1
|
Xu Z, Hu B, Zheng G, Yu W, Yang C, Wang H, Chen K, He S, Liang L, Xu C, Wu X, Zang F, Yuan WE, Chen H. Metformin-grafted polycaprolactone nanoscaffold targeting sensory nerve controlled fibroblasts reprograming to alleviate epidural fibrosis. J Control Release 2024; 367:791-805. [PMID: 38341179 DOI: 10.1016/j.jconrel.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/17/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Abstract
Epidural fibrosis (EF), associated with various biological factors, is still a major troublesome clinical problem after laminectomy. In the present study, we initially demonstrate that sensory nerves can attenuate fibrogenic progression in EF animal models via the secretion of calcitonin gene-related peptide (CGRP), suggesting a new potential therapeutic target. Further studies showed that CGRP could inhibit the reprograming activation of fibroblasts through PI3K/AKT signal pathway. We subsequently identified metformin (MET), the most widely prescribed medication for obesity-associated type 2 diabetes, as a potent stimulator of sensory neurons to release more CGRP via activating CREB signal way. We copolymerized MET with innovative polycaprolactone (PCL) nanofibers to develop a metformin-grafted PCL nanoscaffold (METG-PCLN), which could ensure stable long-term drug release and serve as favorable physical barriers. In vivo results demonstrated that local implantation of METG-PCLN could penetrate into dorsal root ganglion cells (DRGs) to promote the CGRP synthesis, thus continuously inhibit the fibroblast activation and EF progress for 8 weeks after laminectomy, significantly better than conventional drug loading method. In conclusion, this study reveals the unprecedented potential of sensory neurons to counteract EF through CGRP signaling and introduces a novel strategy employing METG-PCLN to obstruct EF by fine-tuning sensory nerve-regulated fibrogenesis.
Collapse
Affiliation(s)
- Zeng Xu
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Bo Hu
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Genjiang Zheng
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Wei Yu
- Shanghai Frontiers Science Center of Drug Target Identification and Delivery, School of Pharmaceutical Sciences, Shanghai Jiao Tong University, Shanghai 200240, China; Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, and School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; National Key Laboratory of Innovative Immunotherapy, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Chen Yang
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Hui Wang
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Keyi Chen
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Shatong He
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Lei Liang
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Chen Xu
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Xiaodong Wu
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Fazhi Zang
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China.
| | - Wei-En Yuan
- Shanghai Frontiers Science Center of Drug Target Identification and Delivery, School of Pharmaceutical Sciences, Shanghai Jiao Tong University, Shanghai 200240, China; Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, and School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; National Key Laboratory of Innovative Immunotherapy, Shanghai Jiao Tong University, Shanghai 200240, China.
| | - Huajiang Chen
- Spine Center, Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai 200003, China.
| |
Collapse
|
2
|
Gupta A, Chhabra HS, Singh V, Nagarjuna D. Lumbar Transforaminal Injection of Steroids versus Platelet-Rich Plasma for Prolapse Lumbar Intervertebral Disc with Radiculopathy: A Randomized Double-Blind Controlled Pilot Study. Asian Spine J 2024; 18:58-65. [PMID: 38433432 PMCID: PMC10910136 DOI: 10.31616/asj.2023.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 03/05/2024] Open
Abstract
STUDY DESIGN Double-blind randomized controlled pilot study. PURPOSE The purpose of this study was to compare outcomes of steroids with autologous platelet-rich plasma (PRP) administered by lumbar transforaminal injection (LTI) in patients with lumbar radiculopathy. OVERVIEW OF LITERATURE Degenerative disc disease of the lumbar spine is one of the most common conditions managed by spine surgeons in routine practice. Once conservative management fails, LTI is diagnostic and often therapeutic. Steroids are the gold standard drug used for LTI but have limitations and side effects. METHODS In this single-center double-blind randomized controlled pilot study, 46 patients were recruited and randomized by the lottery method. The Visual Analog Scale (VAS) for leg pain, modified Oswestry Disability Index (mODI), and Short-Form 12 (SF-12) were assessed at 1 week, 3 weeks, 6 weeks, 6 months, and 1 year. RESULTS Both groups were comparable in terms of demographics, preprocedure VAS scores, mODI, and SF-12 scores (p=0.52). At the 1-week follow-up, the steroid group had significantly better improvement than the PRP group (p=0.0001). At the 3-week follow-up, both groups showed comparable outcomes; however, the PRP group had better symptom improvement. At 6 weeks and 6 months, the PRP group had better outcomes (VAS, p<0.0001; ODI, p=0.02; SF-12, p=0.002). Moreover, 17 and 16 patients in the steroid and PRP groups underwent repeat LTI with steroids or surgery because of pain recurrence during follow-up. At 1 year, no difference in outcomes was observed. CONCLUSIONS PRP may be a useful alternative to steroids for LTI in lumbar radiculopathy. Although improvement was delayed and 1-year outcomes were comparable, the 6-week and 6-month outcomes were better with PRP than with LTI. Multiple PRP injections may be beneficial because of its autologous nature. However, further studies with a larger number of participants, longer follow-up, and repeat LTIs are warranted to draw definite conclusions.
