values over 3 min were determined at seven periods during surgery. Patients with severe cerebrovascular stenosis showed significantly lower ScO2 than other groups during off-pump CABG. During on-pump CABG, ScO2 decreased significantly during cardiopulmonary bypass in all groups and was significantly lower in the severe stenosis group. Pre-operative MRA and intra-operative ScO2 monitoring may help to identify patients at increased risk of brain damage during or following CABG.

This study aimed to investigate the association between the clinical symptoms of central lumbar spinal stenosis (CLSS) and morphological parameters using magnetic resonance imaging (MRI) data. We retrospectively reviewed 117 patients who visited our pain clinic from 2009 to 2013 and were diagnosed as CLSS. All patients underwent MRI of the L-spine and we measured the dural sac cross-sectional area (DSA), spinal canal cross-sectional area (SCA), ligamentum flavum cross-sectional area (LFA) and ligamentum flavum thickness (LFT) at the most stenotic intervertebral level on MRI. Clinical outcomes were investigated using the patient-assessed quantitative measurement of visual analog scale (VAS) and subjective disability was assessed by the Oswestry Disability Index (ODI). Additionally, subjective walking distance (SWD) was also collected from electronic medical records. There were no statistically significant correlations found between the VAS score and the DSA, SCA, LFA, and LFT. A statistically significant linear association existed between the DSA and SCA and the subjective walking distance (r = 0.201, P = 0.045 and r = 0.198, P = 0.049, respectively) indicating that the larger the DSA or SCA, the longer the SWD before the occurrence of claudication. The LFA and LFT were significantly correlated with the ODI score (r = 0.249, P = 0.007 and r = 0.250, P = 0.007, respectively). Larger LFA and LFT values are associated with higher ODI values. A larger DSA and SCA are associated with a longer SWD before claudication occurs. To evaluate CLSS patients, clinicians should more carefully inspect the integral morphological parameters than the individual morphological parameters.

The efficacy of adefovir add-on therapy in treatmentexperienced patients with chronic hepatitis B (CHB) is debatable. This study aimed to evaluate the efficacy of adefovir add-on therapy in CHB patients with antiviral resistance to lamivudine/entecavir sequential therapy. CHB patients who exhibited documented resistance to lamivudine and switched to entecavir 1.0 mg monotherapy were evaluated and 19 of them showed active viral replication (HBV DNA levels ≥ 10⁵ copies/mL) or a history of treatment failure to lamivudine/ entecavir sequential therapy. Adefovir 10 mg/day has been added to these 19 patients and the virologic parameters were monitored every three months for 96 weeks. A primary responder was defined as patient who had a decline in serum HBV DNA ≥ 1 log10 copies/mL after 12 weeks of therapy, compared with the pretreatment value. In 19 CHB patients, 10(52.6%) patients were HBeAg positive, 7 (36.8%) had cirrhosis. The mean duration of previous entecavir therapy was 84.4 ± 22.5 weeks. The mean HBV DNA levels and ALT at baseline were 6.17 ± 0.96 log10 copies/mL, 53 ± 35 IU/L. The reduction of serum HBV DNA levels from baseline was 2.27 ± 1.34, 2.77 ± 1.41, and 3.09 ± 1.37 log10 copies/mL, at 24, 48 and 96 weeks, respectively. The rate of undetectable serum HBV DNA was 10.5% (2/19), 26.3% (5/19), and 31.5% (6/19) and ALT levels were normalized in 5 (55.6%), 6(66.7%), and 6(66.7%) of 9 patients with elevated ALT at baseline. Initial HBV DNA level was the only independent factor that was inversely associated with serum HBV DNA negativity at 96 weeks. Among 7 primary non-responders, 6 patients achieved serum HBV-DNA level < 4 log10 copies/mL at 96 weeks. Until 96 weeks, viral breakthrough was not detected in 19 patients. The adefovir add-on therapy may be helpful, even if not sufficient enough, for CHB patients with antiviral resistance to lamivudine/entecavir sequential therapy.

