Individual differences and health in chronic pain: are sex-differences relevant?

BACKGROUND: Because psychological variables are known to intercorrelate, the goal of this investigation was to compare the unique association between several well-established psychological constructs in pain research and pain-related outcomes. Sex differences are considered because pain is experienced differently across sex groups. METHODS: Participants were 456 consecutive chronic pain patients attending a tertiary pain clinic (mean age = 58.4 years, SD = 14.8, 63.6% women). The study design was cross-sectional. Psychological constructs included personality (NEO-Five Factor Inventory), irrational thinking (General Attitudes and Beliefs Scale), and coping (Social Problem Solving Inventory). Outcomes were pain severity and interference (Brief Pain Inventory) and physical, general, and mental health status (Short Form-36). To decide whether the bivariate analyses and the two-block, multivariate linear regressions for each study outcome (block 1 = age, sex, and pain severity; block 2 = psychological variables) should be conducted with the whole sample or split by sex, we first explored whether sex moderated the relationship between psychological variables and outcomes. An alpha level of 0.001 was set to reduce the risk of type I errors due to multiple comparisons. RESULTS: The moderation analyses indicated no sex differences in the association between psychological variables and study outcomes (all interaction terms p > .05). Thus, further analyses were calculated with the whole sample. Specifically, the bivariate analyses revealed that psychological constructs were intercorrelated in the expected direction and mostly correlated with mental health and overall perceived health status. In the regressions, when controlling for age, sex, and pain severity, psychological factors as a block significantly increased the explained variance of physical functioning (ΔR2 = .037, p < .001), general health (ΔR2 = .138, p < .001), and mental health (ΔR2 = .362, p < .001). However, unique associations were only obtained for mental health and neuroticism (ß = - 0.30, p < .001) and a negative problem orientation (ß = - 0.26, p < .001). CONCLUSIONS: There is redundancy in the relationship between psychological variables and pain-related outcomes and the strength of this association is highest for mental health status. The association between psychological characteristics and health outcomes was comparable for men and women, which suggests that the same therapeutic targets could be selected in psychological interventions of pain patients irrespective of sex.

Cobb angle measurement with a conventional convex echography probe and a smartphone.

BACKGROUND CONTEXT: Serial X-rays are needed during the follow-up of adolescent idiopathic scoliosis. They are done every 6 or 3 months in cases of high risk of progression. Thanks to the advances in ultrasound techniques, deformity measurement systems free from ionizing radiations have been validated, although spinal surgeons did not use them routinely due to the need of special software. OBJECTIVE: The aim of our work is to assess the reproducibility and correlation of an ultrasound measuring system based on the positioning of the transverse processes. STUDY DESIGN: Prospective, single center, randomized, triple blinded. METHODS: Two independent researchers trained in ultrasound examined the spinal deformities of 31 children. The measurements were compared against those performed with an X-ray by three scoliosis expert surgeons. Statistics were performed by an independent researcher. Parametric methods were used. RESULTS: We found a 95% [(0.91-0.97) p < 2.2e-16] correlation between the degree of scoliosis measured with the proposed ultrasound system and the 30 cm × 90 cm X-rays in standing position. There was an intra-observer reliability of 97% [r-squared = 0.97; CI 95% (0.95-0.98) p < 2.2e-16] and an inter-observer reliability of 95% [r-squared = 0.95; CI 95% (0.90-0.97) p < 2.2e-16]. CONCLUSIONS: An approximation of the Cobb angle measure is possible with ultrasound by using the transverse processes as reference. This is a very rapid and simple system for assessing the principal spinal deformity measure in young people, although it does not allow estimating the associated axial or sagittal rotation. These slides can be retrieved under Electronic Supplementary Material.

[Placement of a biventricular resynchronization device in a patient with a persistent left superior vena cava: report of one case]. / Terapia de resincronización cardiaca en paciente con vena cava superior izquierda persistente: caso clínico.

Persistent left superior vena cava is the most common venous congenital malformation and is usually asymptomatic. Its presence could increase the difficulty for transvenous lead implantation. We report a 71-year-old woman with an idiopathic dilated cardiomyopathy, atrial fibrillation and heart failure that required biventricular resynchronization therapy. During the placement of the device a persistent left superior vena cava was detected. The device was placed without problems and the patient had a satisfactory postoperative evolution.

Expression of BCL-2 family genes in germ cells undergoing apoptosis during the first wave of spermatogenesis in the rat.

