The Italian Pain Questionnaire.

In order to overcome the cross-cultural semantic barriers related to the literal translation of the McGill Pain Questionnaire (MPQ) in non-English speaking areas, an Italian Pain Questionnaire (IPQ) has been developed, based on the 3 factorial structures proposed by Melzack and Torgerson: sensory, affective and evaluative. A group of 30 normal subjects (15 doctors and 15 university students) was used to define 5 anchor words of the intensity verbal scale by means of a visual analogue scale, and a 5-point Present Pain Intensity (PPI) verbal scale was derived. For the semantic key, a first group of 80 subjects (30 university students and patients, respectively, and 20 doctors) was asked to sort out appropriate pain descriptors from 203 pain-related words with the help of clinical literature and Italian dictionaries. Subsequently, a second group of 80 subjects (of identical structural composition) was asked to allocate the 56 words previously chosen on the basis of word frequencies (at least 45%) to the most appropriate category in the Italianized MPQ. Testees were then asked to assign an intensity value to each word, using a VAS scale. The final pain vocabulary was formed from those words, which reflected a statistically significant intensity change (P less than 0.05) within each group. The IPQ comprises 42 pain descriptors, distributed into 3 major classes (sensory, affective and evaluative) and 16 subclasses. It represents the most parsimonious, meaningful and idiomatic set of Italian pain descriptors, providing quantitative information that can be treated statistically, yet preserving a close structural parallel with the MPQ.

Doppler analysis of pulmonary venous flow in left atrial myxoma.

In a patient with obstructive left atrial myxoma, we analyzed by pulsed Doppler echocardiography the flow pattern through the mitral valve and in the pulmonary veins. Two mitral flow patterns were observed: the first was present near the medial commissure and along the anterior leaflet and was characterized by the absence of mid-to-late diastolic filling flow; the second was found near the lateral commissure and was characterized by the obstruction of mid-to-late diastolic filling flow, mimicking mitral stenosis. The pulmonary vein flow showed brief and rapidly decelerating anterograde diastolic flow wave and an early systolic retrograde flow wave. These waves were respectively related to the diastolic forward and the systolic backward movement of the tumor. This case report shows that pulmonary vein flow analysis may give new insights into left atrial filling and emptying dynamics in left atrial myxoma.

Intratympanic therapy for Ménière's disease. High-concentration gentamicin with round-window protection.

Many therapeutic options exist for the management of patients with Ménière's disease. In the last few years, the use of intratympanic gentamicin has been investigated as an alternative treatment to vestibular nerve section or labyrinthectomy. In humans, the concentration of gentamicin used for intratympanic treatment of vertigo ranges from 10 mg/mL to 40 mg/mL, and the number of doses from 2 to 14, with a total administered amount between 6 and 2.400 mg. Here lower doses of gentamicin were used, usually had the lowest incidence of hearing loss, but more injections were needed to ablate vestibular function. The purpose of this study was to evaluate the acute and chronic ototoxic effects of intratympanic high-concentration gentamicin after having obliterated the round-window niche with connective tissue in 11 subjects' ears with Ménière's disease. Intratympanic gentamicin was administered according to a predetermined and fixed schedule consisting of two doses of 0.5 mL gentamicin solution, injected once a week with a drug concentration of 80 mg/mL. The total dose of gentamicin was < or = 80 mg. The charts of the patients were surveyed in accordance with the 1995 AAO-HNS guidelines. Three patients had recurrence of vertigo between 3 and 6 months after the second injection and went on to one additional dose of gentamicin. At 2 years follow-up, 10 patients (91%) had complete and 1 (9%) substantial control of vertigo; 3 subjects (27%) had hearing decreased. Tinnitus disappeared or decreased in 3 patients (27%); eight subjects (73%) reported their aural pressure abolished or decreased. The present study demonstrates that in patients with Ménière's disease, 0.5 mL gentamicin solution, with a concentration of 80 mg/mL (total dose < or = 80 mg), injected intratympanically once a week after having obliterated the round-window niche, permits complete or substantial control of vertigo in two-thirds of cases after two doses and in all subjects after three doses. This vertigo control rate is compared to that observed after vestibular nerve section. Hearing results are not different from those with natural control, with endolymphatic sac surgery, and with vestibular nerve section.

Postoperative pain in neurosurgery: a pilot study in brain surgery.

