Blinded Injection Research Articles

THU0352 Blinded VS Ultrasound-Guided Corticosteroid Injections for the Treatment of the Greater Trochanteric Pain Syndrome (SDPT): A Randomized Controlled Trial

BackgroundThe peritrochanteric corticosteroid injections with anesthesics is one of the suggested treatments for the refractory case of the Greater Throcanteric Pain Syndrome and this therapeutic intervention can be guided or...

Does Single Blind Anterior Glenohumeral Steroid Injection Performed by Short Experienced Clinicians Could Provide Clinical Efficacy in Patients with Frozen Shoulder?

BACKGROUND: The purpose of this study was to evaluate the effect of single blinded anterior intra-articular corticosteroid injection to the glenohumeral joint performed by short experienced clinicians in frozen state adhesive capsulitis patients.METHODS: From March to June of 2013, among the patients who visited the shoulder outpatient clinic due to shoulder pain for 5-6 months and those patient diagnosed as frozen state adhesive capsulitis was selected. The diagnosis were based on base, first the global limitation of range of motion, defined as forward elevation <100, external rotation at side <10, internal rotation less than buttock, and abduction <70. Second, the patients had additional radiologic evaluations showing no major pathologies for such stiffness. Clinical outcome, were performed with pain visual analog scale (PVAS) and functional visual analog scale (FVAS), American Shoulder and Elbow Surgeons Shoulder score (ASES), preinjection and postinjection after 2-4 weeks. Finally 82-patients were enrolled. Mean age of the patients was 55.1 years and mean follow-up duration was 25.17 days.RESULTS: The mean preinjection PVAS was 6.91 and postinjection was 3.11, there was 3.8 decreases from preinjection status (p < 0.001). The mean FVAS score showed 4.26 at preinjection and 6.63 afterwards (p < 0.001). The ASES score showed 27.89 increases after injection (p < 0.001). There were 64-patients (78.04%) who reported more than 3 points of decrease of PVAS, who could be judged as effective treatment.CONCLUSIONS: Single anterior glenohumeral steroid injection by short experienced clinicians to the patients with frozen state adhesive capsulitis has shown relatively high efficacy in clinical result evaluated by means of PVAS.

Where and how to inject the knee—A systematic review

ObjectivesThe knee can be injected at different anatomic sites with or without image-guidance. We undertook a systematic review to determine the accuracy of intra-articular knee injection (IAKI) and whether this varied by site, use of image-guidance, and experience of injectors, and whether accuracy of injection, site, or use of image-guidance influenced outcomes following IAKIs. MethodsMedline, Embase, AMED, CINAHL, Web of Knowledge, Cochrane Central Registers for Controlled Trials up to Dec 2012 were searched for studies that evaluated either accuracy of IAKIs or outcomes related to accuracy, knee injection sites, or use of image-guidance. Within-study and between-study analyses were performed. ResultsData from 23 publications were included. Within-study analyses suggested IAKIs at the superomedial patellar, medial midpatellar (MMP), superolateral patellar (SLP) and lateral suprapatellar bursae sites were more accurate when using image-guidance than when blinded (ranges of pooled risk difference 0.09–0.19). Pooling data across studies suggested blinded IAKIs at the SLP site were most accurate (87%) while MMP (64%) and anterolateral joint line (ALJL) sites were (70%) least accurate. Overall about one in five blinded IAKIs were inaccurate. There was some evidence that experience of the injector was linked with improved accuracy for blinded though not image-guided injections. Based on a small number of studies, short but not longer-term outcomes for ultrasound-guided were found to be superior to blinded IAKIs. ConclusionsImage-guided IAKIs are modestly more accurate than blinded IAKIs especially at the MMP and ALJL sites. Blinded injections at SLP site had good accuracy especially if performed by experienced injectors. Further studies are required to address the question whether accurate localization is linked with an improved response.

