Publications by authors named "Guilherme Antonio Moreira de Barros"

28 Publications

  • Page 1 of 1

Analgesic effects of a 5% lidocaine patch after cesarean section: A randomized placebo-controlled double-blind clinical trial.

J Clin Anesth 2021 Oct 8;73:110328. Epub 2021 May 8.

Botucatu Medical School, São Paulo State University (UNESP), Av. Prof. Mário Rubens Guimarães Montenegro, s/n 18618687, Botucatu, SP, Brazil. Electronic address:

Study Objective: This study aimed to evaluate the analgesic effects of a 5% lidocaine patch in acute postoperative pain after cesarean section.

Design: This is a prospective, randomized, double-blind study.

Setting: After surgery, active and placebo patches were applied in the operating room, and patients were evaluated during their stay at the postoperative recovery room and at the hospital ward.

Patients: Seventy-two women (18 years of age or older and American Society of Anesthesiologists status II) scheduled for cesarean section under spinal anesthesia were enrolled in the study.

Interventions: Patients were randomly assigned to an intervention or placebo group. According to the assigned group, a 5% lidocaine patch or a placebo patch was applied 1 cm above and below the Pfannenstiel incision after the surgery.

Measurements: The primary outcome was the pain score, evaluated using an 11-point numerical verbal scale in the first 36 h postoperatively. Secondary outcomes were the quality of recovery 24 h after surgery, consumption of rescue opioids, and the presence of adverse effects.

Main Results: Sixty-five women completed the study. The pain score was lower in the lidocaine group at 6 h (lidocaine group: 2.16 ± 1.71, placebo group: 3.21 ± 2.25; p = 0.031), 12 h (lidocaine: 1.58 ± 0.81, placebo: 2.24 ± 0.74; p = 0.001), 24 h (lidocaine: 0.74 ± 0.89, placebo: 1.94 ± 1.39; p < 0.0001), and 36 h (lidocaine: 0.48 ± 1.03, placebo: 1.68 ± 0.94; p = 0.001) after surgery. There were no differences in secondary outcomes during the follow-up period.

Conclusion: The lidocaine patch reduced pain scores compared to placebo in the first 36 h after the surgery, despite no influence over opioid consumption, quality of recovery, or incidence of side effects.
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http://dx.doi.org/10.1016/j.jclinane.2021.110328DOI Listing
October 2021

Examining the effect of non-specialised clinical rotations upon medical students' Thanatophobia and Self-efficacy in Palliative Care: a prospective observational study in two medical schools.

BMJ Open 2020 11 18;10(11):e041144. Epub 2020 Nov 18.

CEDAR-Center for Educational Development and Research in Health Sciences, University Medical Centre Groningen, Groningen, Netherlands

Introduction: Including palliative care (PC) in overloaded medical curricula is a challenge, especially where there is a lack of PC specialists. We hypothesised that non-specialised rotations could provide meaningful PC learning when there are enough clinical experiences, with adequate feedback.

Objective: Observe the effects of including PC topics in non-specialised placements for undergraduate medical students in two different medical schools.

Design: Observational prospective study.

Setting: Medical schools in Brazil.

Participants: 134 sixth-year medical students of two medical schools.

Methods: This was a longitudinal study that observed the development of Self-efficacy in Palliative Care (SEPC) and Thanatophobia (TS) in sixth-year medical students in different non-specialised clinical rotations in two Brazilian medical schools (MS1 and MS2). We enrolled 78 students in MS1 during the Emergency and Critical Care rotation and 56 students in MS2 during the rotation in Anaesthesiology. Both schools provide PC discussions with different learning environment and approaches.

Primary Outcomes: SEPC and TS Scales were used to assess students at the beginning and the end of the rotations.

Results: In both schools' students had an increase in SEPC and a decrease in TS scores.

Conclusion: Non-specialised rotations that consider PC competencies as core aspects of being a doctor can be effective to develop SEPC and decrease TS levels.
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http://dx.doi.org/10.1136/bmjopen-2020-041144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677329PMC
November 2020

Professional characteristics and the prevalence of advance directives among palliative care professionals: A cross-sectional study.

Palliat Support Care 2020 Oct 29:1-6. Epub 2020 Oct 29.

Medical School, São Paulo State University - UNESP, Botucatu, Brazil.

Objective: This study aimed to investigate the association between professional characteristics and the prevalence of advance directives among palliative care professionals.

Methods: This is a descriptive cross-sectional study. A diverse sample of 327 healthcare professionals completed an online survey investigating demographic variables, length of time working in palliative care, post-graduate qualifications in palliative care, and development of their own advance directives.

Results: The prevalence of advance directives among professionals working in palliative care was associated with factors such as higher academic qualifications, holding a post-graduate qualification in palliative care, and working in palliative care for a longer time. Furthermore, psychologists were most likely to have registered their own advance directives, compared with other healthcare professionals.

Significance Of Results: Post-graduate palliative care education and professional experience in this area appear to be important factors associated with palliative care professionals writing of their own advance directives. However, our study suggests that just being involved in or familiar with the context of palliative and end-of-life care does not guarantee that health professionals register their advance directives.
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http://dx.doi.org/10.1017/S147895152000108XDOI Listing
October 2020

[The anesthesiologist facing terminality: a survey-based observational study].