Collapse
Affiliation(s)
- Anuj Gupta
- Department of Spine Surgery, Max Superspeciality Hospital, Ghaziabad, India
| | | | - Vishwajeet Singh
- Winnipeg Spine Program, University of Manitoba, Winnipeg, MB, Canada
| | | |
Collapse
|
3
|
Ko SB, Kwak SG. Effect of Comprehensive and Integrative Medical Services on Patients with Degenerative Lumbar Spinal Stenosis: A Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2166. [PMID: 38138269 PMCID: PMC10744891 DOI: 10.3390/medicina59122166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Two types of medicinal systems are available in Korea: Western and oriental. These exist as separate services that independently provide medical care to patients. We determined the utility and benefits of compressive and integrated medical services (CIMS) comprising 12 sessions of acupuncture and healing programs over 6 weeks. Methods and Methods: In this two-group parallel single-center randomized controlled assessor-blinded trial, 25 participants were assigned to either the experimental (conventional medical treatment plus CIMS, n = 12) or control (conventional medical treatment, n = 13) group. Spinal nerve root block was performed on the compressed spinal nerve root (identified using magnetic resonance imaging) when no improvement was observed after the initial treatment. The experimental group received 12 cycles of acupuncture and manual therapy for 6 weeks; the control group received conventional medical treatment alone. Results: The average age of participants in the experimental and control groups was 70.73 ± 5.95 and 67.33 ± 8.89 years, respectively. There were no significant differences between the groups in terms of age, body mass index, Leeds Assessment of Neuropathic Symptoms and Signs, sex, and current medical history. We found high compliance for both programs (acupuncture and healing). On exclusion of between-group effects, the visual analog scale (VAS) score improved significantly over time (p = 0.045). Further, comparison of the groups after excluding the effects of visits revealed significantly lower VAS scores in the experimental group than in the control group (p = 0.000). Conclusions: Patients with degenerative lumbar spinal stenosis who mainly complain of radiating pain in the lower leg may benefit from CIMS after spinal nerve root block for ≤3 months after treatment. Our study findings suggest that this treatment improves spinal function and Oswestry Disability Index score. However, CIMS did not improve QoL.
Collapse
Affiliation(s)
- Sang Bong Ko
- Department of Orthopaedic Surgery, School of Medicine, Daegu Catholic University, Daegu Catholic University Hospital, Daegu 42472, Republic of Korea
| | - Sang Gyu Kwak
- Department of Medical Statistics, School of Medicine, Daegu Catholic University, Daegu 42472, Republic of Korea;
| |
Collapse
|
4
|
Hu X, Wu H, Yong X, Wang Y, Yang S, Fan D, Xiao Y, Che L, Shi K, Li K, Xiong C, Zhu H, Qian Z. Cyclical endometrial repair and regeneration: Molecular mechanisms, diseases, and therapeutic interventions. MedComm (Beijing) 2023; 4:e425. [PMID: 38045828 PMCID: PMC10691302 DOI: 10.1002/mco2.425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/21/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
The endometrium is a unique human tissue with an extraordinary ability to undergo a hormone-regulated cycle encompassing shedding, bleeding, scarless repair, and regeneration throughout the female reproductive cycle. The cyclical repair and regeneration of the endometrium manifest as changes in endometrial epithelialization, glandular regeneration, and vascularization. The mechanisms encompass inflammation, coagulation, and fibrinolytic system balance. However, specific conditions such as endometriosis or TCRA treatment can disrupt the process of cyclical endometrial repair and regeneration. There is uncertainty about traditional clinical treatments' efficacy and side effects, and finding new therapeutic interventions is essential. Researchers have made substantial progress in the perspective of regenerative medicine toward maintaining cyclical endometrial repair and regeneration in recent years. Such progress encompasses the integration of biomaterials, tissue-engineered scaffolds, stem cell therapies, and 3D printing. This review analyzes the mechanisms, diseases, and interventions associated with cyclical endometrial repair and regeneration. The review discusses the advantages and disadvantages of the regenerative interventions currently employed in clinical practice. Additionally, it highlights the significant advantages of regenerative medicine in this domain. Finally, we review stem cells and biologics among the available interventions in regenerative medicine, providing insights into future therapeutic strategies.
