Lesión electromiográfica del nervio axilar en fracturas del extremo proximal del húmero. Estudio prospectivo, observacional, analizando el patrón de fractura / Electromyographic axillary nerve injury in fractures of the proximal humerus: Prospective, observational study, analysing the fracture pattern

Objetivo: Descripción y análisis de la relación entre las fracturas de húmero proximal y la lesión traumática del nervio axilar circunflejo. Material y método: Estudio prospectivo, observacional, de una serie de casos consecutivos de fracturas de extremo proximal de húmero. Se realizó valoración radiográfica, clasificando las fracturas según el sistema AO (Arbeitsgemeinshaft für Osteosynsthesefragen, Asociación de Grupo de Trabajo para el Estudio de la Fijación Interna de las Fracturas), y electromiografía (EMG) para la evaluación de la lesión del nervio axilar. Resultados: De 105 casos consecutivos de fracturas de húmero proximal, 31 pacientes cumplían los criterios de inclusión. Muestra: 86% mujeres y 14% hombres con edad media de 71,8 años (30-96 años). De los pacientes incluidos en el estudio, 58% presentó una EMG normal o leve axonotmesis, 23% presentó neuropatía del nervio axilar sin denervación muscular y 19%, lesión con denervación del nervio axilar. Los pacientes que sufrieron fracturas complejas de húmero proximal (AO11B y AO11C) tuvieron más riesgo de presentar lesiones tipo neuropatía axilar con denervación muscular en la EMG, siendo esta relación estadísticamente significativa (p < 0,001). Conclusiones: Los pacientes que sufren fracturas complejas de húmero proximal (AO11B y AO11C) tienen más riesgo de presentar lesiones tipo neuropatía axilar con denervación muscular en la EMG (p < 0,001).(AU)

Objective: Description and analysis of the relation between the proximal humerus fracture patterns and the traumatic injury of the axillary nerve. Material and method: Prospective, observational study of a consecutive case series that analyzed proximal humerus fractures. Radiographic evaluation was performed, and AO (Arbeitsgemeinshaft für Osteosynsthesefragen) system was used to classify the fractures. Electromyography was used to diagnose the axillary nerve injury. Results: Thirty-one patients on 105 who had a proximal humerus fracture met inclusion criteria. Eighty-six percent of the patients included were women and 14% men. The mean age was 71.8 years (30–96 years). Of the patients included in the study, 58% had normal or mild axonotmesis EMG, 23% had axillary nerve neuropathy without muscle denervation and 19% had injury with axillary nerve denervation. Patients who suffered complex fractures of the proximal humerus (AO11B and AO11C) had a higher risk of presenting axillary neuropathy type lesions with muscle denervation in the EMG, this relationship being statistically significant (p<0.001). Conclusion: Patients who have more risk on presenting axillary nerve neuropathy with muscle denervation in electromyography are those who present complex proximal humerus fractures AO11B and AO11C (p<0.001).(AU)

[Translated article] Electromyographic axillary nerve injury in fractures of the proximal humerus: Prospective, observational study, analysing the fracture pattern / Lesión electromiográfica del nervio axilar en fracturas del extremo proximal del húmero. Estudio prospectivo, observacional, analizando el patrón de fractura

Objetivo: Descripción y análisis de la relación entre las fracturas de húmero proximal y la lesión traumática del nervio axilar circunflejo. Material y método: Estudio prospectivo, observacional, de una serie de casos consecutivos de fracturas de extremo proximal de húmero. Se realizó valoración radiográfica, clasificando las fracturas según el sistema AO (Arbeitsgemeinshaft für Osteosynsthesefragen, Asociación de Grupo de Trabajo para el Estudio de la Fijación Interna de las Fracturas), y electromiografía (EMG) para la evaluación de la lesión del nervio axilar. Resultados: De 105 casos consecutivos de fracturas de húmero proximal, 31 pacientes cumplían los criterios de inclusión. Muestra: 86% mujeres y 14% hombres con edad media de 71,8 años (30-96 años). De los pacientes incluidos en el estudio, 58% presentó una EMG normal o leve axonotmesis, 23% presentó neuropatía del nervio axilar sin denervación muscular y 19%, lesión con denervación del nervio axilar. Los pacientes que sufrieron fracturas complejas de húmero proximal (AO11B y AO11C) tuvieron más riesgo de presentar lesiones tipo neuropatía axilar con denervación muscular en la EMG, siendo esta relación estadísticamente significativa (p < 0,001). Conclusiones: Los pacientes que sufren fracturas complejas de húmero proximal (AO11B y AO11C) tienen más riesgo de presentar lesiones tipo neuropatía axilar con denervación muscular en la EMG (p < 0,001).(AU)