Braz J Anesthesiol 2020 May - Jun;70(3):225-232. Epub 2020 Jun 6.

Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Anestesiologia, Campus de Botucatu, Botucatu, SP, Brazil; Sociedade Brasileira de Anestesiologia, Botucatu, SP, Brazil.

Background And Objectives: Advances in medicine, including anesthesiology and resuscitation, have made natural death increasingly rare. As a consequence, dysthanasia has become usual in a scenario for which there is not rationale. The present study aimed to assess the level of knowledge of Brazilian anesthesiologists on the principles of dysthanasia and orthothanasia. Thence, we studied the management preferences of these professionals, vis-à-vis those practices, as well as how medical school contributed to addressing death-related issues.

Method: Quantitative approach, prospective and descriptive cohort that included 150 anesthesiologists, members of the Brazilian Society of Anesthesiology, and who were invited to participate by email. An online questionnaire containing 38 questions was prepared by the authors. The study was approved by the Instructional Research Ethics Committee.

Results: Anesthesiologists, although claiming to know dysthanasia and orthothanasia, mostly acquired knowledge outside medical school. If faced with their own end of care, or of a patient or a loved one, they prefer orthothanasia, to die at home, prioritizing dignity. However, the specialists claimed to have already practiced dysthanasia, even when orthothanasia was the choice management, which caused them negative feelings. Almost all respondents stated that they did not have practical training in undergraduate school on how to face end-of-life issues, although they felt capable of identifying it. Most were not aware of Federal Council of Medicine Resolution 1.805/06 that makes practicing orthothanasia feasible. Anesthesiologists' religion or the political-administrative region of residence had no effect on their preferences.

Conclusions: Anesthesiologists claim to have knowledge on dysthanasia and orthothanasia, but prefer, in the face of a terminally ill patient, to practice orthothanasia, although dysthanasia is usual, and results in frustration and indignation. The medical school curriculum is unsatisfactory in addressing death-related issues.
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http://dx.doi.org/10.1016/j.bjan.2020.03.008DOI Listing
June 2020

Spread the Word: There Are Two Opioid Crises!

Drugs 2020 Aug;80(12):1147-1154

Anesthesiology Department, Medical School, Sao Paulo State University (UNESP), Av. Prof. Mario Rubens Guimaraes Montenegro, s/n, Botucatu, São Paulo, 18618687, Brazil.

Pain is associated with emotional and physical suffering that severely impacts quality of life. Many guidelines for the treatment of moderate to severe cancer pain indicate the use of opioids. For a small proportion of the global population, opioids are readily accessible, but are consequently also subject to risk of overuse and misuse. On the other hand, many regions provide limited access to licensed opioid therapeutics and patients struggle for better pain management. The use of prescription opioids for treatment of severe cancer and acute pain is well established, but opioid use in chronic non-cancer pain is controversial and not supported by the literature. The opioid crisis and the increasing overdose fatalities in some countries have resulted in a resurgence of opiophobia in these countries, but even worse, amplified opiophobia in countries with lower opioid consumption. In this narrative review, we highlight how the opioid crisis of overuse in some countries can negatively impact appropriate access to opioids elsewhere. The availability of opioids for clinical and recreational use differs between countries worldwide-this is an important factor in determining the occurrence of a 'crisis of recreational use of opioids' or a 'crisis of under-prescription of opioids' for pain management.
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http://dx.doi.org/10.1007/s40265-020-01342-8DOI Listing
August 2020

Translation, cultural adaptation, and validation of the Brazilian Portuguese version of the End-of-Life Professional Caregiver Survey.

Palliat Support Care 2020 10;18(5):569-574

School of Nursing, University of Connecticut, Storrs.

Objectives: The aim of this study was to translate, culturally adapt, and psychometrically evaluate the Brazilian version of the "End-of-Life Professional Caregiver Survey" (BR-EPCS).

Method: This is an observational cross-sectional study. The sample was composed of 285 Brazilian healthcare professionals who work or worked in the palliative care area. A minimum number of 280 participants were established, following the recommendation of 10 subjects for each instrument item. The European Organisation for Research and Treatment of Cancer - Quality of Life Group Translation Procedure protocol was used for the translation and the cultural adaptation. For the precise/reliable evaluation of factors measured by the BR-EPCS, Cronbach's alpha (α) and composite reliability coefficients were used. The factorial analyses were made by means of the exploratory structural equation modeling methods and confirmatory factor analysis. We have conducted a multiple linear regression analysis to evaluate the sociodemographic variables' capabilities in the result prediction measured by BR-EPCS factors.

Results: The factorial analysis showed the relevance of two factors: Factor 1 - "Given care effectiveness" (18 items; Cronbach's α = 0.94; Composite Reliability = 0.95) and Factor 2 - "Mourning and ethical and cultural values" (10 items; Cronbach's α = 0.89; Composite Reliability = 0.88). Multiple linear regression analyses revealed that the working time, sex, palliative care training, and its own advance directives are predictors of the constructs assessed by the BR-EPCS.

Significance Of Results: The BR-EPCS is a reliable, valid, and culturally appropriate tool to identify the educational needs of healthcare professionals who work with palliative care. This instrument can be used for educational and research reasons.
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http://dx.doi.org/10.1017/S1478951519000993DOI Listing
October 2020

[The use of analgesics and risk of self-medication in an urban population sample: cross-sectional study].

