[Specifications of motivational interviewing within a cognitive-behavioral therapy of chronic pain]. / Spécificités de l'entretien motivationnel dans le cadre d'une prise en charge cognitivo-comportementale de la douleur chronique.

OBJECTIVES: Cognitive and behavioral approach of chronic pain presents encouraging results by improving physical, functional and psychological states of chronic pain patients. This specific treatment is partially based on the acquisition of new adaptive strategies to help the patients to manage more effectively chronic pain and to improve subsequently their subjective well-being. This requires in parallel to give up noxious emotional, cognitive and behavioral attitudes towards pain. Now, we have to admit that numerous therapeutic failures are directly imputable to difficulties introducing and making the indispensable changes continue in pursuit of the fixed therapeutic objectives. Readiness to change could play a considerable role in the success or not of chronic pain treatment. The main objective of this article is to present the data of the current literature concerning the specificities of the process of change in the field of the chronic pain. METHODS: We present a review of the literature describing at first, the psychological progress made by chronic pain patients longing to manage their suffering better via the trans-theoretical model of intentional change. Secondly, we develop the contributions of the technique of motivational interviewing in the improvement of chronic pain treatment. DISCUSSION: The identification of the motivational profile of chronic pain patients will determine how motivational interviewing can be conducted to improve their readiness for change. There are several strategies used with chronic pain patients in pre-contemplative and contemplative stages. Therapists may facilitate the problem recognition (help chronic pain patients to become aware of and identify the nature of the difficulties they face when trying to cope with their physical suffering); increase the personal concern (empowering chronic pain patients so that they feel fully involved in what they offer and invest in the therapy); develop the intention of change (ensure that the change becomes truly intentional); cultivate optimism (to help chronic pain patients to consider the present situation as being less desperate than it seems); ask open-ended questions (the direct questioning can be used to specify a request or reveal ambivalence about change); present personal feedback (the therapist provides the patient with a maximum of information that may help to appreciate the true value of the effectiveness of their current management of pain); review consequences of change versus non-change (to review the plausible positive (pros) and negative (cons) consequences of change); and summarizing (to summarize the key points discussed during the interview). In the active stage, therapists may use other strategies like: developing a plan for change (to suggest the adoption of certain coping strategies with pain); providing information advice (provide information advice in order to help chronic pain patients to determine how they will take concrete steps to initiate change); and using a change plan worksheet (help chronic pain patients to develop a synthetic view of the change process they will undertake). CONCLUSION: The various strategies discussed in this article are intended to accompany chronic pain patients to a process of change to help them consider a fundamental change in their ways of managing pain, when they are insufficient, ineffective and/or unintentionally aggravating their situation. It is important to help chronic pain patients to become aware of the nature of the adaptive problems they face, but also opportunities for change that are offered in order to encourage them to manage more efficiently and more autonomously their physical and mental suffering. In this context of openness to change, motivational interviewing can be an invaluable help to build a good therapeutic alliance in order to maximize the impact of supported global and multidimensional chronic pain by including a cognitive-behavioral approach for example.

Variation in habitat connectivity generates positive correlations between species and genetic diversity in a metacommunity.

An increasing number of studies are simultaneously investigating species diversity (SD) and genetic diversity (GD) in the same systems, looking for 'species- genetic diversity correlations' (SGDCs). From negative to positive SGDCs have been reported, but studies have generally not quantified the processes underlying these correlations. They were also mostly conducted at large biogeographical scales or in recently degraded habitats. Such correlations have not been looked for in natural networks of connected habitat fragments (metacommunities), and the underlying processes remain elusive in most systems. We investigated these issues by studying freshwater snails in a pond network in Guadeloupe (Lesser Antilles). We recorded SD and habitat characteristics in 232 ponds and assessed GD in 75 populations of two species. Strongly significant and positive SGDCs were detected in both species. Based on a decomposition of SGDC as a function of variance-covariance of habitat characteristics, we showed that connectivity (opportunity of water flow between a site and the nearest watershed during the rainy season) has the strongest contribution on SGDCs. More connective sites received both more alleles and more species through immigration resulting in both higher GD and higher SD. Other habitat characteristics did not contribute, or contributed negatively, to SGDCs. This is true of the desiccation frequency of ponds during the dry season, presumably because species markedly differ in their ability to tolerate desiccation. Our study shows that variation in environmental characteristics of habitat patches can promote SGDCs at metacommunity scale when the studied species respond homogeneously to these environmental characteristics.