Apoptosis is a key event controlling sperm output both in normal and pathological conditions. However, the mechanisms involving germ cell apoptosis is far from being understood. In this work, we have immunoisolated germ cells undergoing apoptosis by taking advantage of the up-regulation of Fas, a dead receptor involved in apoptosis induction in these cells. Analysis of specific markers showed that this cell population is composed of spermatogonia and meiotic spermatocytes. We measured the mRNA levels of several apoptosis-inducing proteins belonging to the BCL-2 family (BAX, BAD, PUMA, BOK and BAK) as well as those that prevent apoptosis (BCL-2, BCL-W and BCL-XL). Results showed that apoptotic germ cells have elevated mRNA levels of all studied genes (both pro and anti-apoptotic) compared with non-apoptotic cells. Our data would help to define the molecular mechanisms involving germ cell apoptosis under physiological conditions.

Trigger point dry needling versus strain-counterstrain technique for upper trapezius myofascial trigger points: a randomised controlled trial.

BACKGROUND: Treatment of active myofascial trigger points includes both invasive and non-invasive techniques. OBJECTIVES: To compare the effects of upper trapezius trigger point dry needling (DN) and strain-counterstrain (SCS) techniques versus sham SCS. STUDY DESIGN: Randomised controlled trial. METHOD: 34 study subjects with active trigger points were randomly assigned to one of three treatment groups, and received either three sessions of DN (n=12), six sessions of SCS (n=10), or sham SCS (n=12) over a 3-week period. Subjective pain response and subjects' own ratings of perceived disability were measured. RESULTS: The analysis of variance mixed model showed a significant time effect for pain (p<0.001), elicited pain (p<0.001), pain pressure threshold (p<0.01), and neck disability index (p=0.016). Pain at rest decreased in all groups, as follows: DN 18.5 mm (95% CI 4.3 to 32.7 mm); SCS 28.3 mm (95% CI 12.4 to 44.1 mm); sham SCS 21.9 mm (95% CI 3.5 to 40.1 mm). Reductions in disability score (points) were significant in the SCS group (5.5, 95% CI 1.6 to 9.4) but not in the DN (1.4, 95% CI -4.9 to 2.1) or sham SCS (1.8, 95% CI -6.4 to 2.7) groups. There was no significant group×time interaction effect for any variables studied. CONCLUSIONS: There were no differences between the sham SCS, SCS, and DN groups in any of the outcome measures. DN relieved pain after fewer sessions than SCS and sham SCS, and thus may be a more efficient technique. Future studies should include a larger sample size. TRIAL REGISTRATION NUMBER: NCT01290653.

[Palliative surgical treatment of spastic paralysis in the lower extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades inferiores.

AIMS: The purpose of this paper is to describe our experience with and to review the best results in the surgical treatment of patients suffering from spastic paralysis of the lower limbs. DEVELOPMENT: To enable a correct indication of the techniques to be employed the authors recommend a thorough examination of the types of deformity (fixed, dynamic or mixed) and the use of specific tests for exploring the different deformities. These are necessary steps to be able to interpret the different disorders in a global manner and thus reach diagnostics that provide us with a proper surgical therapeutic orientation about the spastic hip, knee, ankle and foot. Due to the importance of the overall problem, it is becoming increasingly more frequent to advise multidisciplinary work involving the collaboration of different specialists (neurologists, rehabilitators, physiotherapists, psychologists, paediatricians, neurophysiologists and orthopaedic surgeons). Spasticity is as heterogeneous as the results of the different treatment projects. The techniques used must allow the rehabilitation therapy to be continued. Surgical intervention is recommended when the damage to the CNS has stabilised and the patient is over 4 years old. The psychic state of the patient and the family must also be evaluated. CONCLUSIONS: The objective of the treatment in patients who can walk is to improve motor functioning, the type of gait and to prevent fixed deformities from developing. In patients who do not walk, the aim is to improve their hygiene and their capacity to sit and to walk. These indications are indispensable to be able to successfully perform a little-known area of orthopaedic surgery which does not respond to the techniques used in flaccid paralysis surgery.

[Palliative surgical treatment of spastic paralysis in the upper extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades superiores.