Braz J Anesthesiol 2019 Nov - Dec;69(6):529-536. Epub 2019 Nov 6.

Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Saúde Pública, Botucatu, SP, Brasil.

Background And Objectives: There are few data in the literature characterizing the pattern of analgesic use in Latin American countries, including Brazil. Little is known about the undertreatment of pain and its influence on the habit of self-medication with analgesics. The aim of this study is to define the pattern of analgesic use among chronic pain patients and its potential association with self-medication with analgesics.

Method: Cross-sectional observational study with an urban population sample. Chronic pain was defined as a pain lasting for at least 90 days. The study was approved by the Research Ethics Committee of the institution.

Results: 416 subjects were included; 45.7% (n=190) had chronic pain, with females (72.3%; p=0.04) being the most affected. Self-medication with analgesics is practiced by 78.4% of patients with chronic pain. The most common current analgesic treatment consists of non-steroidal anti-inflammatory drugs (dipyrone and acetaminophen). Weak opioids are rarely used and only 2.6% of subjects with chronic pain were taking these analgesics. None of the subjects were taking potent opioids.

Conclusions: The practice of self-medication with analgesics is frequent among patients with chronic pain, which may be due to the underprescription of more potent analgesics, such as opioids. It can also be said that, given the data presented, there is no crisis of recreational opioid use in the studied population.
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http://dx.doi.org/10.1016/j.bjan.2019.09.005DOI Listing
July 2020

Cross-cultural adaptation and validation for the Brazilian population of the instrument Amyotrophic Lateral Sclerosis-Specific Quality of Life-Short Form (ALSSQOL-SF).

Qual Life Res 2020 Mar 29;29(3):805-813. Epub 2019 Oct 29.

Anesthesiology Department, São Paulo State University (UNESP), Medical School, Av. Prof. Mário Rubens Guimarães Montenegro s/n, Botucatu, SP, 18618687, Brazil.

Objective: This study aims to produce and validate the version of the instrument Amyotrophic Lateral Sclerosis-Specific Quality of Life-Short Form (ALSSQOL-SF) into Portuguese, adapted to the Brazilian cultural context.

Methodology: It is a cross-cultural adaptation and validation study, carried out in two Brazilian Public Universities, in the period from March, 2017, to November, 2018, according to the six steps guidelines of cultural and linguistic adaptation proposed by Beaton et al. (Spine 25(24):3186-3191, 2000). The World Health Organization Quality of Life (WHOQOL-BREF) and the Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRS-R) were used for perform the validation. In order to analyze the correlations between the ALSSQOL-SF, WHOQOL-BREF, and ALSFRS-R scores, Spearman's correlation coefficients were calculated. The project was approved by the Research Ethics Committee of the two participating institutions.

Result: All steps of the transcultural adaptation process were performed without intercurrence. The pilot test had the participation of 30 individuals, and the "Questionário Breve Específico de Qualidade de Vida para Pacientes com ELA (QVELA-20/Br)" tool was developed. During the validation phase, 100 patients were included, most of them were male (58%) with a median age of 59 years. The created version of the questionnaire are positively and strongly correlated with the WHOQOL-BREF and positively and weakly correlated with ALSFRS-R, as expected.

Conclusion: The study produced and validated a version of the instrument ALSSQOL-SF into Portuguese that is adapted to the Brazilian cultural context.
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http://dx.doi.org/10.1007/s11136-019-02342-2DOI Listing
March 2020

[Capsaicin topical cream (8%) for the treatment of myofascial pain syndrome].

Braz J Anesthesiol 2019 Sep - Oct;69(5):432-438. Epub 2019 Sep 10.

Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Departamento de Anestesiologia, Botucatu, SP, Brasil. Electronic address:

Background: Myofascial pain syndrome is a common cause of musculoskeletal pain. The objective of this study was to evaluate the potential analgesic action of 8% capsaicin cream for topical use in patients with myofascial pain syndrome.

Methods: Initially, cream formulations of PLA (Placebo) and CPS (Capsaicin 8%) were developed and approved according to the current requirements of the health authority agency. The 40 participating patients were randomly assigned to the PLA and CPS groups in a double-blind fashion. Before the creams were topically administered, according to the allocation group, the local anesthetic was used for a period of 50minutes directly in the area of interest. The cream was applied to the area of the skin over the trigger point, represented by the area with pain at palpation, in an amount of 10g for 30minutes in a circular area of 24 mm diameter. Subsequently, the cream was removed and the skin tolerability parameters were evaluated. The pain was measured before and during the formulation application, as well as at 1 hour, 7 days, 30 days, and 60 days after the procedure, evaluated using a verbal numerical scale (from 0 to 10: with 0=no pain and 10=worst pain imaginable).

Results: No patient in PLA Group had hyperemia or burning sensation at the site of application, while 85% of patients in CPS Group had hyperemia or burning sensation at 15minutes. These complaints disappeared 24hours after the cream was removed. The pain score in CPS Group decreased steadily up to the 60 day of evaluation (p <0.0001).

Conclusion: Application of the formulations did not cause macroscopic acute or chronic skin lesions in patients, and the 8% capsaicin formulation was beneficial and well tolerated.
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http://dx.doi.org/10.1016/j.bjan.2019.06.008DOI Listing
May 2020

Can an inflammatory reaction in the meninges, caused by spinal puncture through tattooed skin, evolve into adhesive arachnoiditis? An experimental model in rabbits.