"When will I recover?" A national survey on patients' and physicians' expectations concerning the recovery time for acute back pain.

The objective of this study was to compare patients' and physicians' expectations concerning the recovery time for acute back pain, and their determinants. A French national observational survey was performed between October and December 2005. Each physician was asked to include the first three patients aged between 20 and 70 years presenting with acute back pain (VAS > 40 mm) of less than 1 month's duration. A total number of 1982 patients, with a mean age of 48.4 +/- 11.8 years (52.2% men), were enrolled by 834 physicians. Patients and their physicians expected recovery to take the same amount of time in 60.3% of cases (Kappa = 0.43). In 17.4% of cases, patients predicted a shorter recovery time than physicians, and in 22.4% of cases, patients predicted a longer recovery time. Both patients and physicians expected recovery time to be longer in women, and in older, unmarried, obese, and non working patients. Expected recovery time was also longer in patients with no sports activities, low back pain (as opposed to pain at other sites), a high level of disability, a history of back pain, and no triggering factor. The intensity of pain and the number of days of sick leave taken did not affect the patient's prediction of recovery time, but did affect the physicians' expectations. Physicians considered professional status, analgesic intake and previous sick leave to be independent predictive factors, whereas patients did not. Expected recovery time, assessed shortly after the onset of acute back pain is influenced by most of the clinical and demographic factors usually considered risk factors for chronic low back pain. Patients' predictions of recovery time should be assessed in acute back pain, to identify risks for expected chronicity.

Fibromyalgia in the workplace: risk factors for sick leave are related to professional context rather than fibromyalgia characteristics- a French national survey of 955 patients.

BACKGROUND: Work and workplace factors are important in fibromyalgia management. We investigated factors associated with sick leave in professionally active women living with fibromyalgia. METHODS: A questionnaire for fibromyalgia patients in employment was developed by pain and occupational physicians and patients' organizations. Women in full-time work, screened for fibromyalgia with the FiRST questionnaire, were recruited for a national online survey. Sick leave over the preceding year was analyzed. RESULTS: In 5 months, we recruited 955 women, with a mean of 37 days of sick leave in the previous year: no sick leave (36%), up to 1 month (38%), 1 to 2 months (14%), more than 2 months (12%). In the groups displayed no differences in demographic characteristics, fibromyalgia symptoms, functional severity and psychological distress were observed. However, they differed in workplace characteristics, commute time, stress and difficulties at work, repetitive work, noisy conditions, career progression problems and lack of recognition, which were strong independent risk factors for longer sick leave. Sedentary positions, an extended sitting position, heavy loads, exposure to thermal disturbances and the use of vibrating tools did not increase the risk of sick leave. CONCLUSIONS: Women with fibromyalgia frequently take sick leave, the risk factors for which are related to the workplace rather than fibromyalgia characteristics. PERSPECTIVE: This is the first study to assess the impact of occupational and clinical factors on sick leave in women living with fibromyalgia. Risk factors were found to be related to the workplace rather than fibromyalgia and personal characteristics. Workplace interventions should be developed for women with fibromyalgia.

Is there any evidence to support the use of anti-depressants in painful rheumatological conditions? Systematic review of pharmacological and clinical studies.