Objective: Description and analysis of the relation between the proximal humerus fracture patterns and the traumatic injury of the axillary nerve. Material and method: Prospective, observational study of a consecutive case series that analyzed proximal humerus fractures. Radiographic evaluation was performed, and AO (Arbeitsgemeinshaft für Osteosynsthesefragen) system was used to classify the fractures. Electromyography was used to diagnose the axillary nerve injury. Results: Thirty-one patients on 105 who had a proximal humerus fracture met inclusion criteria. Eighty-six percent of the patients included were women and 14% men. The mean age was 71.8 years (30–96 years). Of the patients included in the study, 58% had normal or mild axonotmesis EMG, 23% had axillary nerve neuropathy without muscle denervation and 19% had injury with axillary nerve denervation. Patients who suffered complex fractures of the proximal humerus (AO11B and AO11C) had a higher risk of presenting axillary neuropathy type lesions with muscle denervation in the EMG, this relationship being statistically significant (p<0.001). Conclusion: Patients who have more risk on presenting axillary nerve neuropathy with muscle denervation in electromyography are those who present complex proximal humerus fractures AO11B and AO11C (p<0.001).(AU)

[Translated article] Electromyographic axillary nerve injury in fractures of the proximal humerus: Prospective, observational study, analysing the fracture pattern.

OBJECTIVE: Description and analysis of the relation between the proximal humerus fracture patterns and the traumatic injury of the axillary nerve. MATERIAL AND METHOD: Prospective, observational study of a consecutive case series that analysed proximal humerus fractures. Radiographic evaluation was performed, and AO (Arbeitsgemeinshaft für Osteosynsthesefragen) system was used to classify the fractures. Electromyography was used to diagnose the axillary nerve injury. RESULTS: Thirty-one patients on 105 who had a proximal humerus fracture met inclusion criteria. Eighty-six percent of the patients included were women and 14% men. The mean age was 71.8 years (30-96 years). Of the patients included in the study, 58% had normal or mild axonotmesis EMG, 23% had axillary nerve neuropathy without muscle denervation and 19% had injury with axillary nerve denervation. Patients who suffered complex fractures of the proximal humerus (AO11B and AO11C) had a higher risk of presenting axillary neuropathy type lesions with muscle denervation in the EMG, this relationship being statistically significant (p<0.001). CONCLUSION: Patients who have more risk on presenting axillary nerve neuropathy with muscle denervation in electromyography are those who present complex proximal humerus fractures AO11B and AO11C (p<0.001).

Modulation of the spinal N13 SEP component by high- and low-frequency electrical stimulation. Experimental pain models matter.

OBJECTIVE: The N13 component of somatosensory evoked potential (N13 SEP) represents the segmental response of cervical dorsal horn neurons. Neurophysiological studies in healthy participants showed that capsaicin-induced central sensitization causes an increase of the N13 SEP amplitude. Consequently, in human research, this spinal component may serve as a valuable readout of central sensitization. In this study, we wanted to verify if the sensitivity of the N13 SEP for detecting central sensitization is consistent across different experimental pain models inducing central sensitization and secondary hyperalgesia, namely high and low-frequency electrical stimulation (HFS and LFS). METHODS: In 18 healthy participants, we recorded SEP after bilateral ulnar nerve stimulation before and after secondary hyperalgesia was induced through HFS and LFS applied on the ulnar nerve territory of the hand of one side. The area of secondary hyperalgesia was mapped with a calibrated 128-mN pinprick probe, and the mechanical pain sensitivity with three calibrated 16-64-256-mN pinprick probes. RESULTS: Although both HFS and LFS successfully induced secondary hyperalgesia only LFS increased the amplitude of the N13 SEP. CONCLUSIONS: These findings suggest that the sensitivity of the N13 SEP for detecting dorsal horn excitability changes may critically depend on the different experimental pain models. SIGNIFICANCE: Our results indicate that LFS and HFS could trigger central sensitization at the dorsal horn level through distinct mechanisms, however this still needs confirmation by replication studies.

Electromyographic axillary nerve injury in fractures of the proximal humerus: Prospective, observational study, analysing the fracture pattern. / Lesión electromiográfica del nervio axilar en fracturas del extremo proximal del húmero. Estudio prospectivo, observacional, analizando el patrón de fractura.

