Lidocaine 700 mg medicated plaster for post-herpetic neuralgia: focus on Quality of Life, effectiveness and safety - a retrospective observational study.

OBJECTIVE: Postherpetic neuralgia (PHN) is a neuropathic pain syndrome following herpes zoster (HZ) infection, characterized by pain that persists for months to years after the resolution of the HZ rash. Therapeutic management remains challenging for every clinician. We report the follow-up of patients diagnosed with PHN and treated with lidocaine 700 mg medicated plaster (LMP), focusing on effectiveness, safety, and Quality of Life (QoL). MATERIALS AND METHODS: This study is a retrospective observational investigation of patients with PHN treated with LMP. Patients were regularly followed for pain intensity, co-analgesic consumption, adverse effects, QoL using the EQ-5D, and patient satisfaction for 8 weeks. RESULTS: A total of 31 patients were evaluated. At enrollment, 18 patients (58.1%) were treated with at least one PHN concomitant medication, for which the number and dosing remained constant during the study. Patients had a mean average pain intensity of 6.5±1.0 at baseline, which decreased to 3.6±1.1 at week 4 and 2.8±0.9 at week 8. Four patients reported erythema, and one complained of vesicles eruption associated with pruritus. EQ-5D at weeks 4 and 8 of treatment showed persisting improvements in all domains except for the "anxiety/depression" domain. At week 8, <80% of patients reported to be satisfied or very satisfied. CONCLUSIONS: This study adds further weight to the growing body of clinical and research evidence that LMP treatment is effective and well-tolerated in patients with PHN.

Septic shock due to Escherichia coli meningoencephalitis treated with immunoglobulin-M-enriched immunoglobulin preparation as adjuvant therapy: a case report.

BACKGROUND: Gram-negative bacteria are an uncommon etiology of spontaneous community-acquired adult meningitis and meningoencephalitis. Escherichia coli is a Gram-negative bacterium that is normally present in the intestinal microbial pool. Some Escherichia coli strains can cause diseases in humans and animals, with both intestinal and extraintestinal manifestations (extraintestinal pathogenic Escherichia coli) such as urinary tract infections, bacteremia with sepsis, and, more rarely, meningitis. Meningitis continues to be an important cause of mortality throughout the world, despite progress in antimicrobial chemotherapy and supportive therapy. The mortality rate fluctuates between 15% and 40%, and about 50% of the survivors report neurological sequelae. The majority of Escherichia coli meningitis cases develop as a result of hematogenous spread, with higher degrees of bacteremia also being related to worse prognosis. Cases presenting with impaired consciousness (that is, coma) are also reported to have poorer outcomes. CASE PRESENTATION: We describe the case of a 48-year-old caucasian woman with meningoencephalitis, with a marked alteration of consciousness on admission, and septic shock secondary to pyelonephritis caused by Escherichia coli, treated with targeted antimicrobial therapy and immunoglobulin-M-enriched immunoglobulin (Pentaglobin) preparation as adjuvant therapy. CONCLUSION: Despite the dramatic presentation of the patient on admission, the conflicting data on the use of immunoglobulins in septic shock, and the lack of evidence regarding their use in adult Escherichia coli meningoencephalitis, we obtained a remarkable improvement of her clinical condition, accompanied by partial resolution of her neurological deficits.

Continuous intravenous low-dose diclofenac sodium to control a central fever after ischemic stroke in the intensive care unit: a case report and review of the literature.

INTRODUCTION: Elevation in body temperature within the first 24 hours of ischemic stroke is fairly common and known to be associated with worse outcomes. Only after thoroughly ruling out infection and the noninfectious etiologies and in the appropriate clinical setting should the diagnosis of central fever be made. Acetaminophen and nonsteroidal anti-inflammatory drugs are typical therapeutic options. External cooling is frequently used when pharmacologic interventions are inadequate. However, reports have suggested that neurogenic fevers are somewhat resistant to traditional pharmacologic therapies. CASE PRESENTATION: We describe a case of a Caucasian patient with central fever after ischemic stroke not responsive to acetaminophen administration and external cooling. After an initial bolus of diclofenac sodium (0.2 mg/kg in 100 ml of saline solution for 30 minutes), a continuous infusion (75 mg in 50 ml of saline solution) was started. After 5 days of treatment, the patient's body temperature was below 37.5 °C, and the diclofenac sodium infusion was stopped. CONCLUSIONS: We observed that a low-dose diclofenac sodium infusion was effective in treating fever without systemic side effects. This treatment may be suggested as an alternative to conventional antipyretic drugs, but additional clinical trials are required.

Opioids switching with transdermal systems in chronic cancer pain.