AIMS: In this paper we review the main studies conducted on therapy applied to the bony and soft parts in spastic paralysis of the upper extremity. DEVELOPMENT: Spasticity presents muscular hypertonia and hyperexcitability of the stretch reflex, which are typical of upper motoneuron syndrome. Physiopathologically, spasticity is due to the medullar and supramedullar alteration of the afferent and efferent pathways. Treatment is multidisciplinary and involves the collaboration of rehabilitators, neurophysiologists, neurologists, paediatricians, orthopaedic surgeons and psychologists, who all contribute with their different therapeutic aspects and characteristics (which can be pharmacological, peripheral neurological blockages, surgical, etc.). The characteristic posture of the upper extremities in spastic cerebral palsy is the inward rotation of the shoulder, flexion of the elbow and pronated forearm, and the deformity of the fingers (swan-neck and thumbs-in-palm). The primary objectives in these patients will be to improve communication with their surroundings, perform activities of daily living, increase mobility and walking. CONCLUSIONS: The surgical treatment applied by orthopaedic surgeons in the upper extremities are aimed at achieving an enhanced adaptive functionality rather than morphological normality. Factors to be taken into account include age, voluntary control over muscles and joints, level of severity of the spasticity (Ashworth scale) and stereognostic sensitivity. In general, on soft parts we will use procedures such as dehiscence or lengthening of the flexor muscles of the shoulder and elbow or of the adductor of the thumb; transfer of the pronators in order to adopt the supinating function or of the flexors so as to reinforce the extensors of the forearm, and capsulodesis or tenodesis in the hand. The bony procedures will consist in derotational osteotomies of the humerus and radius and arthrodesis in the wrist or in the metacarpophalangeal joints of the thumb, depending on whether there is greater rigidity or age in the former cases or instability in the latter.

[Anatomic basis of continuous axillary block of the brachial plexus with thoracic reservoir]. / Bases anatómicas del bloqueo axilar continuo del plexo braquial con reservorio torácico.

Although continuous axillary block is effective for periods of up to four to six weeks, pain clinic patients with severe chronic pain in the upper extremities, mainly resulting from neuropathic disease, can require continuous drug delivery by catheter-reservoir for up to three months or longer. We studied possible locations for implanting reservoirs or catheters from the perivascular axillary space in fresh cadavers, checking for possible vascular or nerve damage after applying the usual technique for reservoir implantation. The ideal location for the reservoir is the subcutaneous tissue of the homolateral infraclavicular space of the anterior side of the thorax. The customary procedures for inserting the catheter along the subcutaneous route that extends from the perivascular axillary space to the reservoir carry no risk of damaging vascular or nerve structures.

[What do we know about atypical fractures in patients on biphosphonates treatment? A literature review using a case series]. / ¿Qué sabemos de las fracturas atípicas en los pacientes en tratamiento con bifosfonatos? Revisión bibliográfica a raíz de una serie de casos.

AIM: Retrospective review of long term biphosphonates treated patients who sustained a subtrochanteric or diaphyseal femoral fracture with an atypical pattern. A literature review is presented as an update of the topic. MATERIAL AND METHODS: A retrospective study was conducted on 13 subtrochanteric or diaphyseal fractures in female patients treated with biphosphonates at our institution from September 2007 to March 2011. RESULTS: Four cases of subtrochanteric fractures and 13 diaphyseal fractures were detected. Four patients had bilateral fractures. All cases but one (that affected only the lateral cortex) were complete fractures. Surgically, these kinds of fractures are demanding due to the hardness of the bones. DISCUSSION: It is difficult to know if there is any relationship between bisphosphonates treatment and atypical femoral fractures. Nevertheless, current literature supports a greater benefit of their use in preventing vertebral and non-vertebral fractures. For this reason, biphosphonates continue being considered as a first choice in the prevention of osteoporotic fractures. CONCLUSIONS: Patients on long-term treatment with bisphosphonates may present atypical femoral fractures as a complication. It is considered that the maximum period for biphosphonates treatment should not exceed 5 years.

Tumor de Krukenberg del ovario asociado a teratoma maduro / Krukenberg tumor of the ovary associated with mature teratoma

Se reporta un caso excepcional de tumor de Krukenberg ovárico bilateral asociado a teratoma maduro encontrado en una mujer de 54 años. La ecografía mostró al lado derecho tumor ovárico sólido de 55 mm y al lado izquierdo tumor quístico de 125 mm. Se realizó histerectomía total, salpingooforectomía bilateral, resección del epiplón mayor y muestras peritoneales. Al tercer día postcirugía, la paciente presentó signos de tromboembolismo pulmonar masivo y aunque recibió terapia anticoagulante falleció al quinto día postoperatorio. El estudio histológico mostró infiltración masiva de carcinoma de células en anillo positivas para citoqueratina en ambos ovarios. El ovario derecho mostró la forma sólida clásica del tumor de Krukenberg mientras que el ovario izquierdo correspondió a un quiste dermoide con infiltración tumoral de carcinoma de células en anillo en la pared.