Association Between Disease-Specific Quality of Life and Magnetic Resonance Imaging Outcomes in a Clinical Trial of Prolotherapy for Knee Osteoarthritis

ObjectiveTo assess the relation between knee osteoarthritis (KOA)-specific quality of life (QOL) and intra-articular cartilage volume (CV) in participants treated with prolotherapy. KOA is characterized by CV loss and multifactorial pain. Prolotherapy is an injection therapy reported to improve KOA-related QOL to a greater extent than blinded saline injections and at-home exercise, but its mechanism of action is unclear. DesignTwo-arm (prolotherapy, control), partially blinded, controlled trial. SettingOutpatient. ParticipantsAdults with ≥3 months of symptomatic KOA (N=37). InterventionsProlotherapy: 5 monthly injection sessions; Control: blinded saline injections or at-home exercise. Main Outcome MeasuresPrimary: KOA-specific QOL scores (baseline, 5, 9, 12, 26, and 52wk; Western Ontario and McMaster University Osteoarthritis Index). Secondary: KOA-specific pain, stiffness, function (Western Ontario McMaster University Osteoarthritis Index subscales), and magnetic resonance imaging–assessed CV (baseline, 52wk). ResultsKnee-specific QOL improvement among prolotherapy participants exceeded that among controls (17.6±3.2 points vs 8.6±5.0 points; P=.05) at 52 weeks. Both groups lost CV over time (P<.05); no between-group differences were noted (P=.98). While prolotherapy participants lost CV at varying rates, those who lost the least CV (“stable CV”) had the greatest improvement in pain scores. Among prolotherapy participants, but not control participants, the change in CV and the change in pain (but not stiffness or function) scores were correlated; each 1% CV loss was associated with 2.7% less improvement in pain score (P<.05). ConclusionsProlotherapy resulted in safe, substantial improvement in KOA-specific QOL compared with control over 52 weeks. Among prolotherapy participants, but not controls, magnetic resonance imaging–assessed CV change (CV stability) predicted pain severity score change, suggesting that prolotherapy may have a pain-specific disease-modifying effect. Further research is warranted.

SAT0439 Treatment of lateral epicondylitis with injection of platelet-rich plasma or corticosteroid versus saline: A randomized, double-blind, placebo-controlled trial

BackgroundLateral epicondylitis (LE) is a common musculoskeletal disorder for which an effective treatment strategy still remains absent.ObjectivesTo examine whether one injection with Platelet-rich plasma (PRP) is more effective than saline...

Dextrose Prolotherapy for Knee Osteoarthritis: A Randomized Controlled Trial

Knee osteoarthritis is a common, debilitating chronic disease. Prolotherapy is an injection therapy for chronic musculoskeletal pain. We conducted a 3-arm, blinded (injector, assessor, injection group participants), randomized controlled trial to assess the efficacy of prolotherapy for knee osteoarthritis. Ninety adults with at least 3 months of painful knee osteoarthritis were randomized to blinded injection (dextrose prolotherapy or saline) or at-home exercise. Extra- and intra-articular injections were done at 1, 5, and 9 weeks with as-needed additional treatments at weeks 13 and 17. Exercise participants received an exercise manual and in-person instruction. Outcome measures included a composite score on the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 100 points); knee pain scale (KPS; individual knee), post-procedure opioid medication use, and participant satisfaction. Intention-to-treat analysis using analysis of variance was used. No baseline differences existed between groups. All groups reported improved composite WOMAC scores compared with baseline status (P <.01) at 52 weeks. Adjusted for sex, age, and body mass index, WOMAC scores for patients receiving dextrose prolotherapy improved more (P <.05) at 52 weeks than did scores for patients receiving saline and exercise (score change: 15.3 ± 3.5 vs 7.6 ± 3.4, and 8.2 ± 3.3 points, respectively) and exceeded the WOMAC-based minimal clinically important difference. Individual knee pain scores also improved more in the prolotherapy group (P = .05). Use of prescribed postprocedure opioid medication resulted in rapid diminution of injection-related pain. Satisfaction with prolotherapy was high. There were no adverse events. Prolotherapy resulted in clinically meaningful sustained improvement of pain, function, and stiffness scores for knee osteoarthritis compared with blinded saline injections and at-home exercises.