BACKGROUND: Due to tolerance development and adverse side effects, chronic pain patients frequently need to be switched to alternative opioid therapy OBJECTIVE: To assess the efficacy and tolerability of an alternative transdermally applied (TDS) opioid in patients with chronic cancer pain receiving insufficient analgesia using their present treatment. METHODS: A total of 32 patients received alternative opioid therapy, 16 were switched from buprenorphine to fentanyl and 16 were switched from fentanyl to buprenorphine. The dosage used was 50% of that indicated in equipotency conversion tables. Pain relief was assessed at weekly intervals for the next 3 weeks RESULTS: Pain relief as assessed by VAS, PPI, and PRI significantly improved (p < 0.0001) in all patients at all 3 follow up visits. After 3 weeks of treatment, the reduction in the mean VAS, PPI, and PRI scores in the fentanyl and buprenorphine groups was 68, 77, 74, and 69, 79, and 62%, respectively. Over the same time period the use of oral morphine as rescue medication was reduced from 27.5 +/- 20.5 (mean +/- SD) to 3.75 +/- 8.06, and 33.8 +/- 18.9 to 3.75 +/- 10.9 mg/day in the fentanyl and buprenorphine groups, respectively. There was no significant difference in either pain relief or rescue medication use between the two patient groups The number of patient with adverse events fell during the study. After the third week of the treatment the number of patients with constipation was reduced from 11 to 5, and 10 to 4 patients in the fentanyl and buprenorphine groups, respectively. There was a similar reduction in the incidence of nausea and vomiting. No sedation was seen in any patient after one week of treatment. CONCLUSION: Opioid switching at 50% of the calculated equianalgesic dose produced a significant reduction in pain levels and rescue medication. The incidence of side effects decreased and no new side effects were noted. Further studies are required to provide individualized treatment for patients according to their different types of cancer.

Pain and sensory dysfunction after breast cancer surgery: neurometer CPT evaluation.

The purpose of our study was to evaluate the presence of anatomical and functional damage to the afferent and sensorial fibres using the Neurometer CPT test. A questionnaire regarding pain was sent to 300 women who had undergone surgery six months earlier. Out of 300 patients 67 did not respond; 105 experienced no pain; while 128 felt pain. One hundred and twenty-eight women were divided into two groups: mastectomy with reconstruction and simple mastectomy. The intensity of pain at T0 in women with reconstruction was significantly higher; at T4, on the other hand, was lesser and there was no significant difference between the two groups. In both groups at T4, the daily diary revealed that interference with sleep and normal daily activities were more evident in patients who had undergone reconstruction (p > 0.001). The final results at T4 demonstrated that among patients with reconstruction, 47% showed slight hypoesthesia-paraesthesia in the breast, armpit and arm zones, 39% slight hypoesthesia in the same locations and 18% severe hypoesthesia. Patients with reconstruction, instead, showed different percentages: 75% showed slight hypoesthesia-paraesthesia, 16% a slight hypoesthesia and 9% severe hypoesthesia. Our results support the utilization of the Neurometer CPT test as a device for monitoring post-mastectomy pain.

Neurobiology of pain.

The neurobiology of pain had a notable interest in research focused on the study of neuronal plasticity development, nociceptors, molecular identity, signaling mechanism, ionic channels involved in the generation, modulation and propagation of action potential in all type of excitable cells. All the findings open the possibility for developing new therapeutic treatment. Nociceptive/inflammatory pain and neuropathic pain represent two different kinds of persistent chronic pain. We have reviewed the different mechanism suggested for the maintenance of pain, like descending nociceptive mechanism and their changes after tissue damage, including suppression and facilitation of defence behavior during pain. The role of these changes in inducing NMDA and AMPA receptors gene expression, after prolonged inflammation is emphasized by several authors. Furthermore, a relation between a persistent pain and amygdale has been shown. Molecular biology is the new frontier in the study of neurobiology of pain. Since the entire genome has been studied, we will able to find new genes involved in specific condition such as pain, because an altered gene expression can regulate neuronal activity after inflammation or tissue damage.

Severe traumatic brain injury: management and prognosis.

AIM: The aim of the study is to assess the efficacy of early treatment in severe traumatic brain injury by evaluating patients' survival and functional recovery. METHODS: We subdivided 184 patients into 2 groups (Group A: patients admitted to hospital within the first hour of injury; Group B: patients admitted after the first hour of injury). In order to maintain the mean arterial pressure (MAP) >90 with cerebral perfusion pressure (CPP) >70 mmHg, we used plasma expanders; in 76 patients with MAP >90 mmHg, we administered dopamine, and in 5 cases noradrenaline. In 157 patients we used mechanical ventilation (MV). For orotracheal intubation and sedation/analgesia, we administered: propofol (a bolus of 2 mg/kg+1 mg/kg/h)+midazolam (0.03 mg/kg/h) + cisatracurium besilate (0.2 mg/kg) in 113 patients, or thiopentone sodium (a bolus of 4 mg/kg + 1-2 mg/kg/h)+cisatracurium besilate (0.2 mg/kg) in 44 patients with endocranial hypertension without bleeding and convulsions. After muscle relaxation we administered remifentanyl (0.075 microg/kg/min). Surgical decompression was performed in 57 cases. Data were analysed with Student's t-test. RESULTS: The number of deaths was significantly lower in Group A (P<0.05): 9 patients from Group A and 21 patients from Group B died within 24 h (P<0.05), while 15 patients from Group A and 16 patients from Group B died after the first 24 h period. After the recovery of critical life functions, 53 patients from Group A and 34 patients from Group B were transferred to a medical ward (P<0.0001), while 15 patients from Group A and 21 patients from Group B were transferred to a rehabilitation facility (P<0.05). CONCLUSIONS: Prevention, early treatment of complications and maintenance of homeostasis lead to a better prognosis in terms of survival, functional recovery and to a reduction in economic and social costs.