OBJECTIVE: Description and analysis of the relation between the proximal humerus fracture patterns and the traumatic injury of the axillary nerve. MATERIAL AND METHOD: Prospective, observational study of a consecutive case series that analyzed proximal humerus fractures. Radiographic evaluation was performed, and AO (Arbeitsgemeinshaft für Osteosynsthesefragen) system was used to classify the fractures. Electromyography was used to diagnose the axillary nerve injury. RESULTS: Thirty-one patients on 105 who had a proximal humerus fracture met inclusion criteria. Eighty-six percent of the patients included were women and 14% men. The mean age was 71.8 years (30-96 years). Of the patients included in the study, 58% had normal or mild axonotmesis EMG, 23% had axillary nerve neuropathy without muscle denervation and 19% had injury with axillary nerve denervation. Patients who suffered complex fractures of the proximal humerus (AO11B and AO11C) had a higher risk of presenting axillary neuropathy type lesions with muscle denervation in the EMG, this relationship being statistically significant (p<0.001). CONCLUSION: Patients who have more risk on presenting axillary nerve neuropathy with muscle denervation in electromyography are those who present complex proximal humerus fractures AO11B and AO11C (p<0.001).

Modulation of the N13 component of the somatosensory evoked potentials in an experimental model of central sensitization in humans.

The N13 component of somatosensory evoked potential (N13 SEP) represents the segmental response of dorsal horn neurons. In this neurophysiological study, we aimed to verify whether N13 SEP might reflect excitability changes of dorsal horn neurons during central sensitization. In 22 healthy participants, we investigated how central sensitization induced by application of topical capsaicin to the ulnar nerve territory of the hand dorsum modulated N13 SEP elicited by ulnar nerve stimulation. Using a double-blind placebo-controlled crossover design, we also tested whether pregabalin, an analgesic drug with proven efficacy on the dorsal horn, influenced capsaicin-induced N13 SEP modulation. Topical application of capsaicin produced an area of secondary mechanical hyperalgesia, a sign of central sensitization, and increased the N13 SEP amplitude but not the peripheral N9 nor the cortical N20-P25 amplitude. This increase in N13 SEP amplitude paralleled the mechanical hyperalgesia and persisted for 120 min. Pregabalin prevented the N13 SEP modulation associated with capsaicin-induced central sensitization, whereas capsaicin application still increased N13 SEP amplitude in the placebo treatment session. Our neurophysiological study showed that capsaicin application specifically modulates N13 SEP and that this modulation is prevented by pregabalin, thus suggesting that N13 SEP may reflect changes in dorsal horn excitability and represent a useful biomarker of central sensitization in human studies.

How different experimental models of secondary hyperalgesia change the nociceptive flexion reflex.

OBJECTIVE: In this neurophysiological study in healthy humans, we assessed how central sensitization induced by either high-frequency stimulation (HFS) or topical capsaicin application modulates features of the RIII reflex response. The ability of these stimuli to engage the endogenous pain modulatory system was also tested. METHODS: In 26 healthy participants we elicited an RIII reflex using suprathreshold stimulation of the sural nerve. Subsequently HFS or capsaicin were applied to the foot and the RIII reflex repeated after 15 minutes. Contact heating of the volar forearm served as the heterotopic test stimulus to probe activation of the endogenous pain modulatory system. RESULTS: HFS significantly reduced the pain threshold by 29% and the RIII reflex threshold by 20%. Capsaicin significantly reduced the pain threshold by 17% and the RIII reflex threshold by 18%. Both HFS and capsaicin left RIII reflex size unaffected. Numerical Rating Scale (NRS) pain scores elicited by the heterotopic noxious heat stimulus were unaffected by capsaicin and slightly increased by HFS. CONCLUSIONS: HFS and capsaicin similarly modulated the pain threshold and RIII reflex threshold, without a concomitant inhibitory effect of the endogenous pain modulatory system. SIGNIFICANCE: Our neurophysiological study supports the use of the RIII reflex in investigating central sensitization in humans.

Microbiological assessment of arterial allografts processed in a tissue bank.