Collapse
Affiliation(s)
- Xulin Hu
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
- Department of BiotherapyCancer Center and State Key Laboratory of BiotherapyWest China HospitalSichuan UniversityChengduSichuanChina
| | - Haoming Wu
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Xin Yong
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Department of Paediatrics, West China Second University Hospital, State Key Laboratory of Biotherapy and Collaborative Innovation Center of BiotherapySichuan UniversityChengduSichuanChina
| | - Yao Wang
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Shuhao Yang
- Department of OrthopedicsThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Diyi Fan
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Yibo Xiao
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Lanyu Che
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Kun Shi
- Department of BiotherapyCancer Center and State Key Laboratory of BiotherapyWest China HospitalSichuan UniversityChengduSichuanChina
| | - Kainan Li
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | | | - Huili Zhu
- Department of Reproductive Medicine, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of EducationWest China Second University Hospital of Sichuan UniversityChengduSichuanChina
| | - Zhiyong Qian
- Department of BiotherapyCancer Center and State Key Laboratory of BiotherapyWest China HospitalSichuan UniversityChengduSichuanChina
| |
Collapse
|
5
|
Caudal epidural steroid injections versus selective nerve root blocks for single-level lumbar spinal stenosis: a study protocol for a randomized controlled trial. Trials 2021; 22:524. [PMID: 34372906 PMCID: PMC8351452 DOI: 10.1186/s13063-021-05485-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) is a common degenerative condition associated with old age. Its incidence continues to increase with the rapidly aging population in China. Treatment for LSS usually begins with conservative treatments, as some patients refuse surgical procedures or have surgery contraindications. Caudal epidural steroid injections (CESIs) and selective nerve root blocks (SNRBs) are two commonly used conservative treatments for LSS, which have proven to be effective at relieving LSS symptoms in many studies. However, there are no randomized controlled trials comparing these two procedures. We planned the first study to assess which one of these two procedures is more effective in treating LSS. We will compare the efficacy of these two treatment methods in terms of duration of symptom relief and recurrence rate. We hope our findings will help clinicians choose an optimal treatment for LSS patients. METHODS/DESIGN We plan to conduct a 1-year randomized controlled trial that will include a total of 76 subjects. They will be randomly divided into two groups: group A (patients will receive CESIs) and group B (patients will receive SNRBs). Two days before the procedure, we will assess these patients using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale, Oswestry Disability Index (ODI), and numeric rating scale (NRS) for pain. One day, 2 weeks, 3 months, 6 months, and 1 year after the procedure, we will assess the condition of these patients again with the NRS and ODI. DISCUSSION We hope our findings will lay the foundation for the design of further comprehensive studies and help clinicians make a choice between CESIs and SNRBs for LSS patients. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1900028038 . Registered on 8 December 2019.
Collapse
|
6
|
Ko S, Jun C, Lee JJ, Nam J. Comparison of the effects of corticosteroid and hyaluronic acid-carboxymethylcellulose solution on selective nerve root block for lumbar radiculopathy: A prospective, double-blind, randomized controlled clinical trial. Pain Pract 2021; 21:785-793. [PMID: 33872462 DOI: 10.1111/papr.13018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Selective nerve root block (SNRB) was shown to effectively control radiating pain and reduce the need for surgical intervention. However, repetitive injections may trigger corticosteroid-induced side effects (hypercorticism, hyperglycemia, or fluid retention). This study aims to compare the potency of hyaluronic acid-carboxymethylcellulose (HA-CMC) solution versus that of corticosteroids regarding lower leg radiating pain (LLRP) improvement and functional outcome. METHODS Among 128 patients, 44 patients who complain about having LLRP due to lumbar spinal stenosis and do not have neurological symptoms requiring surgery were enrolled for this study. Group A with 22 patients injected with cocktail A (local anesthetics and corticosteroid) and group B with 22 patients injected with cocktail B (local anesthetics and HA-CMC). Outcome measures were the visual analog scale (VAS), Oswestry Disability Index (ODI), and short form-36 (SF-36). All patients were asked to fill in the questionnaires during the follow-up assessment period at 3 days, 7 days, 2 weeks, 6 weeks, and 12 weeks. RESULTS In all time periods, there were no statistical differences between the two groups for VAS scores and VAS improvement over time, ODI scores and ODI improvement over time, and SF-36 PCS scores and SF-36 mental component score scores. Additionally, the 95% confidence interval of the difference in VAS score improvement between the 2 groups in all time periods was within VAS 5.0, which is the minimum clinically relevant difference. CONCLUSIONS Considering the adverse effects of corticosteroids, and the similar LLRP improvements, functional outcome, and quality of life, the HA-CMC solution may be an alternative option to corticosteroid in SNRB.