The incidence, magnitude, and duration of acute pain experienced by neurosurgical patients after various brain operations are not precisely known, because of a lack of well-designed clinical and epidemiological studies. We assessed these important pain variables in 37 consecutive patients who underwent various brain neurosurgical procedures. Postoperative pain was more common than generally assumed (60%). In two-thirds of the patients with postoperative pain, the intensity was moderate to severe. Pain most frequently occurred within the first 48 hours after surgery, but a significant number of patients endured pain for longer periods. Pain was predominantly superficial (86%), suggesting somatic rather than visceral origin and possibly involving pericranial muscles and soft tissues. Subtemporal and suboccipital surgical routes yielded the highest incidence of postoperative pain. Age and sex were significantly associated with the onset of pain, with female and younger patients reporting higher percentages of postoperative pain. Psychological Minnesota Multiphasic Personality Inventory profiles of patients with and without pain significantly differed on the Hypochondriasis scale, with patients without pain scoring unexpectedly higher than patients with pain. It is possible that hypochondriasis serves as a defense mechanism against pain, at least in some patients. Results of this pilot study indicate that postoperative pain after brain surgery is an important, although neglected, clinical problem, that deserves greater attention by surgical teams, to provide better and more appropriate treatment.

Auriculotemporal syndrome (Frey's syndrome) presenting as tic douloureux. Report of two cases.

Two cases of auriculotemporal nerve syndrome (Frey's syndrome) presenting as trigeminal tic douloureux are reported. This condition, characterized by gustatory sweating and facial hyperemia, is occasionally associated with pain, which is usually described as aching or burning, and long-lasting. In these two cases, however, a tantalizing gustatory pain occurred in excruciating brief paroxysms. The pathophysiology of the syndrome, with particular reference to pain, and possible treatment modalities are discussed.

The current status of pain clinics in Italy: a questionnaire survey.

One hundred-eight questionnaires were mailed to Pain and Headache Centers evenly spread throughout Italy to evaluate the current status of pain clinics and therapy. Sixty-three centers (58.3%) responded: fifty-two (82.5%) were Pain Clinics, while eleven (17.5%) were Headache Clinics. Approximately half of the clinics were run by anesthesiologists (43.3%), followed by neurosurgeons (15%), and neurologists (10%). The Pain Team involved up to 26 members (average number: 7), with representatives from anesthesiologists (71.4%), psychologists and psychiatrists (52.4%), neurologists (36.5%), specialists in internal medicine (23.8%), and neurosurgeons (20.6%). The outpatient pain clinic made up the great majority of the respondents (80.9%), whereas the in-patient service for both emergency and elective pain treatment was available in twenty-six centers (41.3%). A total of 49.445 patients (average number: 810) were treated in a period of one year. Pain syndromes most frequently treated (mean incidence) were (a) cancer pain (39.0%); (b) chronic primary headache (37.3%); (c) non-oncologic extra-cephalic pain (37.0%); and (d) orofacial pain (17.2%). A multidisciplinary team approach was used by 65% of the respondents. Treatment modalities most frequently used were drugs (mean utilization index, MUI: 138), followed by anesthesiological methods (MUI: 70), neuroaugmentive procedures (MUI: 51), psychiatric and psychophysiological methods (MUI: 33), and neurosurgical procedures (MUI: 28). Mean percent immediate and long-term treatment successes (pain relief 50%) were the following: (a) cancer pain (74.7-63.3%): (b) non-oncologic pain (66.7-50.3%); (c) chronic primary headache (64.2-52.6%); and (d) orofacial pain (64.2-52.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Headache lateralization and functional cerebral asymmetry: a task-related EEG power spectrum analysis.

Clinical evidence shows that pain, particularly without organic lesions, tends to be more frequent on the left side of the body. Concomitantly, experimental data indicate that differential sensitivity for the right and left side, the pain threshold and tolerance being usually higher in the dominant than in the non-dominant side of the body. Headache laterality was investigated in 188 consecutive chronic headache patients. Headache was lateralized in approximately 50% of the cases, with an overall right predominance (59%). However, when descriptive diagnosis was taken into consideration, lateralized pain was predominant on the left side in psychogenic headache (p less than .01), whereas somatogenic headache was more often right-sited. Since pain lateralization can hardly be explained by peripheral factors, we assumed that reduced efficiency of the non-dominant side in processing several perceptual and cognitive activities could reflect asymmetry in cerebral organization. As differential engagement of the two hemispheres by appropriate tasks can be demonstrated with the EEG, we have studied 13 chronic headache patients with quantitative EEG analysis, compared with a control group of normal subjects (n = 7). The analysis of alpha-asymmetry, during analytical and spatial tasks, revealed that chronic headache patients showed a trend toward a relative activation of the right hemisphere during both tasks, independently of descriptive diagnosis, suggesting that chronic headache might be considered a "psychosomatic continuum". We postulate that pain perception may be biased by the reduced efficiency of the right hemisphere in sensory processing, so that the sensory message may be misinterpreted or amplified as painful by higher centers, even in absence of nociceptive stimuli.