The aim of this study was to review the evidence supporting the use of anti-depressants in painful rheumatological conditions. A systematic review of papers published between 1966 and 2007, in five European languages, on anti-depressants in rheumatological conditions was performed. Papers were scored using Jadad method and analgesic ES was calculated. We selected 78 clinical studies and 12 meta-analyses, from 140 papers. The strongest evidence of an analgesic effect of anti-depressants has been obtained for fibromyalgia. A weak analgesic effect is observed for chronic low back pain, with an efficacy level close to that of analgesics. In RA and AS, there is no analgesic effect of anti-depressants, but these drugs may help to manage fatigue and sleep disorders. There is no clear evidence of an analgesic effect inOA, but studies have poor methodological quality. Analgesic effects of anti-depressants are independent of their anti-depressant effects. Tricyclic anti-depressants (TCAs), even at low doses, have analgesic effects equivalent to those of serotonin and noradrenalin reuptake inhibitors (SNRIs), but are less well tolerated. Selective serotonin reuptake inhibitors (SSRIs) have modest analgesic effects, but higher doses are required to achieve analgesia. Anti-depressant drugs, particularly TCAs and SNRIs, have analgesic effects in chronic rheumatic painful states in which analgesics and NSAIDs are not very efficient, such as fibromyalgia and chronic low back pain. In inflammatory rheumatic diseases, anti-depressants may be useful for managing fatigue and sleep disorders. Further studies are required to compare anti-depressants with other analgesics in the management of chronic painful rheumatological conditions.

The TCA cycle transferase DLST is important for MYC-mediated leukemogenesis.

Despite the pivotal role of MYC in the pathogenesis of T-cell acute lymphoblastic leukemia (T-ALL) and many other cancers, the mechanisms underlying MYC-mediated tumorigenesis remain inadequately understood. Here we utilized a well-characterized zebrafish model of Myc-induced T-ALL for genetic studies to identify novel genes contributing to disease onset. We found that heterozygous inactivation of a tricarboxylic acid (TCA) cycle enzyme, dihydrolipoamide S-succinyltransferase (Dlst), significantly delayed tumor onset in zebrafish without detectable effects on fish development. DLST is the E2 transferase of the α-ketoglutarate (α-KG) dehydrogenase complex (KGDHC), which converts α-KG to succinyl-CoA in the TCA cycle. RNAi knockdown of DLST led to decreased cell viability and induction of apoptosis in human T-ALL cell lines. Polar metabolomics profiling revealed that the TCA cycle was disrupted by DLST knockdown in human T-ALL cells, as demonstrated by an accumulation of α-KG and a decrease of succinyl-CoA. Addition of succinate, the downstream TCA cycle intermediate, to human T-ALL cells was sufficient to rescue defects in cell viability caused by DLST inactivation. Together, our studies uncovered an important role for DLST in MYC-mediated leukemogenesis and demonstrated the metabolic dependence of T-lymphoblasts on the TCA cycle, thus providing implications for targeted therapy.

The influence of foster-home care on psychiatric patients.

Adult patients placed into foster families by six administrations in three provinces of Canada were oberved at time of placement and followed up 18 months later. Over this period, they exhibited a substantial decline in symptoms-almost as great as with similar patients retained in the hospital. However, there was virtually no improvement in social functioning, despite the fact that the use of foster homes has been advocated mainly for the resocialization that was expected to occur there. In discussing the reasons for this paradoxical finding, recommendations are offered regarding the use of foster homes by mental health administrations.

Incidence of venographically proved deep vein thrombosis after knee arthroscopy.

BACKGROUND: Deep vein thrombosis is a common, important complication of major orthopedic surgery, particularly knee arthroplasty. Knee arthroscopy is performed more frequently and in younger patients than knee arthroplasty. However, the true risk of deep vein thrombosis in patients who undergo this procedure is unknown. OBJECTIVE: To determine the incidence of deep vein thrombosis after knee arthroscopy in a large cohort of patients. METHODS: Consecutive patients scheduled for knee arthroscopy were eligible for the study. Enrolled study patients received no thromboprophylaxis. They were discharged home the day of surgery and underwent unilateral contrast venography approximately 1 week after their operation. The primary outcome measure was the incidence of venous thromboembolism. Risk factors for deep vein thrombosis were evaluated. RESULTS: Among the 184 patients who had adequate venography, deep vein thrombosis was detected in 33 (17.9%; 95% confidence interval, 12.7%-24.3%). Of these, 9 were proximal (4.9%; 95% confidence interval, 2.3%-9.1%). No patient died and no patient presented with clinically suspected pulmonary embolism. Of 33 patients, only 20 (60.6%) with deep vein thrombosis had symptoms while 13 (39.4%) were asymptomatic. The risk of deep vein thrombosis was significantly higher among patients who had a tourniquet applied for more than 60 minutes. CONCLUSIONS: The results of our study demonstrate that 17.9% of patients develop deep vein thrombosis after knee arthroscopy (most being either proximal or extensive). It is reasonable to perform a randomized trial to determine whether the incidence of deep vein thrombosis can be safely reduced in patients undergoing knee arthroscopy.