Treatment of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline

Background: Lateral epicondylitis (LE) is a common musculoskeletal disorder for which an effective treatment strategy remains unknown. Purpose: To examine whether a single injection of platelet-rich plasma (PRP) is more effective than placebo (saline) or glucocorticoid in reducing pain in adults with LE after 3 months. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 60 patients with chronic LE were randomized (1:1:1) to receive either a blinded injection of PRP, saline, or glucocorticoid. The primary end point was a change in pain using the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire at 3 months. Secondary outcomes were ultrasonographic changes in tendon thickness and color Doppler activity. Results: Pain reduction at 3 months (primary end point) was observed in all 3 groups, with no statistically significant difference between the groups; mean differences were the following: glucocorticoid versus saline: −3.8 (95% CI, −9.9 to 2.4); PRP versus saline: −2.7 (95% CI, −8.8 to 3.5); and glucocorticoid versus PRP: −1.1 (95% CI, −7.2 to 5.0). At 1 month, however, glucocorticoid reduced pain more effectively than did both saline and PRP; mean differences were the following: glucocorticoid versus saline: −8.1 (95% CI, −14.3 to −1.9); and glucocorticoid versus PRP: −9.3 (95% CI, −15.4 to −3.2). Among the secondary outcomes, at 3 months, glucocorticoid was more effective than PRP and saline in reducing color Doppler activity and tendon thickness. For color Doppler activity, mean differences were the following: glucocorticoid versus PRP: −2.6 (95% CI, −3.1 to −2.2); and glucocorticoid versus saline: −2.0 (95% CI, −2.5 to −1.6). For tendon thickness, mean differences were the following: glucocorticoid versus PRP: −0.5 (95% CI, −0.8 to −0.2); and glucocorticoid versus saline: −0.8 (95% CI, −1.2 to −0.5). Conclusion: Neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline.

A New Innovative Therapy for Sports Related Soft Tissue Injuries: Platelet-Rich Plasma (PRP)

Introduction: Platelet-rich plasma (PRP) is the cellular component of plasma that settles after centrifugation, and contains numerous growth factors. There is increasing interest in the sports medicine about providing endogenous growth factors directly to the injury site, using autologous blood products such as PRP, to potentially facilitate healing and earlier return to. Despite this interest, and apparent widespread use, there is a lack of high-level evidence trials assessing the efficacy of PRP. Systematic review: We performed a systematic review of the literature and included clinical studies on PRP injections for ligament, muscle or tendon injuries. A few randomized controlled clinical trials have assessed the efficacy of PRP injections and none have demonstrated scientific evidence of efficacy. Scientific studies should be performed to assess clinical indications, efficacy, and safety of PRP, and this will require appropriately powered randomized controlled trials with adequate and validated clinical and functional outcome measures and sound statistical analysis. Original research: Our group recently studied the effects of a platelet-rich plasma injection in patients with chronic midportion Achilles tendinopathy at 1-year follow-up in a randomized controlled trial; Fifty-four patients, aged 18 to 70 years, with chronic tendinopathy were randomized to receive either a blinded injection containing platelet-rich plasma or saline (placebo group) in addition to an eccentric training program. The validated mean Victorian Institute of Sports Assessment-Achilles score improved in both the platelet-rich plasma group and the placebo group after 1 year. There was no significant difference in increase between both groups (adjusted between-group difference, 5.5; 95% confidence interval, −4.9 to 15.8, P = .292). This randomized controlled trial showed no clinical and ultrasonographic superiority of platelet-rich plasma injection over a placebo injection. Overall conclusion: Based on the systematic review and original research, the potential risks involved with PRP are fortunately very low. PRP got the potentiality to facilitate healing and earlier return to sport after musculoskeletal injury, but benefits remain unproven to date and there is a need for high quality studies with a randomized design. Aspetar is currently performing a level I evidence research project into the benefits of PRP in muscle injuries.