Serotonin precursors in chronic primary headache. A double-blind cross-over study with L-5-hydroxytryptophan vs. placebo.

Serotonin (5-HT) plays a crucial role in mediating the descending pain inhibitory systems and in the pathophysiology of migraine. Previous studies regarding the use of 5-Hydroxytryptophan (5-HTP), the active precursor of 5-HT, in the treatment of Chronic Primary Headache (CPH) have been inconclusive so far. In order to assess the efficacy of the serotonin active precursor in chronic headache prophylaxis, a double-blind cross-over study has been carried out in 31 patients with CPH, comparing L-5-HTP to placebo. Clinical syndromes included: (a) migraine (16 patients); (b) mixed headache (6 patients); (c) psychogenic headache (5 patients); (d) muscle contraction headache (4 patients). L-5-HTP was administered for two months at daily doses of 400 mg p.o. The reduction in severity and frequency of headache in patients taking the active drug and placebo was noted. Mood patterns were also taken into consideration. L-5-HTP proved to be more effective than placebo in reducing both headache frequency and severity, but the difference was not statistically significant. Favourable responses (greater than 50% average reduction in headache symptoms) were obtained in 48% of the cases after the second month of treatment. No significant difference in therapeutic response was observed as related to different clinical syndromes, except for psychogenic headache patients, who responded poorly to the active drug. Side effects, experienced in 19% of the cases, were generally mild and transient. We conclude that L-5-HTP is a medication of moderate efficacy and remarkable safety, providing us with another alternative approach to CPH prophylaxis.

Chronic post-traumatic headache: clinical, psychopathological features and outcome determinants.

The epidemiological and clinical profile of Chronic Post-Traumatic Headache (CPTH) has been studied in 57 out of 130 consecutive patients hospitalized, following closed head injuries, at the Institute of Neurosurgery of the University of Milan. The incidence of CPTH has been 44%. Age of the patients ranged between 4 and 69 years. Clinical pictures included closed head injuries of different degree of severity: mild, moderate and severe. Time of onset, headache frequency, character, intensity, duration and associated symptoms showed a great degree of variability. However, chronic muscle contraction headache was the commonest clinical syndrome followed by migraine. Moderate correlations have been found between the severity of CPTH disturbance of consciousness, following the head trauma, and positive findings at CT scan. Moreover the comparison of personality profiles (MMPI) of CPTH (n=26) with a post-traumatic control group, without headache (n=17) showed higher scores on hypocondriasis, depression, hysteria and schizophrenia scales only in the severe CPTH group. Age of the patients, duration of unconsciousness, neurological deficits, course length and pending litigation or compensations were unrelated to the occurrence and outcome of CPTH. These findings suggest the importance of both physical and psychological determinants (social or emotional maladjustment) in the pathogenesis of CPTH.

CBF changes during headache-free periods and spontaneous/induced attacks in migraine with and without aura: a TCD and SPECT comparison study.

BACKGROUND: The aim of the present study was to compare cranial arteries blood flow velocity as measured by means of transcranial Doppler sonography (TCD) with mean regional cerebral blood flow (rCBF) as measured by means of single photon emission computed tomography (SPECT) in migraine with and without aura during headache-free periods and spontaneous and/or induced attacks. METHODS: Regional cerebral blood flow (rCBF) and systematic ultrasonic Doppler flow were studied by Technetium-99m hexamethylpropilaminoxime (99mTc-HM-PAO) single photon emission computed tomography (SPECT) and transcranial Doppler sonography (TCD) respectively in controls (n=14) and in migraine with (n=13) and without aura (n=35) during headache free-intervals and spontaneous/histamine-induced attacks. RESULTS: In the migraine without aura group, Doppler flow examinations of the common carotid artery, external and internal carotid artery, ophthalmic artery and middle cerebral artery bilaterally did not reveal significant changes as compared with controls. During attacks, TCD examinations showed a moderate, although not statistically significant, reduction of blood flow velocity in the middle cerebral artery and in the internal carotid artery bilaterally as related to the interictal phase, concomitant with an increase of the flow velocity in the ophthalmic and external carotid artery. SPECT of these patients did not show, on the average, rCBF asymmetries during pain-free periods, although positive findings (i.e., focal hypoperfusion) were found in approximately half of the cases. During attacks, 74% of patients displayed a unilateral hypoperfusion, mainly in the occipital region. Low-flow areas were generally but not always consistent with the site of pain. In the migraine with aura group, significant reduction of blood flow velocity in middle cerebral artery was recorded by TCD on the affected side during attacks, as compared with the pain-free side. Hypoperfusion was registered between attacks by SPECT in approximately 2/3 of the patients. During attacks, a marked reduction of rCBF occurred in most patients (85%), mainly in the parieto-occipital region. The posterior rCBF asymmetries revealed at the SPECT and consistent with the general reduction of blood flow velocity documented by TCD may be related to cerebrovascular tone instability. CONCLUSIONS: Our findings do not support the paradigm that migraine with and without aura are two different entities.