Collapse
Affiliation(s)
- Sangbong Ko
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
| | - ChungMu Jun
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
| | - Jae Jun Lee
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
| | - Junho Nam
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
| |
Collapse
|
7
|
Nobre LV, Cunha GP, Sousa PCCBD, Takeda A, Cunha Ferraro LH. [Peripheral nerve block and rebound pain: literature review]. Rev Bras Anestesiol 2019; 69:587-593. [PMID: 31690509 DOI: 10.1016/j.bjan.2019.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/03/2019] [Accepted: 05/15/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate, describe, and assess the phenomenon of "rebound pain" as a clinically relevant problem in anesthetic practice. CONTENT The phenomenon of "rebound pain" has been demonstrated and described as a very severe pain, which occurs after a peripheral nerve block resolution with the recovery of sensitivity. The incidence of rebound pain is unknown. Usually, it occurs between 12 to 24hours after surgery and adversely affecting sleep quality. It is not yet possible to establish a mechanism as a definitive cause or trigger factor of rebound pain. Studies suggest that rebound pain is a side effect of peripheral nerve blocks, despite their effectiveness in pain control. Currently, the extent and clinical significance of rebound pain cannot be well determined due to the lack of large prospective studies. CONCLUSION Rebound pain assessment should always be considered in clinical practice, as it is not a rare side effect of peripheral nerve blocks. There are still many challenging questions to be answered about rebound pain, so large prospective studies are needed to address the issue. For prevention, the use of peripheral nerve block techniques that avoid nerve damage and adequate perioperative analgesia associated with patient education on the early administration of analgesics, even during the period of analgesia provided by peripheral nerve block, is recommended. A better understanding of the "rebound pain" phenomenon, its pathophysiology, associated risk factors, and long-term consequences may help in developing more effective preventive strategies.
Collapse
Affiliation(s)
- Layana Vieira Nobre
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Graziella Prianti Cunha
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Paulo César Castello Branco de Sousa
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Alexandre Takeda
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Leonardo Henrique Cunha Ferraro
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil.
| |
Collapse
|
8
|
Nobre LV, Cunha GP, Sousa PCCBD, Takeda A, Cunha Ferraro LH. Peripheral nerve block and rebound pain: literature review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31690509 PMCID: PMC9391878 DOI: 10.1016/j.bjane.2019.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background and objectives To investigate, describe, and assess the phenomenon of “rebound pain” as a clinically relevant problem in anesthetic practice. Content The phenomenon of “rebound pain” has been demonstrated and described as a very severe pain, which occurs after a peripheral nerve block resolution with the recovery of sensitivity. The incidence of rebound pain is unknown. Usually, it occurs between 12 and 24 hours after surgery and, adversely affecting sleep quality. It is not yet possible to establish a mechanism as a definitive cause or trigger factor of rebound pain. Studies suggest that rebound pain is a side effect of peripheral nerve blocks, despite their effectiveness in pain control. Currently, the extent and clinical significance of rebound pain cannot be well determined due to the lack of large prospective studies. Conclusion Rebound pain assessment should always be considered in clinical practice, as it is not a rare side effect of peripheral nerve blocks. There are still many challenging questions to be answered about rebound pain, so large prospective studies are needed to address the issue. For prevention, the use of peripheral nerve block techniques that avoid nerve damage and adequate perioperative analgesia associated with patient education on the early administration of analgesics, even during the period of analgesia provided by peripheral nerve block, is recommended. A better understanding of the “rebound pain” phenomenon, its pathophysiology, associated risk factors, and long-term consequences may help in developing more effective preventive strategies.
Collapse
Affiliation(s)
- Layana Vieira Nobre
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Graziella Prianti Cunha
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Paulo César Castello Branco de Sousa
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Alexandre Takeda
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Leonardo Henrique Cunha Ferraro
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil.
| |
Collapse
|