Background and Objectives Spontaneous intracranial hypotension (SIH) is characterized by a severe and disabling headache that is usually orthostatic in nature. Cisternography is a useful diagnostic test for evaluating the presence and location of cerebrospinal fluid (CSF) leakage, and a targeted epidural blood patch (EBP) based on the cisternography findings is a very effective treatment modality for SIH. However, the effects of EBPs are not predictable, making repeat EBPs essential in some cases. The aim of the present study was to find the relationship between the EBP response and cisternographic findings, hypothesizing that the number of required EBPs would increase with an increased number of CSF leakage levels as determined by radionuclide cisternography. Methods All patients who underwent an EBP and had been discharged with significant improvements in symptoms of SIH during 2006 to 2011 were enrolled. Patients who had no radionuclide cisternographic results were excluded. The demographic variables, number of EBPs, cisternographic findings (location, bilaterality, and number of leakage sites), and preprocedural and postprocedural pain scores were reviewed. Results There was no correlation found between the cisternographic findings and the number of EBPs. Only the preprocedural pain scores showed a statistically significant correlation with the number of EBPs. Conclusions Our study suggests that the response to the EBP is related to the severity of symptoms but not to the number and locations of cisternographic CSF leakages.

An attempt was made to modify the surface of sensitized Alloy 600, without affecting the bulk properties, by a laser surface melting (LSM) technique in order to improve its resistance to intergranular stress corrosion cracking (IGSCC) in oxidizing environments. A surface layer of 150–200 μm was melted by a CO 2 CW laser beam. The microstructures of the laser-surface-melted specimens were characterized using optical, scanning, and transmission electron microscopy. Slow strain rate tests (SSRTs) at a strain rate of about 4×10 −7 s −1 were carried out in a 0.1 M sodium tetrathionate (Na 2 S 4 O 6 ) solution at room temperature in order to evaluate the resistance to IGSCC of the laser-surface-melted specimens. The microstructure of the melted and resolidified layer had a cellular/columnar structure which consisted of cells 1–2 μm in diameter. The thin, solidified-surface layer was observed to act as an excellent barrier to the initiation and propagation of stress corrosion cracking in the experimental conditions. The fracture mode of the sensitized Alloy 600 changed from a brittle intergranular fracture to a typical ductile transgranular failure. The improved IGSCC resistance of the laser-surface-melted specimens can be attributed in part to Cr redistribution at the boundaries of the cells and grains and in part to the elimination of microstructural inhomogeneities such as precipitates, inclusions at the grain boundaries, during rapid melting and resolidification by the laser surface treatment.

To improve the corrosion resistance of Alloy 600, a typical alloy for steam-generator tubing in nuclear power plants, the surface of the alloy was modified by melting or alloying with a continuous CO 2 laser beam. In laser surface melting (LSM), a rapidly solidified surface layer of 300 μm in thickness was obtained. Anodic polarization measurements showed that the corrosion resistance of the laser-surface-melted specimen was improved slightly. This might be attributed to the elimination of microstructural inhomogeneities, such as precipitates, inclusions and segregated impurities pre-existing at grain boundaries. For laser surface alloying (LSA), chromium was electroplated on the surface of the specimens before laser-beam irradiation. The alloyed layer showed a pore- and oxide-free and very homogeneous microstructure, with a chromium composition of 28–30 at%. The corrosion properties of the alloyed specimen were examined by anodic polarization, electrochemical potentiodynamic reactivation, the modified Huey and slow-strain-rate tests. The properties, in particular intergranular corrosion resistance, were significantly improved compared with those of as-received or LSM specimens. The improvement in corrosion resistance might result from the easy formation of a more stable passive film on the alloyed surface layer with high chromium content.