Reg Anesth Pain Med 2019 Mar 11;44(3):355-359. Epub 2019 Jan 11.

Department of Anesthesiology, Botucatu Medical School, University of São Paulo State, UNESP, São Paulo, Brazil.

Background And Objectives: As the number of people with tattoos has been increasing, anesthesiologists are more and more faced with the decision to perform a neuraxial blockage through tattooed skin. In this study, we evaluated the possibility of puncture through tattooed skin determines acute inflammatory changes in the meninges and spinal cord and later evolve into adhesive arachnoiditis.

Method: Forty-two male rabbits were randomized into 3 groups of 14: G1, spinal puncture through non-tattooed skin and saline solution injection; G2, spinal puncture through tattooed skin and saline solution injection, captive for 30 days; G3, spinal puncture through tattooed skin and saline solution injection, captive for 360 days. The animals were anesthetized and ultrasound-guided spinal puncture was performed in the intervertebral spaces between S1 - S2. During the period of captivity, the animals were clinically assessed for sensitivity and motor function. After that, they were sacrificed and the lumbosacral portion of the spinal cord was excised for histological analysis.

Results: No histological changes were found on group 1. Eleven animals from group two presented with foci of perivascular lymphocytic inflammatory infiltrate in the pia mater and/or arachnoid. In Group 3, eight rabbits presented with inflammatory changes in the meninges, which were associated with thickening and/or adhesion of the pia mater and arachnoid in some cases and five rabbits presented only thickening of pia-mater.

Conclusions: Spinal puncture through tattooed skin of rabbits can trigger acute inflammatory changes in the meninges and after a prolonged period of observation evolve into adhesive arachnoiditis.
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http://dx.doi.org/10.1136/rapm-2018-100085DOI Listing
March 2019

Spiritual needs of patients with cancer in palliative care: an integrative review.

Curr Opin Support Palliat Care 2017 Dec;11(4):334-340

aBotucatu Medical School, Paulista State University (UNESP), Botucatu, São Paulo, Brazil bNursing School, Federal University of Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brazil.

Purpose Of Review: The experience of a life crisis, such as the experience of end-of-life terminality whenever facing cancer can make the spiritual needs of patients clear. The goal of this revision was to synthesize the existing evidence regarding the spiritual needs of patients with cancer in palliative care.

Recent Findings: An integrated revision of the literature was conducted regarding the database sources from PubMed, CINAHL, EMBASE, LILACS and Scopus, without publishing year restrictions. There were 16 primary studies included. A total of 1469 patients have been evaluated, whereas eight groups of spiritual needs have been identified: finding the meaning and purpose of life; finding the meaning in experiencing the disease; being connected to other people, God and nature; having access to religious/spiritual practices; physical, psychological, social and spiritual wellbeing; talking about death and the experience of dying; making the best out of their time; being independent and being treated like a normal person.

Summary: It is essential to pay attention to patients' spiritual dimensions regarding palliative care. Therefore, patients' spiritual needs must be identified and remedied or mitigated. It is necessary to develop studies that find specific strategies and interventions for the treatment of these needs.
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http://dx.doi.org/10.1097/SPC.0000000000000308DOI Listing
December 2017

Total Spinal Anesthesia Failure: Have You Assessed the Sensory Anesthesia in Sacral Dermatomes?

Anesth Analg 2017 05;124(5):1674-1677

From the *Department of Anesthesiology, Botucatu Medical School- Universidade. Estadual Paulista, Botucatu, São Paulo, Brazil; †Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada; ‡Department of Anesthesiology, São Luis Hospital, São Paulo, São Paulo, Brazil; §Department of Critical Care Medicine, Kingston General Hospital Research Institute, Kingston, Ontario, Canada; and ‖Department of Anesthesiology, Queen's University, Kingston, Ontario, Canada.

Intrathecal local anesthetic maldistribution is a well-known cause of spinal anesthesia failure (SAF). This could potentially result in sensory blockade restricted to the sacral dermatomes. We sought to determine the overall incidence of SAF and the role of sacral dermatomes in differentiating between total and partial failures. Of the 3111 spinals prospectively examined, 194 (6.2%) were classified as failures. Of the 72 presumed total failures based on the initial assessment, evaluation of the sacral dermatomes revealed sensory blockade in 32 (44%; 95% confidence interval, 32.7%-56.6%). Sacral dermatome assessment after SAF may be important in safely guiding subsequent anesthetic management.
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http://dx.doi.org/10.1213/ANE.0000000000001966DOI Listing
May 2017

The P-A-C-I-E-N-T-E Protocol: An instrument for breaking bad news adapted to the Brazilian medical reality.

Rev Assoc Med Bras (1992) 2017 Jan;63(1):43-49

Department of Anesthesiology, Faculdade de Medicina de Botucatu, Unesp, Botucatu, SP, Brazil.

Objective: There are plenty of published tools for breaking bad medical news; however, none of them is culturally appropriate to our reality or published in the Brazilian literature. This study proposes a genuinely Brazilian communication tool and evaluates its acceptance among doctors and nurses.