Prevention of deep vein thrombosis after major knee surgery--a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo.

Consecutive patients undergoing knee arthroplasty or tibial osteotomy at four participating hospitals received either enoxaparin, 30 mg subcutaneously every 12 h (n = 66) or an identical-appearing placebo (n = 65). All study medications started the morning after the operation and were continued up to a maximum of 14 days. Patients underwent surveillance with 125I-fibrinogen leg scanning and impedance plethysmography. Bilateral contrast venography was performed routinely at Day 14 or at time of discharge, if sooner. Deep vein thrombosis was detected by venography in 35 of 54 patients (65%) in the placebo group and in 8 of 41 patients in the enoxaparin group (19%), a risk reduction of 71%, P less than 0.0001. For the entire study group, deep vein thrombosis was detected by either venography of non-invasive tests in 37 of 64 patients (58%) in the placebo group and in 11 of 65 patients (17%) in the enoxaparin group, a risk reduction of 71%, P less than 0.0001. Proximal vein thrombosis was found in 19% of the placebo patients and in none of the enoxaparin patients, a risk reduction of 100%, P less than 0.001. Bleeding complications occurred in 5 of 65 patients (8%) in the placebo group and in 4 of 66 patients (6%) in the enoxaparin group, P = 0.71. There were no differences in the amount of blood loss, minimum hemoglobin levels and number of units of packed red cells given between the two treatment groups. We conclude that a fixed dose regimen of enoxaparin, started post-operatively, is an effective and safe regimen for reducing the frequency of deep vein thrombosis after major knee surgery.

Processes human umbilical veins as arterial substitutes--evaluation in canine models.

Human umbilical cord vein segments have been used as vessel substitutes for damaged or occluded arteries, as aorto-coronary by-passes and as arterio-venous fistulae for dialysis. The Dardik-Biograft fixed with glutaraldehyde and the Mindich-Bioflow, fixed with ethanol and dialdehyde starch, are commercially available. They were implanted in dogs as replacements for a segment of the abdominal aorta. Post-implantation status was followed by angiography. They were evaluated after removal from sacrificed animals with the aid of scanning electron microscopy and histological techniques. Attention was focused on vessel patency, dimensional stability, integrity of the anastomosis line, lumen wall microstructure, evidence of suture damage and thrombus deposition pattern. Both types of grafts gave functional by-passes for at least until 6 months post-implantation. The Dardik-Biograft appeared more prone to thrombus formation near the anastomosis. Sparse cellular development was also noted. The Mindich-Bioflow gave rise to a prosthesis of superior thromboresistance which was more subject to mechanical damage.

Treatment of vein of Galen aneurysmal malformation.

The authors report the case of a vein of Galen aneurysmal malformation in a 1-year-old baby presenting with an enlarging head. The lesion was a direct arteriovenous fistula in a dilated vein of Galen and was treated by complete embolization in one session. Four months after occlusion of the shunt, the ectatic vein of Galen and torcular were normal, and the head circumference had stabilized. This case serves as an opportunity to emphasize the quality of results that can be obtained with endovascular techniques. Proper analysis of the vein of Galen angioarchitecture allows planning for appropriate treatment with the lowest possible risk of morbidity and mortality.

Separated and divorced women compared with married controls. Selected life satisfaction, stress and health indices from a community survey.