Transdermal buprenorphine combined with spinal morphine and naropine for pain relief in chronic peripheral vasculopathy.

THE AIM: of this study was to evaluate the effectiveness and the safety of the association of buprenorphine transdermal delivery system (TDS) (Transtec TDS) and peridural infusion of morphine and naropine, for the control of ischemic pain in patients suffering from peripheral arteriopathy. The administration of an opioid, pure agonist, as morphine, with a partial agonist opioid, as the buprenorphine, was used. Buprenorphine has shown a higher liposolubility in supraspinal districts, while the morphine acts above all on the mu receptor subtype of the spinal cord. In this way it's possible a contemporary activation of spinal and supraspinal antinociceptive mechanisms. Furthermore, the incidence of side effects is reduced by buprenorphine, which antagonizes the central effect of morphine. In this study, 43 patients were recruited, suffering from chronic pain in Fontaine stage III-IV obstructive arteriopathy, scheduled for surgery. The patients have been divided into 2 equal groups for age, sex, pathology and intensity of pain. In the first group (TTDS), at first session, a buprenorphine patch 35 microg/h (Transtec TDS) has been applied, and after 24h, a peridural catheter with elastomeric system was positioned; 100 mL (2 mg/mL) of naropine and 2 mg of morphine, 4 mL/h in 24 h, were administered. In the second group (naropine morphine, NM), buprenorphine patch was not applied and analgesia was obtained only by using peridural catheter with elastomeric system at the same doses administered in the first group. At the daily control patients with visual analogical scale (VAS)=or>40 mm received an additional dose of morphine from 2 mg to 6+/-2 mg. VAS (0-100 mm) and the evaluation of the number of the hours of sleep were used to evaluate the analgesic effectiveness of the treatment. Side effects, opioid tolerance and abuse were always recorded. All parameters were evaluated daily for a period of 20+/-5 days. The results indicate that in group TTDS there was an improvement of pain symptomatology, also confirmed by the increased hours of sleep and the lower incidence of side effects. Instead in group NM, pain control was less effective, 18 patients needed a rescue dose of morphine, and the incidence of side effects increased.

Sedation in gynaecologic oncology day surgery.

Gynaecologic oncology day surgery deals primarily with the diagnosis of endometrial, cervical, vulvar and vaginal tumors. Conscious sedation is an important technique used in gynaecologic oncology day surgery. It is often associated with regional anaesthesia. The goals of conscious sedation are to provide effective pain control with complete safety, reduction of the recovery time, of the infection risk and cost. Since the consequences of the immunosuppressive effects of the opiates and the surgical stress could lead to an increased susceptibility to post-operative infections and a possible lack of immunological defence in the cancer patients, we investigated the possibility of eliminating the administration of opiates during minor operations in gynaecologic oncology day surgery. In this study, 400 patients, aged between 35 and 77 years, underwent surgery using sedation at the day hospital annexed to the Gynaecology and Obstetrics Department of the 2nd University of Naples, Italy. The patients were randomized into two equal study groups, according to a computer-generated randomised list. All patients were seen by the consultant anaesthetist three days before surgery. In all cases, during surgery, we monitored the main vital parameters such as ECG, HR and RR, BT, BP and SO. The drugs commonly used were: opioids, hypnotics and benzodiazepines, associated or not, with local anaesthetics. By using these drugs, pain and anxiety were reduced, sedation and amnesia were accomplished. In our experience, conscious sedation seems to be the best choice in gynaecologic oncology day surgery because it presents low toxicity, is short acting and readily reversible, has a low cost and, finally, because it is more comfortable for the patients. Moreover, it is possible to eliminate the administration of opiates during conscious sedation for less invasive surgical procedures.

[Vector cardiography features of right ventricular activation delays: nosologic classification and clinical correlation]. / La vettorcardiografia nei ritardi di attivazione ventricolare destra: inquadramento nosologico e correlazione clinica.

Electrovectorcardiographic features of 150 patients showing right ventricular activation delays (RVAD) has been analyzed. This analysis of RAVD, especially for type I, which is the group with the widest morphologic variability, has permitted a more detailed classification: a type I with 5 subtypes, a type II with 1 subtype, a type III and an intermediate type between type II and III. Fifty-five per cent of the patients were included in type I and its variant and most were classified, often without cardiac disease, as belonging to the classic type I. Thirty per cent of RVAD were of type II; 12% of type III and the remaining were in the intermediate group between type II and III. The various morphologies, moreover, were correlated with the clinical picture: the classic type I was never seen in subjects with cardiac disease, while the others types and subtypes were present either in subjects with cardiac disease or in elderly subjects, also without relevant pathologies (senile heart, especially, the type IA") or in otherwise healthy subjects. In a medical-social context, checking for RVAD, in the absence of cardiac disease, might usefully avoid further investigation. It is underlined the usefulness of this correlation for clinical prognostic judgement.