Method: This was a prospective study. The data were collected after specific training of doctors and nurses on the bad news communication techniques based on the P-A-C-I-E-N-T-E ("patient," in Portuguese) Protocol. This instrument is in accordance with the Brazilian reality and was based on the SPIKES communication tool.

Results: The worst task to be performed during communication is "talking about death" followed by "discussing the end of curative treatment attempts" and "diagnosis" itself. Among the respondents, 48% reported they did not receive formal training for communicating. Also, 52% of respondents do not use any systematic approach in their daily practice when communicating with patients, but 97% considered the proposed P-A-C-I-E-N-T-E Protocol as a useful and appropriate communication tool.

Conclusion: The P-A-C-I-E-N-T-E Protocol proved to be suitable to the Brazilian context.
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http://dx.doi.org/10.1590/1806-9282.63.01.43DOI Listing
January 2017

Does Spinal Block Through Tattooed Skin Cause Histological Changes in Nervous Tissue and Meninges?: An Experimental Model in Rabbits.

Reg Anesth Pain Med 2015 Sep-Oct;40(5):533-8

From Botucatu Medical School, University of São Paulo State, UNESP, Botucatu, São Paulo, Brazil.

Background And Objectives: Although there is no documented evidence that tattoo pigments can cause neurological complications, the implications of performing neuraxial anesthesia through tattooed skin are unknown. In this study, we aimed to assess whether spinal puncture performed through tattooed skin of rabbits determines changes over the spinal cord and meninges. In addition, we sought to evaluate the presence of ink fragments entrapped in spinal needles.

Methods: Thirty-six young male adult rabbits, each weighing between 3400 and 3900 g and having a spine length between 38.5 and 39 cm, were divided by lot into 3 groups as follows: GI, spinal puncture through tattooed skin; GII, spinal puncture through tattooed skin and saline injection; and GIII, spinal puncture through skin free of tattoo and saline injection. After intravenous anesthesia with ketamine and xylazine, the subarachnoid space was punctured at S1-S2 under ultrasound guidance with a 22-gauge 2½ Quincke needle. Animals in GII and GIII received 5 μL/cm of spinal length (0.2 mL) of saline intrathecally. In GI, the needle tip was placed into the yellow ligament, and no solution was injected into the intrathecal space; after tattooed skin puncture, 1 mL of saline was injected through the needle over a histological slide to prepare a smear that was dyed by the Giemsa method to enable tissue identification if present. All animals remained in captivity for 21 days under medical observation and were killed by decapitation. The lumbosacral spinal cord portion was removed for histological analysis using hematoxylin-eosin stain.

Results: None of the animals had impaired motor function or decreased nociception during the period of clinical observation. None of the animals from the control group (GIII) showed signs of injuries to meninges. In GII, however, 4 animals presented with signs of meningeal injury. The main histological changes observed were focal areas of perivascular lymphoplasmacyte infiltration in the pia mater and arachnoid. There was no signal of injury in neural tissue in any animal of both groups. Tissue coring containing ink pigments was noted in all GI smears from the spinal needles used to puncture the tattooed skin.

Conclusions: On the basis of the present results, intrathecal injection of saline through a needle inserted through tattooed skin is capable of producing histological changes over the meninges of rabbits. Ink fragments were entrapped inside the spinal needles, despite the presence of a stylet.
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http://dx.doi.org/10.1097/AAP.0000000000000282DOI Listing
May 2016

Comparison of droperidol and ondansetron prophylactic effect on subarachnoid morphine-induced pruritus.

Braz J Anesthesiol 2015 Jul-Aug;65(4):244-8. Epub 2015 Apr 28.

Universidade Católica de Pelotas (UCPel), Pelotas, RS, Brazil.

Background And Objectives: The prophylactic effect of ondansetron on subarachnoid morphine-induced pruritus is controversial, while evidence suggests that droperidol prevents pruritus. The aim of this study is to compare the effects of droperidol and ondansetron on subarachnoid morphine-induced pruritus.

Methods: 180 ASA I or II patients scheduled to undergo cesarean sections under subarachnoid anesthesia combined with morphine 0.2mg were randomized to receive, after the child's birth, metoclopramide 10mg (Group I - control), droperidol 2.5mg (Group II) or ondansetron 8mg (Group III). Postoperatively, the patients were assessed for pruritus (absent, mild, moderate or severe) or other side effects by blinded investigators. Patients were also blinded to their group allocation. The tendency to present more severe forms of pruritus was compared between groups. NNT was also determined.

Results: Patients assigned to receive droperidol [Proportional odds ratio: 0.45 (95% confidence interval 0.23-0.88)] reported less pruritus than those who received metoclopramide. Ondansetron effect was similar to metoclopramide [Proportional odds ratio: 0.95 (95% confidence interval 0.49-1.83)]. The NNT for droperidol and ondansetron was 4.0 and 14.7, respectively.

Conclusions: Ondansetron does not inhibit subarachnoid morphine-induced pruritus.
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http://dx.doi.org/10.1016/j.bjane.2013.11.005DOI Listing
December 2016

Parecoxib reduces renal injury in an ischemia/reperfusion model in rats.

Acta Cir Bras 2015 Apr 1;30(4):270-6. Epub 2015 Apr 1.

UNESP, Botucatu, SP, Brazil.

Purpose: To evaluate the effect of parecoxib (an NSAID) on renal function by measuring plasma NGAL (serum neutrophil gelatinase-associated lipocalin) levels in an induced-ischemia rat model.