A stratified sample of 31 French-Canadian and 33 English-Canadian separated or divorced (S/D) mothers and matched married controls were identified by telephone in four high-income census tracts of Montreal. The 128 women were home-interviewed by questionnaire which included extensive sections on health, stress and life satisfaction. It was predicted that modern S/D women with children would be better off as regards satisfaction, stress and health than pre-women's liberation era women, and that they would be as well or better off than the married controls. These hypotheses were supported only in part. The S/D were significantly worse off than the married in four areas (general life satisfaction, sexual satisfaction, self-esteem and use of professional therapists) and on almost all other health-stress measures, there were trends favouring the married. There were no significant differences or no trends favouring the S/D. Nonetheless, the S/D did appear to be considerably better off when compared with the picture of the S/D in the earlier literature. The greater frequency of depressions and greater use of therapists by the English-Canadian women was thought to reflect their weaker network of supportive relatives as well as the impact of recent political changes in Quebec.

Variations in plasma sodium concentration in post-operative patients depend on an electrolyte-free water balance, part of a tonicity balance.

BACKGROUND: There is an inverse relationship between changes in the concentration of sodium in plasma (PNa) and intracellular fluid (ICF) volume. Intakes and losses of sodium (Na), potassium (K) and water can be divided into two volumes: isotonic and electrolyte-free water (EFW). Calculations of these volumes assess a tonicity balance, a tonicity imbalance results in a change of PNa: when EFW is added to body fluids, PNa decreases. Moreover, the concept of EFW permits a good understanding of the renal contribution to the defence of body tonicity. PURPOSE: To illustrate that the measurement of a tonicity balance provides the best estimate of changes in PNa in an ICU setting. METHODS: Twenty-two patients were admitted to the Post-Operative Intensive Care Unit. We investigated how well changes in EFW balance correlated with PNa variations and what is the best formula to calculate EFW in this setting. RESULTS: PNa changes depend on EFW balance; there is no significant relationship with other classical factors such as urinary osmolality or Na-free water. CONCLUSION: The utility of a tonicity balance is demonstrated. A formula is derived facilitating at the bedside the prediction of changes in PNa following fluid therapy: PNa2 = [(PNa1.TBW) + balance (Na + K)]/[TBW + balance H2O]. PNa changes can be understood and/or modified exclusively by a careful measurement of intakes and losses of Na, K and water.

[Pheochromocytoma, first manifestation of Von Hippel-Lindau disease: a possibility to be considered]. / Phéochromocytome, première manifestation de la maladie de von Hippel-Lindau: une éventualité à connaître.

Von Hippel-Lindau (VHL) disorder is an autosomal dominant disease characterized by the almost constant development of hemangioblastomas in the central nervous system (cerebellum, spinal cord and retina). In addition, various types of tumors including renal cell carcinomas, pancreatic cysts and pheochromocytomas are frequently observed in VHL gene carriers. Linkage of the VHL locus to the RAF-1 oncogene on the short arm of chromosome 3 (3p25-26) has been recently reported. Pheochromocytoma is of particular interest because of the risk of inaugural malignant hypertensive crisis but especially because of a great degree of interfamily variability (from 0 to 92% of affected members in previously reported large kindreds). We have studied a French series of 25 pheochromocytoma (11 males, 14 females) in VHL affected patients. Twenty pheochromocytoma (80%) occurred in a familial context, whereas 5 (20%) were consistent with "apparent sporadic cases". The mean age at pheochromocytoma diagnosis was 27 years (5-55 years). Bilateral tumours have been documented in 13 cases (52%). The prevalence of pheochromocytoma revealing VHL was 14 out 25 (56%). In these cases, VHL diagnosis was considered up to 25 years later. In 6 cases (2 deceased) pheochromocytoma was the only manifestation of VHL. Thus, search for VHL must be systematic in the presence of pheochromocytoma, in the interest of the patients themselves and of potential at-risk family members (prevention of hypertensive crisis linked to latent tumours). Basic check-up (neurological and somatic examination, ophthalmoscopy, familial inquiry) may be completed with cerebral CT scan or MRI and abdominal ultrasonography followed, if positive or doubtful, by abdominal MRI or selective angiography.

[Pancytopenia in rheumatoid arthritis treated with methotrexate]. / Pancytopénies au cours de la polyarthrite rhumatoïde traitée par méthotrexate.

