Ultrasound-Guided Continuous Thoracic Paravertebral Infusion of Methylene Blue in the Treatment of Postherpetic Neuralgia: A Prospective, Randomized, Controlled Study

A rationally designed nuclei-targeting FAPI 04-based molecular probe with enhanced tumor uptake for PET/CT and fluorescence imaging

PURPOSE

Fibroblast activation protein inhibitor (FAPI) -based probes have been widely studied in the diagnosis of various malignant tumors with positron emission tomography/computed tomography (PET/CT). However, current imaging studies of FAPI-based probes face challenges in rapid clearance rate and potential false-negative results. Furthermore, FAPI has been rarely explored in optical imaging. Considering this, further modifications are imperative to improve the properties of FAPI-based probes to address existing limitations and broaden their application scenarios. In this study, we rationally introduced methylene blue (MB) to FAPIs, thereby imparting nuclei-targeting and fluorescence imaging capabilities to the probes. Furthermore, we evaluated the added value of FAPI-based fluorescence imaging to traditional PET/CT, exploring the potential application of FAPI-based probes in intraoperative fluorescence imaging.

METHODS

A new FAPI-based probe, namely NOTA-FAPI-MB, was designed for both PET/CT and fluorescence imaging by conjugation of MB. The targeting efficacy of the probe was evaluated on fibroblast activation protein (FAP)-transfected cell line and human primary cancer-associated fibroblasts (CAFs). Subsequently, PET/CT and fluorescence imaging were conducted on tumor-bearing mice. The tumor detection and boundary delineation were assessed by fluorescence imaging of tissues from hepatocellular carcinoma (HCC) patients.

RESULTS

NOTA-FAPI-MB demonstrated exceptional targeting ability towards FAP-transfected cells and CAFs in comparison to NOTA-FAPI. This benefit arises from the cationic methylene blue (MB) affinity for anionic nucleic acids. PET/CT imaging of tumor-bearing mice revealed significantly higher tumor uptake of [18F]F-NOTA-FAPI-MB (standard uptake value of 2.20 ± 0.31) compared to [18F]F-FDG (standard uptake value of 1.66 ± 0.14). In vivo fluorescence imaging indicated prolonged retention at the tumor site, with retention lasting up to 24 h. In addition, the fluorescent probes enabled more precise lesion detection and tumor margin delineation than clinically used indocyanine green (ICG), achieving a 100.0% (6/6) tumor-positive rate for NOTA-FAPI-MB while 33.3% (2/6) for ICG. These findings highlighted the potential of NOTA-FAPI-MB in guiding intraoperative surgical procedures.

CONCLUSIONS

The NOTA-FAPI-MB was successfully synthesized, in which FAPI and MB simultaneously contributed to the targeting effect. Notably, the nuclear delivery mechanism of the probes improved intracellular retention time and targeting efficacy, broadening the imaging time window for fluorescence imaging. In vivo PET/CT demonstrated favorable performance of NOTA-FAPI-MB compared to [18F]F-FDG. This study highlights the significance of fluorescence imaging as an adjunct technique to PET/CT. Furthermore, the encouraging results obtained from the imaging of human HCC tissues hold promise for the potential application of NOTA-FAPI-MB in intraoperative fluorescent surgery guidance within clinical settings.

Combined Therapy of Paravertebral Nerve Pulsed Radiofrequency and Subcutaneous Block for Acute/Subacute Herpetic Neuralgia: A Retrospective Study

OBJECTIVES

This retrospective study aimed to investigate the effectiveness and safety of early combined therapy with CT-guided paravertebral nerve (PVN), pulsed radiofrequency (PRF), and subcutaneous block on acute/subacute herpes zoster (HZ).