Methods: Forty male Wistar rats were randomly assigned to one of four groups: Ischemia (I), Ischemia/parecoxib (IP), No-ischemia (NI), and No-ischemia/parecoxib (NIP). Body weight, mean arterial pressure, heart rate, body temperature, NGAL levels, and renal histology were compared across groups.

Results: The Ischemia (I) group, which did not receive parecoxib, showed the highest NGAL levels (p=0.001), while the IP group, which received the medication, had NGAL levels similar to those of the non-ischemic (NI and NIP) groups.

Conclusion: Parecoxib resulted in renal protection in this experimental model.
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http://dx.doi.org/10.1590/S0102-865020150040000006DOI Listing
April 2015

[Comparison of droperidol and ondansetron prophylactic effect on subarachnoid morphine-induced pruritus].

Rev Bras Anestesiol 2015 Jul-Aug;65(4):244-8. Epub 2015 Mar 9.

Universidade Católica de Pelotas (UCPel), Pelotas, RS, Brasil.

Background And Objectives: The prophylactic effect of ondansetron on subarachnoid morphine-induced pruritus is controversial, while evidence suggests that droperidol prevents pruritus. The aim of this study is to compare the effects of droperidol and ondansetron on subarachnoid morphine-induced pruritus.

Methods: 180 ASA I or II patients scheduled to undergo cesarean sections under subarachnoid anesthesia combined with morphine 0.2mg were randomized to receive, after the child's birth, metoclopramide 10mg (Group I - control), droperidol 2.5mg (Group II) or ondansetron 8mg (Group III). Postoperatively, the patients were assessed for pruritus (absent, mild, moderate or severe) or other side effects by blinded investigators. Patients were also blinded to their group allocation. The tendency to present more severe forms of pruritus was compared between groups. NNT was also determined.

Results: Patients assigned to receive droperidol [Proportional odds ratio: 0.45 (95% confidence interval 0.23-0.88)] reported less pruritus than those who received metoclopramide. Ondansetron effect was similar to metoclopramide [Proportional odds ratio: 0.95 (95% confidence interval 0.49-1.83)]. The NNT for droperidol and ondansetron was 4.0 and 14.7, respectively.

Conclusions: Ondansetron does not inhibit subarachnoid morphine-induced pruritus.
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http://dx.doi.org/10.1016/j.bjan.2013.11.005DOI Listing
June 2015

Topical (S)-ketamine for pain management of postherpetic neuralgia.

An Bras Dermatol 2012 May-Jun;87(3):504-5

Department of Anesthesiology, School of Medicine of Botucatu, Universidade Estadual Paulista "Julio de Mesquita Filho", SP, Brazil.

Herpes zoster infection may cause postherpetic neuralgia, which is defined by prolonged pain predominantly mediated by central nervous system hypersensitivity. This phenomenon may be reversed by (S)-ketamine (SKET), but its use results in intolerable side effects, while its topical administration seems to be safe. It is a cross-over design study with 12 patients randomly divided into two groups. There was a significant effect of time on pain intensity, but no statistical difference in pain scores for SKET or placebo use in this sample in this treatment regimen. Only few mild cutaneous reactions were observed with topical SKET use.
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http://dx.doi.org/10.1590/s0365-05962012000300032DOI Listing
March 2013

The effects of subarachnoid administration of preservative-free S(+)-ketamine on spinal cord and meninges in dogs.

Anesth Analg 2012 Feb 13;114(2):450-5. Epub 2011 Dec 13.

Anesthesiology Department, Sao Paulo State University, Botucatu/SP, Brazil.

Background: The N-methyl-d-aspartate receptor antagonist ketamine and its active enantiomer, S(+)-ketamine, have been injected in the epidural and subarachnoid spaces to treat acute postoperative pain and relieve neuropathic pain syndrome. In this study we evaluated the effects of a single dose of preservative-free S(+)-ketamine, in doses usually used in clinical practice, in the spinal cord and meninges of dogs.

Methods: Under anesthesia (IV etomidate (2 mg/kg) and fentanyl (0.005 mg/kg), 16 dogs (6 to 15 kg) were randomized to receive a lumbar intrathecal injection (L5/6) of saline solution of 0.9% (control group) or S(+)-ketamine 1 mg/kg(-1) (ketamine group). All doses were administered in a volume of 1 mL over a 10-second interval. Accordingly, injection solution ranged from 0.6% to 1.5%. After 21 days of clinical observation, the animals were killed; spinal cord, cauda equina root, and meninges were removed for histological examination with light microscopy. Tissues were examined for demyelination (Masson trichrome), neuronal death (hematoxylin and eosin) and astrocyte activation (glial fibrillary acidic protein).

Results: No clinical or histological alterations of spinal tissue or meninges were found in animals from either control or ketamine groups.

Conclusion: A single intrathecal injection of preservative-free S(+)-ketamine, at 1 mg/kg(-1) dosage, over a concentration range of 6 to 15 mg/mL injected in the subarachnoid space in a single puncture, did not produce histological alterations in this experimental model.
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http://dx.doi.org/10.1213/ANE.0b013e31823a5d1bDOI Listing
February 2012

Intrapleural analgesia after endoscopic thoracic sympathectomy.