The transmission of microbial infection through tissue allografts is one of the main risks that must be controlled in tissue banks. Therefore, microbiological monitoring controls and validated protocols for the decontamination of tissues during processing have been implemented. This study is based on the evaluation of data from microbiological cultures of arteries (mainly long peripheral arteries) processed in the tissue bank of Valencia (Spain). Donors' profile, pre- and post-disinfection tissue samples were assessed. The presence of residual antibiotics in disinfected tissues was determined and the antimicrobial potential of these tissues was tested. Our overall contamination rate was 23.69%, with a disinfection rate (after antibiotic incubation) of 87.5%. Most (76.09%) of the microbial contaminants were identified as Gram positive. Arterial allografts collected from body sites affected by prior organ removal showed higher risk of contamination. Only vancomycin was detected as tissue release. The antimicrobial effect on Candida albicans was lower than that for bacterial species. Risk assessment for microbial contamination suggested the donor's skin and the environment during tissue collection as the main sources for allograft contamination. Antibiotic-disinfected arterial allografts showed antimicrobial potential.

Theta-burst versus 20 Hz repetitive transcranial magnetic stimulation in neuropathic pain: A head-to-head comparison.

OBJECTIVE: High-frequency repetitive transcranial magnetic stimulation (rTMS) has been shown to reduce neuropathic pain, but intermittent "theta-burst" stimulation (iTBS) could be a better alternative because of shorter duration and greater ability to induce cortical plasticity. Here we compared head-to-head the pain-relieving efficacy of the two modalities when applied daily for 5 days to patients with neuropathic pain. METHODS: Forty-six patients received 20 Hz-rTMS and/or iTBS protocols and 39 of them underwent the full two procedures in a random cross-over design. They rated pain intensity, sleep quality, fatigue and general health status daily during 5 consecutive weeks. RESULTS: Pain relief during the month following stimulation was superior after 20 Hz-rTMS relative to iTBS (F(1,38) = 4.645; p = 0.037). Correlation between respective levels of maximal relief showed a significant deviation toward the 20 Hz-rTMS effect. A greater proportion of individuals responded to 20 Hz-rTMS (52% vs 32%, 95 %CI[0.095-3.27]; p = 0.06), and reports of fatigue significantly improved after 20 Hz-rTMS relative to iTBS (p = 0.01). General health and sleep quality scores did not differentiate both techniques. CONCLUSIONS: High-frequency rTMS appeared superior to iTBS for neuropathic pain relief. SIGNIFICANCE: Adequate matching between the oscillatory activity of motor cortex and that of rTMS may increase synaptic efficacy, thus enhancing functional connectivity of motor cortex with distant structures involved in pain regulation.

Brain activity sustaining the modulation of pain by empathetic comments.

Empathetic verbal feedback from others has been shown to alleviate the intensity of experimental pain. To investigate the brain changes associated with this effect, we conducted 3T-fMRI measurements in 30 healthy subjects who received painful thermal stimuli on their left hand while overhearing empathetic, neutral or unempathetic comments, supposedly made by experimenters, via headsets. Only the empathetic comments significantly reduced pain intensity ratings. A whole-brain BOLD analysis revealed that both Empathetic and Unempathetic conditions significantly increased the activation of the right anterior insular and posterior parietal cortices to pain stimuli, while activations in the posterior cingulate cortex and precuneus (PCC/Prec) were significantly stronger during Empathetic compared to Unempathetic condition. BOLD activity increased in the DLPFC in the Empathetic condition and decreased in the PCC/Prec and vmPFC in the Unempathetic condition. In the Empathetic condition only, functional connectivity increased significantly between the vmPFC and the insular cortex. These results suggest that modulation of pain perception by empathetic feedback involves a set of high-order brain regions associated with autobiographical memories and self-awareness, and relies on interactions between such supra-modal structures and key nodes of the pain system.

Prison infrastructure, the right to health and a suitable environment for the inmates of the Women's Annex in Chorrillos Prison (Peru).

OBJECTIVES: Decide how prison infrastructure guarantees health's right a suitable environment of Establecimiento Penitenciario Anexo de Mujeres de Chorrillos (EPAMCh) prisoners. MATERIAL AND METHOD: For the materials was used an interview guide addressed to 10 specialist and interview guide addressed to 30 prisoners. About the method, it was selected the qualitative approach, the applied type with the phenomenological design. RESULTS: The interview experts said that Establecimiento Penitenciario Anexo de Mujeres de Chorrillos current infrastructure and don´t give minima sanitary services. In the polls, the prisoners unanimously answered that conditions were precarious, but mostly said that they were willing to incorporate to a health education program and bet for a preventive medicine without forget the curative. DISCUSSION: Is Important foment the preventive medicine in order to get a strong health education in jails. To reverse this reality would mean change a guarantee in their health rights and a suitable environment.