OBJECTIVES: Six cases of pancytopenia were analyzed retrospectively among 350 patients with rheumatoid arthritis treated with methotrexate. Pancytopenia is an uncommon but severe secondary effect of methotrexate. CASE REPORTS: Five patients were hospitalized for infectious complications or hemorrhage with favorable outcome. One patient died due to septic shock. There were risk factors in all 6 patients: 5 were over 65 years of age, creatinine clearance was under 50 ml/min in 4, hypoalbuminemia was found in 4 and methotrexate was combined with an antiinflammatory drug in 4 and with ranitidine in 2. The pharmacological imputability of methotrexate was probable in 4 of the 6 patients. DISCUSSION: Acute pancytopenia in patients treated with methotrexate can be prevented by recognizing risk factors, regular laboratory tests and supplementation of all patients with folic acid according to protocols to be established.

[Pubic symphysitis secondary to fistula. Physiopathological hypothesis]. / Symphysite pubienne secondaire à une fistule. Hypothèse physiopathologique.

Symphysitis of the pubis due to Streptococcus occurred after endoscopic resection of the prostate in a 69-year-old man. Despite a well conducted antibiotic regimen, signs persisted one year later and required arthrography that showed a prostato-symphysis fistula. This procedure might be used to find an explanation of certain persistent cases of symphysitis. Fistulization between the prostate and the pubic symphysis would be a new pathogenic hypothesis for symphysitis of the pubis.

[Evaluation of two commercial bovine vascular heterografts (author's transl)]. / Evaluation de deux hétérogreffes bovines commerciales pour le remplacement vasculaire.

Two commercially available grafts made from chemically modified bovine carotif arteries, Artegraft (Surgikos Corp. U.S.A.) and Solcograft (Solco A.G. Switzerland), were evaluated. Preliminary evaluation indicates that these products compare favorably with other more common chemically treated grafts of biological origin. Morphological characteristics, inflammatory response and thrombogenic potential were measured. Their structure suggest that each of the processes conserve the collagen morphology of the media and the adventitia originally present in the precursor arteries. Test implantations in dogs reveal a tendency to undergo stenosis near the anastomoses within a few months. After six months of in-vivo function, these grafts are not invaded with the expected neo-formed cells and new collagen in their central portion; this process takes place only near the anastomoses.

[Awake craniotomy. Considerations in special situations]. / Craneotomía en el paciente consciente. Consideraciones en situaciones especiales.

Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. In the past it was used for the surgical management of intractable epilepsy, but nowadays, its indications are increasing, and it is a widely recognized technique for the resection of mass lesions involving the eloquent cortex, and for deep brain stimulation. The procedure is safe, provides excellent results, and saves money and resources. The anesthesiologist should know the principles underlying neuroanesthesia, the technique of scalp blockade, and the sedation protocols, as well as feeling comfortable with advanced airway management. The main anesthetic aim is to keep patients cooperating when required (analgesia-based anesthesia). This review attempts to summarize the most recent evidence from the clinical literature, a long as the number of patients undergoing craniotomies in the awake state are increasing, specifically in the pediatric population.

The embryonic expression patterns of zebrafish genes encoding LysM-domains.

The function and structure of LysM-domain containing proteins are very diverse. Although some LysM domains are able to bind peptidoglycan or chitin type carbohydrates in bacteria, in fungi and in plants, the function(s) of vertebrate LysM domains and proteins remains largely unknown. In this study we have identified and annotated the six zebrafish genes of this family, which encode at least ten conceptual LysM-domain containing proteins. Two distinct sub-families called LysMD and OXR were identified and shown to be highly conserved across vertebrates. The detailed characterization of LysMD and OXR gene expression in zebrafish embryos showed that all the members of these sub-families are strongly expressed maternally and zygotically from the earliest stages of a vertebrate embryonic development. Moreover, the analysis of the spatio-temporal expression patterns, by whole mount and fluorescent in situ hybridizations, demonstrates pronounced LysMD and OXR gene expression in the zebrafish brain and nervous system during stages of larval development. None of the zebrafish LysMD or OXR genes was responsive to challenge with bacterial pathogens in embryo models of Salmonella and Mycobacterium infections. In addition, the expression patterns of the OXR genes were mapped in a zebrafish brain atlas.