In vitro activity of acetylsalicylic acid on replication of varicella-zoster virus.

Topical application of a mixture of acetylsalicylic acid (ASA) and diethyl ether is effective in the treatment of acute herpes zoster and postherpetic neuralgia. To study whether the other-than-analgesic effects of that treatment could be due to an antiviral activity of ASA the effects of the drug on the replication of varicella zoster virus (VZV) were assessed by the fluorescent focus assay on MRC5 and Vero cells. ASA caused a marked reduction in the spread of infection in MRC5 monolayers while in growing Vero cells the effective dose proved toxic. ASA concentrations (5-10 mM) which were effective in vitro against VZV are higher than the plasma concentrations attained in the standard treatment of chronic inflammatory states, but are consistent with the skin concentration attained by topical application of ASA/diethyl ether mixture. These data support similar findings relating the antiviral activity of acetylsalicylic acid to influenza virus, CMV, and HIV.

Hypnosis and spasmodic torticollis--report of four cases: a brief communication.

Dystonia and particularly spasmodic torticollis are neuromuscular disorders that are extremely resistant to most therapies (physical, medical, or surgical). Torticollis is a unilateral spasm of the neck muscles, particularly of the sternocleidomastoid, that produces violent, tonic turning of the head to one side. The etiology remains uncertain, although the role of psychogenic factors has been emphasized. This article reviews the literature and reports four cases of spasmodic torticollis treated successfully with hypnosis. In all four cases, psychogenic causes were involved. Postural hypnosis (i.e., hypnosis in the standing position) was employed to counteract and minimize muscle spasms due to postural reflexes. A hypnobehavioral approach was adopted along with hypnotic strategies that included hierarchical desensitization, sensory-imaging conditioning, ego-boosting suggestions, and hypnosis-facilitated differential muscle retraining. In two cases, a combined hypnosis and electromyographic-biofeedback approach was used to equilibrate and retrain affected neck muscles. Although the hypnotherapeutic process took several months to induce and stabilize significant changes, outcome results were good to excellent in all cases, with marked reduction of the torticollis and the hypertrophy of the neck muscles as well as a reduced interference of symptoms in daily living.

[Herpetic vestibular neuronitis: a hypothesis]. / Neuronite vestibolare erpetica: un'ipotesi.

Abundant experimental research has shown the potentially damaging effects that the herpes simplex virus (HSV) may have on peripheral or central nervous pathways. Fifty subjects (ages 20-45) with labial herpes virus (HSV-1) and 15 (ages 25-35) with genital herpes virus (HSV-2) were studied through recording spontaneous and optokinetic nystagmus (OKN) and using the eye-tracking-test (ETT) by means of electronystagmography (ENG). Recording was carried out during the first two days after vesicular eruption and seven days later, when cutaneous manifestations had disappeared. Thirty-five of the 50 subjects with HSV-1 showed spontaneous nystagmus, frequently with a vertical component, which in most cases had disappeared by the seventh control day. We recorded qualitative alterations of OKN as well as ETT in 19 patients while in 3 subjects only ETT was abnormal. All the subjects were normal on the seventh control day. At no time did any of the patients with HSV-2 show objective signs involving the peripheral or central vestibular system. Our research shows that HSV infection, especially HSV-1 infection, determines subclinical alterations of the vestibular function, probably due to the involvement of the brainstem. Therefore the virus is to be taken into account in establishing the etiology of "unknown" vertigo.

SUNCT syndrome associated with cavernous angioma of the brain stem.

A 62-year-old male patient with 2 years of SUNCT syndrome is described. The patient presented with long-lasting periods of frequent attacks of intense orbital pain with a duration of about 1 min, associated with ipsilateral conjunctival injection, lacrimation and rhinorrhea. Cranial MRI and cerebral angiography demonstrated an ipsilateral cavernous angioma of the pons, involving the trigeminal roots. As the pain was refractory to most treatments, including carbamazepine, the patient asked for, and eventually underwent, direct surgical excision of the malformation. Following the operation, his neurological conditions rapidly deteriorated and he died of postoperative complications (haemorrhage).