METHODS

A total of 98 medical records were analyzed. All patients underwent CT-guided PRF on PVN immediately followed by a single subcutaneous block with lidocaine and dexamethasone in acute/subacute phase. The therapy efficacy was evaluated by pain numeric rating scale (NRS) and effective rate, which was defined as a percent of cases with a reduction in pain NRS>50% at day 1, week 2, 4, 12, and 24 after the procedure. The incidences of medication reduction and postherpetic neuralgia (PHN) were also retrieved. Further comparison was conducted between acute group (disease duration<30 days from HZ onset) and subacute group (30 day

RESULTS

Early combined therapy indicated an immediate and sustained improvement in pain NRS as compared with before treatment ( P <0.0001), with effective rates of 74%, 79%, 80%, 76%, and 79% at day 1, week 2, 4, 12, and 24 after procedure, respectively. At the end of follow-up, the proportion of patients with a reduction of >50% in prior medications amounted to 83% and the incidence of clinically meaningful PHN decreased to 23%. The clinical efficacy was more profound in acute group than in subacute group at every time points ( P <0.05). No severe complications occurred.

DISCUSSION

Our data revealed surprising levels of pain relief by combination therapies of PRF and subcutaneous block targeting different sites of pain pathway, thus suggesting a valuable treatment option for acute/subacute herpetic neuralgia.

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MESH Headings

• Humans
• Retrospective Studies
• Pulsed Radiofrequency Treatment/methods
• Neuralgia/complications
• Neuralgia, Postherpetic/therapy
• Herpes Zoster/complications
• Herpes Zoster/therapy

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Grants Collapse

Affiliation(s)

Wei Zhang Departments of Day Surgery
Bin Yu Departments of Day Surgery
Zipu Jia Departments of Day Surgery
Chunmei Zhao Day Surgery and Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
Fang Luo Day Surgery and Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China

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A bibliometric and visualization analysis of global research on postherpetic neuralgia from 2000 to 2022: A review

Postherpetic neuralgia (PHN) represents a notable clinical challenge as it is the most prevalent and severe complication of herpes zoster (HZ). The primary objective was to investigate the current research status and hotspots of PHN research during the period from 2000 to 2022. The literature pertaining to PHN was gathered through the utilization of the Web of Science Core Collection, spanning from January 2000 to December 2022. The software, CiteSpace version 6.2.R2, was employed to produce visual depictions of publications related to PHN across various dimensions such as year, country/region, institution, journal, author, keyword, and reference. This study involved a total of 3505 papers. The USA held a dominant position in the production of scholarly articles. Argentina exhibited the highest frequency of participation in international collaboration. Out of all the institutions, Pfizer exhibited the highest degree of productivity. Harvard University exhibited the highest frequency of participation in international collaboration. The Pain exhibited the most noteworthy productivity rate and citation count among all other journals. Ralf Baron was identified as the most productive author, whereas DWORKIN RH attained the highest citation count. Contemporary scholarly investigations are predominantly centered on identifying risk factors, devising preventative measures, and exploring novel and secure methods of pain management. The current investigation has revealed the focal areas and patterns of studies pertaining to PHN. Presently, the research in this field is focused on identifying the risk factors and preventive measures for PHN, alongside exploring novel and secure pain management strategies.

Analgesic effect of subcutaneous injection of different concentrations of methylene blue after hemorrhoidectomy: A retrospective study

Objective

Subcutaneous injection of methylene blue around the anus may help reduce postoperative pain. However, the concentration of methylene blue is still controversial. Therefore, Our study aims to investigate the efficacy and safety of different methylene blue injected concentrations subcutaneously in pain treatment after hemorrhoidectomy.

Methods

A total of 180 consecutive patients with grade III or IV hemorrhoids from March 2020 to December 2021 were reviewed. All patients underwent hemorrhoidectomy under spinal anesthesia and were divided into three groups. Group A received subcutaneous injection of 0.1% methylene blue after hemorrhoidectomy, group B received subcutaneous injection of 0.2% methylene blue, and Group C did not received subcutaneous injection of methylene blue. The primary outcome measures were the visual analog scale (VAS) pain score on postoperative days 1, 2, 3, 7, 14, and total analgesic consumption within 14 days. Secondary outcomes were complications after hemorrhoidectomy, including acute urinary retention, secondary bleeding, perianal incision edema, and perianal skin infection, and the Wexner scores used to assess the level of anal incontinence at one and three months after surgery.