Peripartum cardiomyopathy (PPCM) is a primary myocardial disease without any demonstrable cause and with onset in the last month of pregnancy or within six months of delivery [1]. Mortality is as high as 20 to 50% [2]. PPCM may suddenly occur when medical monitoring has been neglected and should be managed with great care by anesthesiologists and obstetricians. A 40-year-old (weight 81.5 kg, height 157 cm) multigravida (1-0-1-1) was admitted at 34 weeks 1 day of gestation with a chief complaint of preterm labor. Her medical history included obesity and gestational diabetes mellitus in a previous pregnancy. At 32 weeks gestation, she developed gestational hypertension without other significant preeclampsia signs and symptoms. At the time of admission the patient had a blood pressure (BP) of 180/100 mmHg, heart rate (HR) of 106 beats/min and respiratory rate (RR) of 20 breaths/min. She was diagnosed with pregnancy-induced hypertension, preterm labor occurred so emergency cesarean section was decided. Physical examination yielded no specific findings. In blood tests hemoglobin was 14.5 g/dl, hematocrit 40.9%, and coagulation and electrolyte were within normal range, as were chest x-ray and electrocardiogram (ECG). Hence combined spinal-epidural anesthesia was planned. The patient arrived in the operating room with premedication and antacids. ECG, non-invasive blood pressure and pulse oxymetry were monitored. Vital signs were BP 178/105 mmHg, HR 112 beats/min, RR 20 breaths/min and oxygen saturation 96%. Oxygen was administered via nasal prong at 2 L/min. Combined spinal epidural technique (Portex®, Smith Medical International Ltd, Kent, UK) with 7 mg of 0.5% heavy bupivacaine and 15 µg of fentanyl was done in left lateral decubitus position and midline approach at L3-4 interspace. Level of block was checked after 5 and 10 minutes and was found to be up to thoracic 6th and 4th segment respectively. Surgery proceeded without event and a healthy baby was delivered. Intravenous Carbetocin (Duratocin®, Ferring International Center, Switzerland) 100 µg and midazolam 2 mg were given after delivery. Total estimated blood loss was 700 ml. The patient received 2,000 ml of lactated Ringer's solution, and urine output was 200 ml. The operation lasted 65 minutes without adverse hemodynamic events. Patient was transferred to the postanesthetic care unit and then, over an hour later, to general ward, with stable vital signs. On POD 2, the patient's general condition was good but as her BP was 160-180/90-110 mmHg, anti-hypertensive medication was given. She was supposed to be discharged on POD 4, but suddenly had chest pain and dyspnea, and oxygen saturation by pulse oxymetry became unstable as 81%. Accordingly, oxygen was administered via a reservoir mask, but oxygen saturation continued to be unstable. Immediately, endotracheal intubation and cardiopulmonary cerebral resuscitation were performed and the patient was transferred to the intensive care unit. On chest x-ray the patient had both pulmonary edema and cardiomegaly. Arterial blood gas analysis (FiO2 0.6) gave pH of 7.24, CO2 of 50 mmHg, O2 of 66 mmHg, bicarbonate of 22 mEq/L, base excess of - 6.0 mEq/L and oxygen saturation of 95%. Laboratory results at that time were B-type natriuretic peptide (BNP) 2,114 pg/ml and D-dimer 3.18 pg/ml; other laboratory tests were within the normal range. A computed tomography chest scan to test for possible pulmonary emboli revealed pulmonary congestion and cardiomegaly but no pulmonary emboli. A transthoracic echocardiography (TTE) revealed a left ventricular ejection fraction of 33%, and severe left ventricular dysfunction with mild mitral regurgitation (Fig. 1). Therefore, she was given dobutamine, heparin and furosemide under a diagnosis of PPCM with acute pulmonary edema. On POD 6, her vital signs were BP 150/95 mmHg, HR 105 beats/min, RR 20 breaths/min and oxygen saturation of 96-99%. As her symptoms had improved her endotracheal tube was removed. On POD 7, vital signs remained stable. Arterial blood gas analysis (FiO2 0.4) gave a pH of 7.48, CO2 of 32.5 mmHg, O2 of 139.7 mmHg, bicarbonate of 22.7 mEq/L, base excess of - 1.6 mEq/L and oxygen saturation of 97%. TTE done on the same day showed a left ventricular ejection fraction of 36%. Since left ventricular ejection fraction improved slightly compared with POD 4, the patient was transferred to a general ward. On POD 13 the patient was discharged without symptoms, and a follow-up examination was scheduled for 6 month later. Fig. 1 A transthoracic echocardiography revealed a left ventricular ejection fraction of 33%, and severe left ventricular dysfunction with mild mitral regurgitation. The clinical features of PPCM include symptoms of congestive heart failure and chest pain [1]. Signs can include hypertension, tachycardia, tachypnea, pulmonary rales, S 3 heart sound and pedal edema. Because these symptoms and signs overlap with many other conditions ranging from normal pregnancy to pulmonary thromboembolism, diagnosis is often delayed and the disorder is under-recognized. Echocardiography is the most important diagnostic method and also provides information on the severity of peripartum cardiomyopathy and its prognosis [3]. Our patient did not complain of any particular symptoms until POD 3; symptoms such as dyspnea and chest pain occurred on POD 4 and then suddenly worsened. PPCM usually presents in the postpartum period when physiologic changes of pregnancy should be normalizing [4]. In most cases, PPCM was occurred during cesarean section or immediate postoperative period. However, our patient who developed PPCM on POD 4 could be regarded as a delayed type. Also, symptoms of PPCM overlap with many other condition and these were suddenly occurred and aggravated at any time. Therefore, PPCM should be evaluated early and exclude pulmonary thromboembolism when symptoms such as congestive heart failure occur in the postpartum period. Risk factors include advanced maternal age, multiparity, multiple gestation, obesity, gestational hypertension, preeclampsia and black race [1]. The prognosis of PPCM is related to its presentation as well as to recovery of ventricular dysfunction [1]. The ejection fraction normalizes in about 50% of patients. However, a second pregnancy is usually not recommended, because PPCM recurs in more than 30% [5]. In conclusion, delayed PPCM can be occurred in the patients with advanced maternal age, obesity and gestational hypertension. Therefore, these patients should be provided with adequate preoperative optimization using a multidisciplinary approach, proper use of anesthetic technique, careful intraoperative monitoring as well as vigilant postoperative care.