309 A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, MULTICENTER STUDY OF rhFGF18 ADMINISTERED INTRAARTICULARLY USING SINGLE OR MULTIPLE ASCENDING DOSES IN PATIENTS WITH PRIMARY KNEE OSTEOARTHRITIS (OA), SCHEDULED FOR TOTAL KNEE REPLACEMENT

in-person instruction on at-home knee exercise. The primary outcome measure was a composite score on the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 100 points), which assessed knee pain, function and stiffness on a per subject basis. The secondary outcome was the Knee Pain Scale (KPS) which assessed knee pain severity and frequency on a per knee basis; both were done at baseline, 5, 9 12, 26 and 52 weeks. Procedure-related opioid medication use, subject satisfaction and adverse events were also assessed. Results: Analysis was by intention to treat. No significant baseline differences existed between the groups in age, gender, pain duration, body mass index or WOMAC scores. 89 subjects (57±8.3 years old, 59 female) with moderate to severe KOA received an average of 4.3±0.7 prolotherapy injection sessions over a 17-week treatment period. All groups reported improved composite WOMAC scores compared to baseline status (p < 0.01) at 52 weeks. However, WOMAC scores for prolotherapy subjects, adjusted for gender, age and body mass index showed significantly greater improvement onWOMAC score at 52 weeks; 15.32±3.52 points for prolotherapy compared to 7.68±3.41 points for saline injection (p < 0.05) and 8.25±3.33 points for exercise (p< 0.05). The improvement by prolotherapy subjects exceeded minimal clinical important difference. KPS scores of prolotherapy subjects showed similar improvement per injected knee compared to baseline status (p < 0.001) and controls (p < 0.05). Prescribed post-procedure opioid medication resulted in rapid diminution of prolotherapy injection pain. Satisfaction with prolotherapy was high and there were no adverse events. Conclusions: Prolotherapy resulted in safe, significant, sustained improvement of pain, function and stiffness scores compared to blinded saline injections and at-home exercises in knee osteoarthritis.

One-Year Follow-up of Platelet-Rich Plasma Treatment in Chronic Achilles Tendinopathy

Background Achilles tendinopathy is a common disease among both athletes and in the general population in which the use of platelet-rich plasma has recently been increasing. Good evidence for the use of this autologous product in tendinopathy is limited, and data on longer-term results are lacking. Purpose To study the effects of a platelet-rich plasma injection in patients with chronic midportion Achilles tendinopathy at 1-year follow-up. Study Design Randomized controlled trial; Level of evidence, 1. Methods Fifty-four patients, aged 18 to 70 years, with chronic tendinopathy 2 to 7 cm proximal to the Achilles tendon insertion were randomized to receive either a blinded injection containing platelet-rich plasma or saline (placebo group) in addition to an eccentric training program. The main outcome was the validated Victorian Institute of Sports Assessment–Achilles score. Patient satisfaction was recorded and ultrasound examination performed at baseline and follow-up. Results The mean Victorian Institute of Sports Assessment–Achilles score improved in both the platelet-rich plasma group and the placebo group after 1 year. There was no significant difference in increase between both groups (adjusted between-group difference, 5.5; 95% confidence interval, –4.9 to 15.8, P = .292). In both groups, 59% of the patients were satisfied with the received treatment. Ultrasonographic tendon structure improved significantly in both groups but was not significantly different between groups (adjusted between-group difference, 1.2%; 95% confidence interval, –4.1 to 6.6, P = .647). Conclusion This randomized controlled trial showed no clinical and ultrasonographic superiority of platelet-rich plasma injection over a placebo injection in chronic Achilles tendinopathy at 1 year combined with an eccentric training program.

Platelet-rich plasma for chronic achilles tendinopathy: a double-blind randomised controlled trial with one year follow-up

IntroductionChronic Achilles tendinopathy occurs frequently and is very hard to treat. The disease involves local degeneration of tendon tissue, of which regeneration may be improved by injecting platelet-rich plasma (PRP),...

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain. We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies. Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as "in" the capsule, whereas 49 were identified as "outside" the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches. The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.