Results

There was no significant difference among three groups in sex, age, course of the disease, hemorrhoid grade and the number of incisions, and there was no significant difference in the volume of methylene blue injected between group A and group B. The VAS pain score and total analgesics consumption within 14 days in group A and group B were significantly lower than those in group C, but the differences between group A and group B were not statistically significant. The Wexner scores of group B were significantly higher than those of group A and group C one month after the operation, but the differences between group A and group C were not statistically significant. In addition, the Wexner score among three groups decreased to zero at three months after operation. There was no significant difference in the incidence of other complications among three groups.

Conclusion

The perianal injection of 0.1% methylene blue and 0.2% methylene blue have a similar analgesic effect in pain treatment after hemorrhoidectomy, but 0.1% methylene blue has higher safety.

Combining Ozonated Autohemotherapy with Pharmacological Therapy for Comorbid Insomnia and Myofascial Pain Syndrome: A Prospective Randomized Controlled Study

Objective

To examine the efficacy and safety of ozonated autohemotherapy (O3-AHT) combined with pharmacological therapy for comorbid insomnia and myofascial pain syndrome (MPS).

Materials and Methods

One hundred and eighteen patients were randomly divided into two groups: the control group (N = 50) and the O3-AHT group (N = 53). Patients in both groups were given the same pharmacological management for three weeks. Patients in the O3-AHT group were treated with ozonated autohemotherapy (the concentration of ozone was 20 µg/ml in the first week, 30 µg/ml in the second week, and 40 µg/ml in the third week) combined with pharmacological therapy. Primary (the insomnia severity index (ISI) and visual analogue scale (VAS)) and secondary outcomes (the Epworth sleepiness scale (ESS), polysomnography data, the anxiety and preoccupation about sleep questionnaire (APSQ), the beck depression index (BDI), and the multidimensional fatigue inventory (MFI)) were examined at pretreatment, posttreatment, 1 month, and 6 months.

Results

Fifty patients in the control group and fifty-three patients in the O3-AHT group completed the study. In both groups, insomnia and pain symptoms were relieved significantly compared with pretreatment. Compared with the control group, the O3-AHT group had significantly improved sleep quality, pain, and negative mood at different time points. No adverse complications were observed in either group.

Conclusion

Compared with pharmacological therapy alone, ozonated autohemotherapy combined with pharmacological therapy can ameliorate insomnia, reduce pain intensity, improve negative mood, and alleviate fatigue more effectively without serious adverse complications.

Pulsed Radiofrequency Combined With Methylene Blue Paravertebral Nerve Block Effectively Treats Thoracic Postherpetic Neuralgia

Objective

To compare the effect, safety, and patient satisfaction of pulsed radiofrequency combined with methylene blue paravertebral nerve block and pulsed radiofrequency alone in the treatment of thoracic postherpetic neuralgia (PHN).

Methods

A total of seventy-two patients with PHN diagnosed in the Department of Pain Management of Shengjing Hospital at China Medical University, from September 2019 to April 2021, were enrolled in the study. Patients were randomly divided into two groups. Group A (n = 36) received pulsed radiofrequency treatment. Group B (n = 36) received pulsed radiofrequency + methylene blue paravertebral nerve block. Patients were followed-up at 1 day, 1 week, 1 month, 3 months, and 6 months after treatment. Observation at each follow-up included basic patient characteristics, Visual Analog Scale (VAS), Hospital Anxiety and Depression Scale (HAD), the Insomnia Severity Index (ISI), patient satisfaction, complications, and side effects.

Results

Compared with preoperative values, the VAS scores significantly decreased in both groups at each postoperative time point (1 day, 1 week, and 1, 3, and 6 months; all p < 0.05). Compared with group A, VAS scores in group B were significantly lower 1 week and 1 month after surgery (p < 0.05). Patients in group B had lower HAD scores than those in group A 1 week after surgery (p < 0.05). Patients in group B had lower ISI scores than those in group A 1 day, 1 week, and 1, 3, and 6 months after surgery (p < 0.05). The pregabalin dosage in group B was lower than that in group A at 1 and 6 months after surgery (p < 0.05). Patient satisfaction was higher in group B than in group A at 1 week and 6 months after surgery (p < 0.05). There were no serious complications or side effects in either group.