Background: Although paclitaxel is a widely used chemotherapeutic agent for the treatment of solid cancers, side effects such as neuropathic pain lead to poor compliance and discontinuation of the therapy. Ethyl pyruvate (EP) is known to have analgesic effects in several pain models and may inhibit apoptosis. The present study was designed to investigate the analgesic effects of EP on mechanical allodynia and apoptosis in dorsal root ganglion (DRG) cells after paclitaxel administration. Methods: Rats were randomly divided into 3 groups: 1) a control group, which received only vehicle; 2) a paclitaxel group, which received paclitaxel; and 3) an EP group, which received EP after paclitaxel administration. Mechanical allodynia was tested before and at 7 and 14 days after final paclitaxel administration. Fourteen days after paclitaxel treatment, DRG apoptosis was determined by activated caspase-3 immunoreactivity (IR). Results: Post-treatment with EP did not significantly affect paclitaxel-induced allodynia, although it tended to slightly reduce sensitivities to mechanical stimuli after paclitaxel administration. After paclitaxel administration, an increase in caspase-3 IR in DRG cells was observed, which was co-localized with NF200-positive myelinated neurons. Post-treatment with EP decreased the paclitaxel-induced caspase-3 IR. Paclitaxel administration or post-treatment with EP did not alter the glial fibrillary acidic protein IRs in DRG cells. Conclusions: Inhibition of apoptosis in DRG neurons by EP may not be critical in paclitaxel-induced mechanical allodynia. (Korean J Pain 2013; 26: 135-141)

Background: The pathophysiological and neurochemical changes following spinal injury are not yet elucidated. This study was designed to evaluate the morphological changes of the dorsal horn of the spinal cord and profiles of pain behaviors following intraspinal injection of NMDA in rats. Methods: Rats were randomized into three groups: a sham-operated control group and groups where the rats received 10 mM or 100 mM N-methyl-D-aspatate (NMDA) injected into their spinal dorsal horn. Following injection, hypersensitivity to cold and mechanical stimuli and excessive grooming behaviors were assessed serially for four weeks. Morphological changes of the spinal cord were evaluated four weeks after intraspinal injection. Results: Few animals in the NMDA groups developed hypersensitivity to cold and mechanical stimuli. The number of groomers and the severity of excessive grooming were significantly higher in the 100 mM NMDA group than those values of the control and 10 mM NMDA groups. The size of the neck region (lamina III-IV) was significantly smaller in the 100 mM NMDA group than in the control and 10 mM NMDA groups. Conclusions: In conclusion, intraspinal injection of NMDA in rats leads to the pathological sequela in the spinal cord and to excessive grooming behavior. These results support the use of NMDA and excessive grooming behavior after excitotoxic SCI as a model to study chronic pain after SCI. (Korean J Pain 2010; 23: 109-115)

The implantation of spinal cord stimulators (SCSs) to treat chronic intractable pain is steadily increasing. And there is an increased likelihood of instances where other therapies or procedures are found to interfere with SCS function, which in turn may result in pain. Since SCS utilize electric impulses as well as magnets, special considerations need for patients with a SCS in situ who require these procedures. The present report describes a case where radiofrequency (RF) ablation of the third occipital nerve resulted in spontaneous activation of a cervical SCS device.