Investigating the effect of intra-operative infiltration with local anaesthesia on the development of chronic postoperative pain after inguinal hernia repair. A randomized placebo controlled triple blinded and group sequential study design [NCT00484731

BackgroundInguinal hernia repair is one of the most frequently performed procedures in Switzerland (15'000/year). The most common complication postoperatively is development of chronic pain in up to 30% of all patients irrespective of the operative technique.Methods/Design264 patients scheduled for an inguinal hernia repair using one of three procedures (Lichtenstein, Barwell and TEP = total extraperitoneal hernioplasty) are being randomly allocated intra-operatively into two groups. Group I patients receive a local injection of 20 ml Carbostesin® 0.25% at the end of the operation according to a standardised procedure. Group II patients get a 20 ml placebo (0.9% Saline) injection. We use pre-filled identically looking syringes for blinded injection, i.e. the patient, the surgeon and the examinator who performs the postoperative clinical follow-ups remain unaware of group allocation. The primary outcome of the study is the occurrence of developing chronic pain (defined as persistent pain at 3 months FU) measured by VAS and Pain Matcher® device (Cefar Medical AB, Lund, Sweden).The study started on July 2006. In addition to a sample size re-evaluation three interim analyses are planned after 120, 180 and 240 patients had finished their 3-months follow-up to allow for early study termination.DiscussionUsing a group sequential study design the minimum number of patients are enrolled to reach a valid conclusion before the end of the study.To limit subjectivity, both a VAS and the Pain Matcher® device are used for the evaluation of pain. This allows us also to compare these two methods and further assess the use of Pain Matcher® in clinical routine.The occurrence of chronic pain after inguinal hernia repair has been in focus of several clinical studies but the reduction of it has been rarely investigated. We hope to significantly reduce the occurrence of this complication with our investigated intervention.Trial RegistrationOur trial has been registered at ClinicalTrials.gov. The trial registration number is: [NCT00484731].

Nerve Blocks at the Wrist for Carpal Tunnel Release Revisited: The Use of Sensory-Nerve and Motor-Nerve Stimulation Techniques

Because the median nerve at the wrist has mainly sensory endings, the aim of this study was to assess the response of the median nerve to nerve stimulation at the wrist and to evaluate the quality of median nerve block. A control group of patients who received blinded injections was analyzed and compared post hoc. One hundred and eleven patients scheduled for ambulatory endoscopic carpal-tunnel release performed under median and ulnar nerve blocks at the wrist were prospectively studied. The blocks were performed with a nerve stimulator. Nerve-stimulation techniques were explained to the patient before the block was performed. The patient was trained to inform the anesthetist of their perception of an electrical paresthesia that was synchronized to the nerve stimulator. The anesthetist recorded the first response of the patient to nerve stimulation: sensory (S), sensory-motor (SM), or motor response (M). When the minimal stimulating current was obtained, an equal volume of 4 mL of 1.5% mepivacaine was injected on median and ulnar nerves. If necessary, a lateral subcutaneous injection of 2 mL of 1.5% mepivacaine was administered at the wrist crease in the musculocutaneous nerve area. Thirty-five patients who received blinded local anesthetics injections were included post hoc. Quality of anesthesia was compared between groups. Responses included 89 S (80.2%), 18 SM (16.2%), and 4 M (3.71%). No differences occurred in time to perform the block, minimal current intensity, and efficacy. More punctures were necessary in the M group compared with the S group and the control group (P < .05). The onset time of sensory blocks increased significantly in control-group patients (P < .05), but the duration of the nerve-block procedure decreased in comparison with the M group. Respectively, 10% and 20% of patients experienced mild or severe pain in the nerve-stimulation group and control group. At 20 minutes, the block was complete for the median and ulnar nerves in 96.4% and 85% of the nerve-stimulation patients and control patients (P < .05). Two patients in the control group experienced painful mechanical paresthesia. Neither permanent nor transient nerve injuries were observed during or after the nerve block or surgery. This study describes how infrequently an initial motor response is identified when a nerve stimulator is used on the median nerve at the wrist. A very high success rate of median and ulnar nerve block at the wrist is obtained by use of sensory or sensory-motor-nerve stimulation and less than 10 mL of anesthetic solution.

Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study

Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy. The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread. The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients. Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.

Injection pain and postinjection pain of the anterior middle superior alveolar injection administered with the Wand ® or conventional syringe

Objective The purpose of this prospective, randomized, blinded study was to compare the pain of injection and post-injection pain of the AMSA injection using the computer-assisted Wand Plus ® injection system versus a conventional syringe. Study design Using a crossover design, 40 subjects randomly received 2 blinded AMSA injections using the Wand Plus ® system and a conventional syringe, at 2 separate appointments. The AMSA injection site was centered halfway between the midpalatine raphe and gingival margin of the first and second premolars. The pain of needle insertion, anesthetic solution deposition pain, and postinjection pain were recorded on a Heft-Parker VAS for the 2 AMSA injections. Results For needle insertion, 38% of the subjects had moderate/severe pain with the Wand Plus ® and 34% moderate/severe pain with the conventional syringe, with no significant difference between techniques. There was a significant difference for solution deposition pain, with the conventional syringe causing more moderate/severe pain (42% conventional vs. 25% for the Wand Plus ®). Regarding postinjection pain, after numbness wore off there was no significant difference between the Wand Plus ® injection technique (0% moderate pain) and the conventional syringe technique (8% moderate pain). Postinjection, approximately 8% to 10% of the subjects experienced slight palatal swelling and 2% experienced temporary numbness. These problems resolved quickly and were considered minor. Conclusions The AMSA injection, using the Wand Plus ®, resulted in similar pain ratings for needle insertion as the conventional syringe but statistically lower pain ratings upon anesthetic solution deposition. However, the AMSA, using either the Wand Plus ® or a conventional syringe, has the potential to be a painful injection. We found the incidence of postinjection pain and sequelae was low with both techniques.

Chloroprocaine is Less Painful than Lidocaine for Skin Infiltration Anesthesia

Skin infiltration of local anesthetics causes pain. In a double-blinded protocol, 22 volunteers received random intradermal injections to the volar surface of the forearm with each of the following solutions: normal saline solution 0.9% (NSS), lidocaine 1% (L), lidocaine 1% and sodium bicarbonate 8.4% (L+BIC), 2-chloroprocaine 2% (CP), 2-chloroprocaine 2% and sodium bicarbonate 8.4% (CP+BIC), and NaCHO3 8.4% (BIC). Initially, each volunteer received an open-labeled injection of NSS. A 100-mm visual analog scale (VAS, 1–100) was used to assess pain with each injection. The pH of each solution was stable for the length of the study. Repeated measures of variance were used for analysis. The VAS scores (mean ± sd) for open-label and blinded NSS injections were 15.5 ± 15.9 and 14.0 ± 18.1, respectively. The scores for the studied solutions were as follows: BIC, 47.2 ± 25.5; L, 25.8 ± 27.6; L+BIC, 16.0 ± 14.2; CP, 8.6 ± 7.4; and CP+BIC, 6.8 ± 6.7. No significant difference was found between CP and alkalinized CP, but the injection of both solutions was significantly less painful than that of all other solutions (P < 0.05). The pH of the solutions was not related to the pain score. We found that chloroprocaine caused less pain at injection than the more commonly used lidocaine.

Laparoscopic ultrasonography: a training model.

The purpose of this study was to develop a surgical training program and to test the accuracy of laparoscopic ultrasound in detecting injected lesions in pig livers. Pig livers were divided into eight segments and injected with Surgilube "malignant" and silicone "benign" lesions. All were examined by laparoscopic ultrasound followed by liver explantation to confirm results. First, a pilot study was conducted on six swine by injecting Surgilube lesions and performing laparoscopic ultrasound through 3 different ports (left upper quadrant (I), umbilicus (II), and right lower quadrant (III)) to determine per-segment accuracy and to optimize port placement. Second, blinded injection of Surgilube and silicone implants was done on 18 pigs with laparoscopic ultrasound conducted through the two most accurate ports from the pilot study. This model was then tested during a resident training workshop. In the pilot study, per-lesion and per-segment sensitivity was 96 percent, with no difference among the three ports used. Ports I and II were chosen for the blinded study for their convenience in performing laparoscopic colectomy. In the blinded study, per-segment sensitivity, specificity, and accuracy were 97 percent, 94 percent, and 96 percent and 99 percent, 94 percent, and 97 percent for ports I and II, respectively. At the conclusion of a pilot workshop, trainee per-segment sensitivity, specificity, and accuracy were 60 percent, 80 percent, and 70 percent, respectively. The major difficulty was differentiating benign from malignant lesions. A useful liver laparoscopic ultrasound training model for surgeons was developed with good preliminary results. It is anticipated that further training will enhance laparoscopic ultrasound accuracy rates before application of this modality in humans.