An exceptional case of bilateral Krukenberg tumor of the ovary associated with mature teratoma presented in a 54 years old patient is reported. The ultrasound showed a 55 mm solid right ovarian tumor and a 125 mm left cystic ovarian tumor. Hysterectomy and bilateral salpingoophorectomy was performed including omental resection and peritoneal biopsies. Massive pulmonary embolism was detected in the third day after the surgery. Even anticoagulant therapy was established the patient died in the fifth postoperative day. The histological study revealed massive infiltration of signet ring cell carcinoma with positive expression for cytokeratin in both ovaries. The right ovary showed the classical solid form of the tumor. The left ovary was a dermoid cyst with signet ring cell carcinoma infiltrating the cystic wall.

Terapia de resincronización cardiaca en paciente con vena cava superior izquierda persistente: Caso clínico / Placement of a biventricular resynchronization device in a patient with a persistent left superior vena cava: Report of one case

Persistent left superior vena cava is the most common venous congenital malformation and is usually asymptomatic. Its presence could increase the difficulty for transvenous lead implantation. We report a 71-year-old woman with an idiopathic dilated cardiomyopathy, atrial fibrillation and heart failure that required biventri-cular resynchronization therapy. During the placement of the device a persistent left superior vena cava was detected. The device was placed without problems and the patient had a satisfactory postoperative evolution.

[Requirement of fast ventricular stimulation to induce atrio ventricular nodal tachycardia: report of one case]. / Necesidad de estimulación ventricular rápida en la inducción de taquicardia por reentrada del nodo aurículo-ventricular: Caso clínico.

We report a 59 year-old woman who had recurrent episodes of paroxystic supraventricular tachycardia despite pharmacologic therapy. A previous electrophysiological study (EPS) was done two years earlier without induction of any sustained arrhythmia. A new EPS was performed, during which atrial and ventricular programmed stimulation failed to induce tachycardia, and only by fast ventricular stimulation during intravenous isoproterenol infusion, a typical atrio ventricular nodal reentrant tachycardia (AVNRT) was induced. We successfully ablated the slow nodal pathway. After ablation the tachycardia was not inducible. We comment the occasional difficulties to induce AVNRT and the importance of a complete induction protocol to avoid false negative studies during the EPS.

[Cryoablation of pulmonary veins as complementary treatment of atria I fibrillation in valvular surgery]. / Criocoagulación de venas pulmonares como tratamiento complementario de la fibrilación auricular en cirugía valvular.

BACKGROUND: The Cox MAZE III operation for the treatment of atrial fibrillation (AF) is complex and consumes significant operative time. Cryoablation of the pulmonary veins (CPV) is a simpler alternative for patients that require concomitant valvular surgery. AIM: To evaluate CPV in patients with AF submitted to valvular surgery. PATIENTS AND METHODS: Twenty one patients had simultaneous valvular surgery and CPV, 81 % of them had permanent AF for an average of 5 years. Twenty patients had mitral valve disease. The etiology was rheumatic in 14. Average left atrial diameter was 60 mm. In 7 patients the mitral valve was replaced, in 5 it was repaired, in 7 both mitral and aortic valve were replaced, in 1 the mitral valve was repaired and the aortic valve was replaced and in 1 only the aortic valve was replaced. A combined transeptal and superior approach was used for all patients. The CPV was performed after the valvular procedure with cryothermy at -60 degrees C for 2 minutes with two 15 mm cryoprobes applied simultaneously. RESULTS: CPV increased surgical time by 10 to 20 minutes. Operative mortality was 4.8% (1 patient). One patient developed a pericardial effusion and another a complete heart block that required a permanent pacemaker. All patients improved their functional class. At the end of an average 10.5 months of follow-up, 50% of patients were in normal sinus rhythm and 25% persisted in AF. The remaining patients were in some type of regular rhythm. CONCLUSIONS: CPV as a complementary procedure in patients with AF undergoing valvular surgery had good results to abate AF. It restored normal sinus rhythm in 50% of the cases, with low morbidity and mortality and little increment in surgical time.

[Multisite right ventricular stimulation for cardiac failure refractory to biventricular resynchronization therapy. Case report]. / Estimulación ventricular derecha multisitio en insuficiencia cardíaca refractaria a tratamiento con resincronización biventricular.