Acta Cir Bras 2011 Dec;26(6):508-13

Postgraduate Program in Anesthesiology, Botucatu School of Medicine, UNESP, Bauru, SP, Brazil.

Purpose: To compare analgesia traditionally used for thoracic sympathectomy to intrapleural ropivacaine injection in two different doses.

Methods: Twenty-four patients were divided into three similar groups, and all of them received intravenous dipyrone. Group A received intravenous tramadol and intrapleural injection of saline solution. Group B received intrapleural injection of 0.33% ropivacaine, and Group C 0.5% ropivacaine. The following aspects were analyzed: inspiratory capacity, respiratory rate and pain. Pain was evaluated in the immediate postoperative period by means of the visual analog scale and over a one-week period.

Results: In Groups A and B, reduced inspiratory capacity was observed in the postoperative period. In the first postoperative 12 hours, only 12.5% of the patients in Groups B and C showed intense pain as compared to 25% in Group A. In the subsequent week, only one patient in Group A showed mild pain while the remainder reported intense pain. In Group B, half of the patients showed intense pain, and in Group C, only one presented intense pain.

Conclusion: Intrapleural analgesia with ropivacaine resulted in less pain in the late postoperative period with better analgesic outcomes in higher doses, providing a better ventilatory pattern.
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http://dx.doi.org/10.1590/s0102-86502011000600017DOI Listing
December 2011

[Methods of evaluation of the effectiveness of the treatments for pain].

Drugs Today (Barc) 2009 Oct;45 Suppl C:13-7

Responsável pelo Serviço de Terapia Antálgica e Cuidados Paliativos do HC da Faculdade de Medicina de Botucatu - UNESP.

Pain is a subjective condition and, thus, difficult to measure. The best tools to assess pain are the pain evaluation questionnaires, which provide either diagnostic, pain evolution or pain intensity information. To provide information which could help differentiate between nociceptive pain and neuropathic pain is one of the most important functions of these questionnaires. The questionnaires can measure pain intensity, quality of life, or sleep quality. Quality of life and sleep are two really important characteristics to assess the pain impact on patients' life. Pain intensity assessing questionnaires combine physical evaluations with questions, providing information either from the patient sensations or clinical assessment of pain manifestations as well as the underlying biological mechanisms (such as hyperalgesia or allodynia). For example, the Pain Detect questionnaire has two parts: the patient form (intuitive, with pictures and easy understandable) and the physician form. Thus, in this questionnaire, subjective information is provided by the patient and the objective one is provided by the physician. Other pain intensity questionnaires are NPSI, DN4, LANSS or StEP. Quality of life questionnaires are versatile (can be used in different pathologies). These questionnaires include functional self-evaluation questions, and other ones associated to physical and mental health. Two of such quality of life questionnaires are SF-36 and NHP. Sleep evaluation questionnaires include quantitative features such as the number of sleep interruptions, sleep latency or sleep duration as well as qualitative characteristics such as rest sensation, mood and dreams. One of the most used sleep evaluation questionnaires is PSQI, which includes patient questions and bed-partner questions, providing information from two points of view.
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October 2009

The effects of intrathecal administration of betamethasone over the dogs' spinal cord and meninges.

Acta Cir Bras 2007 Sep-Oct;22(5):361-5

Department of Anesthesiology, Division of Pain Management and Palliative Care Subject, School of Medicine of Botucatu, São Paulo State University, Botucatu, SP, Brazil.

Purpose: To determinate the potential clinical and histological changes due the injection of betamethasone, when administered into the canine intrathecal space.

Methods: Twenty one animals were included in a random and blind manner in the study. After general anesthesia, intrathecal puncture was performed and 1 ml of the random solution was injected. The G1 dogs received 0.9% saline solution, the G2 dogs received 1.75 mg betamethasone and the G3 dogs received 3.5 mg of betamethasone. The animals were clinically evaluated for 21 days and then sacrificed. The lumbar and sacral portions of the spinal cord were removed for light microscopy histological analyses.

Results: No clinical changes were observed in any of the animals included in this study. No histological changes were observed in G1 animals. Inflammatory infiltration was observed in two dogs, one in G2, another in G3. Hemorrhage and necrosis were also seen in the G2 dog which inflammatory infiltration was detected. In other two dogs, one from G2 and another from G3, there was discreet fibrosis and thickness of the arachnoid layer which was focal in one and diffuse in the other.

Conclusion: Intrathecal administration of betamethasone caused histological changes in the spinal cord and meninges in some of the dogs involved in this study.
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http://dx.doi.org/10.1590/s0102-86502007000500007DOI Listing
September 2008

Pain: current aspects on peripheral and central sensitization.

Rev Bras Anestesiol 2007 Feb;57(1):94-105

CET/SBA da Faculdade de Medicina de Botucatu da Universidade Estadual de São Paulo (FMB-UNESP), Botucatu, SP.

Background And Objectives: Current research has focused on the biochemical and structural plasticity of the nervous system secondary to tissue injury. The mechanisms involved in the transition from acute to chronic pain are complex and involve the interaction of receptor systems and the flow of intracellular ions, second messenger systems, and new synaptic connections. The aim of this article was to discuss the new mechanisms concerning peripheral and central sensitization.

Contents: Tissue injury increases the response of nociceptors, known as sensitization or facilitation. These phenomena begin after the local release of inflammatory mediators and the activation of the cells of the immune system or specific receptors in the peripheral and central nervous system.