Placental angioarchitecture in monochorionic twin pregnancies: Relationship to fetal growth, fetofetal transfusion syndrome, and pregnancy outcome

Objective: We sought to correlate placental vasculature with fetal growth and outcome in monochorionic twins. Study Design: Eighty-two patients with consecutive monochorionic pregnancies underwent biweekly ultrasonography for determination of fetal growth and well-being. After delivery, blinded placental injection studies delineated vascular anastomoses and territory share. Degree of balance in arteriovenous anastomoses equaled the number of arteriovenous anastomoses in one direction minus the number in the other. Results: Pregnancies affected by fetofetal transfusion syndrome (n = 21) had numbers of arteriovenous and venovenous anastomoses that were similar to those in pregnancies without fetofetal transfusion syndrome but fewer arterioarterial anastomoses ( P < .0001). Fetofetal transfusion syndrome occurred in 78% of pregnancies with ≥1 arteriovenous and no arterioarterial anastomoses. Birth weight discordancy correlated with placental territory discordancy ( P < .0001) and the degree of balance in arteriovenous anastomoses ( P = .004). The larger placental share twin had a greater growth velocity than its smaller placental share co-twin ( P = .008) for all but one anastomotic pattern. Where arteriovenous anastomoses were aligned with the net venous outflow to the fetus with the smaller territory, co-twins had similar birth weights and growth velocities irrespective of placental share. Fetal survival was higher in pregnancies with an arterioarterial anastomosis ( P = .01) but lower with a venovenous anastomosis ( P = .01). Survival of both fetuses was inversely associated with birth weight discordancy ( P < .0001). Conclusion: Although interrelationships among the various types of anastomoses are complex, our data suggest that the placental territory share and the pattern of arteriovenous anastomoses influence fetal growth, that arterioarterial anastomoses protect against fetofetal transfusion syndrome, and that venovenous anastomoses reduce perinatal survival. (Am J Obstet Gynecol 2000;182:417-26.)

Infiltration of morphine into an abdominal wound; effects on pain relief and endocrine/immune response

We wanted to evaluate pain relief and endocrine /immune response after local administration of morphine into an abdominal wound. In a randomised double blind design 29 patients undergoing hysterectomy received two blinded injections of morphine and saline. Before surgery the patients in the control group ( n=15) got 10 mg of subcutaneous morphine into an arm and at skin incision 30 ml of saline was infiltrated directly into the wound. The patients in the wound group ( n=14) received 1 ml of saline into an arm before surgery and 10 mg of morphine in 30 ml of saline into the wound at skin incision. Patient controlled analgesia (PCA) with i.v. morphine was used after surgery. Repeated blood samples were obtained from the day before the surgery until 3 days later and analysed for cortisol and interleukin-6 (IL-6). There were no differences between the groups either in pain relief or in the consumption of PCA morphine. The wound group used 47±15 mg of i.v. morphine and the control group used 50±16 mg. Peak values for IL-6 and cortisol appeared at 4 h. The area under the curve (AUC) of cortisol at 0–6, 0–10 and 0–20 h was significantly lower in the control group than in the wound group ( P<0.05). High doses of i.v. morphine reduced cortisol and IL-6 levels in the early hours after surgery. The injection of morphine into the wound did not improve pain relief or reduce the consumption of i.v. morphine after surgery. The endocrine stress response to trauma was modified by preoperative administration of morphine.