The prevalence of congestive heart failure has increased in the world. Despite advances in pharmacological treatment, some patients have progression of the disease and deterioration of their functional class. In this group of patients cardiac resynchronization therapy has been accepted as a treatment option. However, some patients are non-responders to cardiac resynchronization, and others who respond favorably, will experience reappearance of their symptoms. For these patients, multisite stimulation with the implant of a second electrode in the right ventricle has been published as a new option. We report a 76 year-old woman with a dilated cardiomyopathy, who was treated with resynchronization therapy with good clinical response during two years, but symptoms of congestive heart failure reappeared and her functional class deteriorated to NYHA class IV. She was successfully treated with right ventricular multisite stimulation, with a reduction of symptoms that has lasted during the two months of follow up after the procedure.

Insulin resistance is not associated with liver fibrosis progression in HIV/hepatitis C virus-coinfected patients.

Insulin resistance (IR) is a common condition in chronic hepatitis C. Recent studies have reported that IR is associated with liver fibrosis progression in these patients. However, there is no information available on this issue in human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected patients. For these reasons, we investigate the relationship between IR and liver fibrosis in patients with HIV and HCV infections. This was a cross-sectional study where patients from an Infectious Diseases Unit with HIV/HCV coinfection who underwent a liver biopsy, with available frozen sera samples at the time of biopsy and a known or estimated date of infection were included. IR was determined by the homeostasis model assessment (HOMA-IR) method. The relationship between histological findings and several variables, including HOMA-IR values, was examined. Seventy-nine patients fulfilled the inclusion criteria. Age at HCV infection >21 years was the only variable independently associated with advanced liver fibrosis (stages F3 and F4) [adjusted odds ratio (AOR) 4.15; 95% confidence interval (CI) 1.5-11.3]. The variables associated with a fibrosis progression rate above the median were age at HCV infection >21 years (AOR 6.41; 95% CI 2.16-27.96) and previous exposure to nevirapine (AOR 8.9; 95% CI 2.01-39.36). There was no association between HOMA-IR values and the presence of advanced fibrosis or a faster fibrosis progression. Thus IR is not associated with liver damage or fibrosis progression in HIV/HCV-coinfected individuals.

[Loss of biventricular resynchronization due to an uncommon cause: Report of one case]. / Pérdida de resincronización biventricular: Causa inhabitual. Caso clínico.

Cardiac resynchronization therapy is a non-pharmacological treatment for patients with dilated cardiomyophaty and congestive heart failure. The success of this therapy depends of permanent biventricular stimulation. We report an 84 year-old man, with intermittent loss of biventricular pacemaker stimulation despite having adequate sensing and stimulation thresholds in the right atrium and both ventricles. The problem was solved after correcting some programming parameters.

[Comparison of three brands of intracardiac pacemaker leads]. / Seguimiento en fase aguda de catpeteres electrodos de estimulación endocavitaria permanente: comparación de tres modelos.

BACKGROUND: Electrode lead design and materials influence their performance, stability and manipulation characteristics. In our laboratory, we use straight intracardiac, active fixation, steroid eluting leads. These features are shared by three brands of pacemaker distributors. AIM: To compare the short term results of three brands of leads used in our laboratory in patients requiring the implant of a pacemaker or cardioverter. MATERIAL AND METHODS: One hundred and four patients (mean age 70 years, 59 males) subjected to a pacemaker or cardioverter implant were studied and followed during the first three months post implant. In these patients, 49 Guidant Flextend 4087 or 4088, 27 Saint Jude Tendril 1488T and 10 Medtronic Capsurefix 5076 leads were implanted in the right atrium and 60 Guidant Flextend 4087 or 4088, 29 Saint Jude Tendril 1488T and 19 Medtronic Capsurefix 5076 leads were implanted in the right ventricle. RESULTS: Implant parameters were adequate for all leads. A sub-acute rise in ventricular stimulation threshold was detected in one Flextrend lead. Three atrial leads (two Flextend and one Capsurefix) and one Capsurefix ventricular lead experienced an acute displacement. One patient with a Flextend lead, had a cardiac tamponade caused by an atrial perforation. CONCLUSIONS: The three brands of leads tested can be successfully implanted with comparable parameters and without differences in the evolution of patients during the first three months.

Síndrome de Twiddler: una causa infrecuente de disfunción de marcapaso definitivo. Caso clínico / Twiddler syndrome: Report of one case

We report a 26year old patient who had a single chamber pacemaker implantation one year before. During a routine pre-operative evaluation, pacemaker dysfunction was demonstrated due to sensing and pacing failure, associated to left pectoral muscle rhythmic contraction. Chest X-ray confirmed Twiddler syndrome, in which twisting or rotation of the device inside the pocket results in lead dislodgement and device malfunction.