Background and Aims: Adefovir dipivoxil (ADV) is a nucleotide analogue that is known to be effective for lamivudine-resistant hepatitis B virus (HBV) mutants as well as wild-type HBV. The aim of this study is to assess the efficacy of ADV against lamivudine-resistant genotype C HBV mutants. Methods: Thirty-five patients with breakthrough hepatitis due to lamivudine-resistant HBV received ADV 10 mg daily with discontinuation of lamivudine. Quantitative HBV DNA, HBeAg, liver function test including alanine aminotransferase (ALT) was checked every 4–12 weeks to evaluate the efficacy of ADV. Results: ADV was administered for a median of 48 weeks (range: 24–120 weeks). The rate of serum HBV DNA loss was 68.6%, 80.0%, 84.0%, and 88.2% at weeks 12, 24, 36, and 48, respectively. The rate of serum HBeAg seroconversion was 8.3% and 14.3% at weeks 24 and 48, respectively. The rate of serum ALT normalization at week 48 was 70.6%. Within 32 weeks after stopping ADV therapy, serum HBV DNA levels increased to a median of 378.9 pg/ml in 88.9% of patients, who were treated for a median of 40 weeks. Moreover, in some patients, the ALT level increased to more than five times the upper limit of normal. Conclusions: Administration of ADV is an effective option for the treatment of patients with lamivudine-resistant genotype C HBV infection.

It has been unclear whether immediate antiviral therapy or observation under the expectation of spontaneous inactivation of hepatitis B virus (HBV), is more appropriate for the treatment of chronic hepatitis B (CHB) with acute exacerbation. We intended to analyze the short-term natural course of CHB with acute exacerbation and evaluate the efficacy of lamivudine.We analyzed 35 CHB patients with acute exacerbation (positive HBV DNA or HBeAg and ALT400 IU/L) between March 2000 and May 2003. We regularly checked serum HBV DNA, HBeAg and liver function tests including ALT every 1 to 3 months. If ALT was above 100 IU/L during the follow-up period, patients were treated with 100 mg lamivudine orally once a day. We compared the efficacy of lamivudine use between this group and the group provided with immediate lamivudine trial at their first visit.27 CHB patients with acute exacerbation were observed without immediate lamivudine trial. In 5 of these patients normal ALT, negative HBeAg and HBV DNA were maintained during 19 months (group 1a). Slightly elevated or normal ALT was maintained without HBeAg seroconversion in 3 patients (group 1b). However, serum ALT flared up above 100 IU/L in 19 patients within 5 months. So, lamivudine was tried on these patients (group 2). The serum HBV DNA was extremely low, being 6.5 pg/mL in group 1a compared to 518.1 pg/mL in group 2. Spontaneous inactivation of HBV was observed in 71.4% (5/7) of patients with HBV DNA less than 20 pg/ mL at the first visit. ALT was lower and HBV DNA was higher in group 2 than the 8 patients who received immediate lamivudine trial at the first visit (group 3). The response rate of lamivudine was similar between group 2, 56.3% (9/16) and group 3, 62.5% (5/8).Spontaneous inactivation of HBV was expected in CHB with acute exacerbation and extremely low level of HBV DNA (less than 20 pg/mL) in a short term follow-up period. Immediate lamivudine therapy might be more appropriate in most CHB patients with acute exacerbation.

AIM: The generation of oxygen free radicals has been implicated in the pathogenesis of experimental pancreatitis. The aim of this study was to determine the role of oxygen free radicals in patients with acute pancreatitis. METHODS: The plasma levels of C-reactive protein (CRP), lipid peroxide (LPO), myeloperoxidase (MPO) and superoxide dismutase (SOD) were measured in 13 patients with acute pancreatitis and 14 healthy volunteers. RESULTS: Among the patients with acute pancreatitis, there were higher plasma levels of LPO and MPO and lower SOD activity in patients with severe pancreatitis than in those with mild pancreatitis. However, there was no significant difference in the serum marker of oxidative stress no matter what the etiology was. The LPO level was especially correlated with the concentration of serum CRP and CT severity index. CONCLUSION: The oxygen free radicals may be closely associated with inflammatory process and the severity of acute pancreatitis. Especially, the concentration of plasma LPO is a meaningful index for determining the severity of the disease.