Conclusion

Pulsed radiofrequency combined with methylene blue paravertebral nerve block is superior to pulsed radiofrequency alone in the treatment of thoracic PHN, which can significantly relieve PHN and improve the condition of sleep and emotional disorders. Therefore, it is a safe and effective treatment method.

Clinical Efficacy of Pulsed Radiofrequency Combined with Intravenous Lidocaine Infusion in the Treatment of Subacute Herpes Zoster Neuralgia

Objective

Under the guidance of a digital subtraction angiography (DSA) machine, via fluoroscopic imaging techniques, patients diagnosed with herpes zoster neuralgia at the subacute stage, where self-reported pain lasts between 30 and 90 days, were treated with nerve pulsed radiofrequency surgery combined with intravenous lidocaine infusion or saline infusion as control. This study explores the clinical efficacy, safety, and clinical value of the combined treatment compared with nerve pulsed radiofrequency surgery alone.

Methods

In this study, 72 patients diagnosed with herpes zoster neuralgia at the subacute stage were randomly divided into two groups with matched gender, age, and clinical symptoms. Both groups received pulsed radiofrequency surgery for the affected nerve segments under DSA fluoroscopy. Five days after the operation, 0.9% saline was administered daily for five consecutive days (50 ml per day, intravenous infusion) to group A (n = 36), and lidocaine was administered daily for five consecutive days (3 mg per kg per day, intravenous infusion) to group B (n = 36). Patients with poor pain control during the treatment were given 10 mg morphine tablets for pain relief to reach visual analog scale (VAS) ≤4 points. Data of the following categories were collected: VAS score, self-rating anxiety scale (SAS) score, depression self-rating scale (SDS) score, Pittsburgh sleep quality score (PSQI), 45 body area rating scale score, skin temperature measurement using infrared thermography, analgesic drug use before and after treatment at six different time points: before surgery (T₀), one day after surgery (T₁), three days after surgery (T₂), five days after surgery (T₃), one month after surgery (T₄), and two months after surgery (T₅). Blood was collected from all patients in the morning before surgery and right after the last intravenous infusion of lidocaine at T₃. Serum inflammatory indexes including white blood cell count, lymphocyte count, neutrophils count, erythrocyte sedimentation rate count, C-reactive protein (CRP) level, calcitonin gene-related peptide (CGRP) level, and interleukin-6(IL-6) level were determined. Lastly, the incidence of complications and adverse reactions throughout the study was recorded.

Results

In total, 64 out of 72 patients completed the whole study. Two patients met the exclusion criteria in group A, one patient refused to participate, and one was lost to follow-up. Two patients met the exclusion criteria in group B, and two were lost to follow-up. Three patients in group B experienced vomiting during lidocaine treatment. The adverse symptom was relieved after symptomatic treatment. No patients in the two groups had severe complications such as hematoma at the puncture site, pneumothorax, and nerve injury. Compared with before treatment, the mean of VAS score, SAS score, SDS score, PSQI score, and skin temperature of both groups at each time point after interventional surgery were all significantly reduced. Furthermore, at each time point after surgery, the above indicators of group B patients were significantly lower than those of group A patients. After treatment, the consumption of analgesics in both groups was significantly lower than before treatment. Compared with group A, the consumption of analgesics was also significantly lower in group B. In addition, serum inflammatory indexes at the T₃ time point of the two groups of patients were lower than T₀. Among them, the erythrocyte sedimentation rate, CRP level, CGRP level, and interleukin-6 level of group B were significantly lower than those of group A. The incidence of postherpetic neuralgia (PHN) in group B patients (6.25%) was also lower than that in group A patients (25%).

Conclusion

DSA-guided nerve pulse radiofrequency surgery combined with intravenous lidocaine infusion can effectively relieve pain in patients diagnosed with herpes zoster nerves at the subacute stage, reduce the number of analgesic drugs used in patients, reduce postherpetic neuralgia incidence rate, and improve sleep and quality of life.

Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain

PURPOSE OF REVIEW

Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important.

RECENT FINDINGS

With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applications have emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects. Rib fracture regional analgesia options have also expanded and continue to improve.  Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.