Conclusions: Tissue and neuronal lesions result in sensitization of the nociceptors and facilitation of the central and peripheral nervous conduction.
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http://dx.doi.org/10.1590/s0034-70942007000100011DOI Listing
February 2007

[Accidental spinal metoclopramide injection: case report.].

Rev Bras Anestesiol 2004 Oct;54(5):663-7

Departamento de Anestesiologia, Faculdade de Medicina de Botucatu, UNESP.

Background And Objectives: Accidental injection of non-spinal drugs in epidural and spinal spaces is a possible anesthetic complication. This report presents a case of inadvertent spinal metoclopramide injection.

Case Report: Female patient, 17 years old, 69 kg, BMI = 26.2, physical status ASA I, 36 weeks and 4 days gestation, with acute fetal suffering and C-section indication. Patient presented with heart rate of 82 bpm, blood pressure of 130 x 70 mmHg, SpO2 of 97% and regular sinusoidal cardiac rhythm. Spinal anesthesia performed with a local anesthetic and opioid association, 15 mg of 0.25% hyperbaric bupivacaine and 25 microg fentanyl. Patient referred unspecific 'discomfort' 5 minutes after blockade installation. Blood pressure was 190 x 120 mmHg, heart rate was 145 bpm and SpO2 was 95%. Checking the vials, one bupivacaine vial and one metoclopramide vial were found. Symptoms were severe frontal headache, blurred view, nausea, vomiting and initial agitation evolving to sleepiness and torpor, in addition to hypertension and tachycardia. Tramadol, dipyrone, ondansetron and support measures were administered. Patient was asymptomatic 30 minutes after with BP of 150 x 100 mmHg and HR of 120 bpm. Patient was discharged from PACU to the ward 140 minutes after with sensory, motor and autonomic block recovery and normal hemodynamic parameters. Patient was discharged 48 hours later without neurological sequelae, together with the neonate.

Conclusions: Close attention should be paid to any administered drug, regardless of the route. It is desirable to standardize vial colors and storage sites aiming at minimizing this type of accident.
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http://dx.doi.org/10.1590/s0034-70942004000500006DOI Listing
October 2004

[Patient controlled analgesia in a university hospital.].

Rev Bras Anestesiol 2003 Feb;53(1):69-82

Departamento de Anestesiologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista.

Background And Objectives: The rapid development seen in recent years in surgical and anesthetic techniques allowed for an increased indication of invasive procedures. At the same time, with the aging of the population, the postoperative recovery period became the focus of major concern for the healthcare team. For such, new analgesic techniques were developed, among them, Patient Controlled Analgesia (PCA). In Brazil, the Acute Pain Service (SEDA) of the Anesthesiology Department, Botucatu Medical School - UNESP, has been using PCA for many years. Aiming at verifying the quality of the service provided, this research has evaluated the efficacy and safety of the technique, in addition to identifying and characterizing patients submitted to PCA.

Methods: Participated in this retrospective study 679 patients treated by SEDA with the PCA method only, during a 3-year period. Patients were randomly included in the study with no restrictions concerning age, gender and type of surgery, considering only the possibility of PCA. The following parameters were evaluated: gender, age, type of surgery, pain score, treatment duration, analgesic drugs used, administration route, side effects and complications.

Results: The PCA technique was used in 3.96% of patients submitted to surgical procedures and in 1.64% of all hospitalized patients. Thoracic surgeries were the most frequent procedures and accounted for 25% of patients. Morphine was the most commonly used analgesics (54.2%) and the epidural route was the most frequent route of administration. Mean verbal numeric scale was 0.8 (0-10), and side effects were present in 22.4% of treated patients.

Conclusions: Results were considered excellent in terms of quality of analgesia, although with the incidence of some side effects. The PCA technique was widely accepted by the medical specialties of the hospital.
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http://dx.doi.org/10.1590/s0034-70942003000100010DOI Listing
February 2003

[Intrathecal drugs for chronic pain control.].

Rev Bras Anestesiol 2002 Sep;52(5):628-43

Departamento de Anestesiologia, Serviço de Terapia Antálgica e Cuidados Paliativos, FMB, UNESP.

Background And Objectives: Chronic pain is a challenge for modern medicine. New methods and drugs have been proposed to control pain. Intrathecal administration is a feasible and safe option, but still requires further investigations. This study aimed at reviewing available and well established drugs as well as new promising alternatives for the daily practice.

Contents: Several neuraxial drugs with analgesic action are reviewed. Desirable and undesirable effects of opioids, local anesthetics, alpha2-agonists, excitatory and inhibitory aminoacid antagonists, acetylcholine, acetyl-cholinesterase inhibitors, calcium channel blockers, adenosine, serotonin, tricyclic antidepressants and prostaglandin synthesis inhibitors are analyzed.

Conclusions: Several advances were achieved in controlling pain with intrathecal administration of the above-mentioned drugs. Certainly some will be used, thus enriching therapeutic armamentarium, and others will be temporarily or permanently abandoned. However, several clinical and experimental studies will still be needed for knew knowledge to be incorporated and safely used by professionals dealing with chronic pain.
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http://dx.doi.org/10.1590/s0034-70942002000500014DOI Listing
September 2002