Electrophysiology in diagnosis and management of neuropathic pain.

Electrophysiological techniques demonstrate abnormalities in somatosensory transmission, hence providing objective evidence of 'somatosensory lesion or disease' which is crucial to the diagnosis of neuropathic pain (NP). Since most instances of NP result from damage to thermo-nociceptive pathways (thin fibres and spino-thalamo-cortical systems), specific activation of these is critical to ensure diagnostic accuracy. This is currently achieved using laser pulses or contact heat stimuli, and in a near future probably also with contact cold and intra-epidermal low-intensity currents. Standard electrical stimuli, although of lesser diagnostic yield, are useful when large and small fibres are affected together. Nociceptive evoked potentials to laser (LEPs) and contact heat (CHEPs) have shown adequate sensitivity and specificity to be of clinical use in the differential diagnosis of NP, in conditions involving Aδ of C-fibres and spino-thalamo-cortical pathways. LEPs have also a role in the detection of patients at risk of developing central post-stroke pain after brainstem, thalamic or cortical injury. Cognitive cortical responses and autonomic reactions (sympathetic skin responses) reflect pain-related arousal and can document objectively positive symptoms such as allodynia and hyperalgesia. They are of help in the differential diagnosis of somatisation disorders, by discriminating conscious simulation (malingering) from conversive sensory loss. The electrophysiological approach to patients suspected, or at risk, of NP is a cost-effective procedure that should never be absent in the diagnostic armamentarium of pain clinics.

Infraestructura penitenciaria, los derechos a la salud y a un ambiente adecuado de las internas del Establecimiento Penitenciario Anexo de Mujeres de Chorrillos (Perú) / Prison infrastructure, the right to health and a suitable environment for the inmates of the Women's Annex in Chorrillos Prison (Peru)

Objetivos: Determinar cómo la infraestructura penitenciaria garantiza los derechos a la salud y a un ambiente adecuado de las internas del Establecimiento Penitenciario Anexo de Mujeres de Chorrillos (EPAMCh). Material y método: En cuanto a los materiales, se empleó una guía de entrevista dirigida a 10 especialistas en la materia y una guía de encuesta destinada a 30 internas. Por lo que se refiere al método, se seleccionó el enfoque cualitativo de tipo aplicado y un diseño fenomenológico. Resultados: Los expertos en la entrevista afirmaron en su mayoría que la infraestructura actual en el Establecimiento Penitenciario Anexo de Mujeres de Chorrillos no permite prestar los servicios sanitarios mínimos. Por otro lado, en la encuesta, de modo unánime, las internas respondieron que las condiciones son precarias, pero mayoritariamente manifestaron su disposición a incorporarse a un programa educativo sanitario y a apostar por la medicina preventiva sin prescindir de la curativa. Discusión: Es importante fomentar la medicina preventiva. Para ello, es necesario nivelar el grado de instrucción de las internas y conseguir una sólida educación sanitaria. Revertir esta realidad significaría un cambio en la garantía de sus derechos a la salud y de sus derechos a un ambiente adecuado

Objective: To determine how the prison infrastructure can guarantee health rights and an adequate environment for inmates at the Women's Annex of Chorrillos Prison (EPAMCh. Material and method: The materials consisted of a guided interview conducted with 10 specialists on the subject and a guided survey completed by 30 inmates. The method consisted of an applied qualitative approach with a phenomenological design. Results: The experts interviewed said that the current infrastructure of the Women's Annex of Chorrillos Prison is in a state of crisis and does not provide even minimal healthcare services. The surveys completed by the prisoners gave the unanimous response that conditions were precarious, but the majority said that they were willing to form part of a health education program and to commit to preventive medicine without forgetting curative methods. Discussion: Preventive medicine must be promoted. To do this, prisoners' educational levels need to be improved and solid health education systems in prisons should be provided. Changes would need to be made in the guarantees of their rights to health and to adequate surroundings to bring about the necessary changes

Programa de ahorro de sangre en cirugía cardiaca: resultados / Patient blood management in cardiac surgery: Results

Objetivo: El objetivo principal del estudio fue valorar la repercusión de la implantación de un programa de ahorro de sangre en pacientes intervenidos mediante cirugía cardiaca programada con el análisis de la tasa transfusional y las complicaciones. Materiales y métodos: Estudio unicéntrico, observacional, retrospectivo, comparativo que incluyó a 604 pacientes mayores de 15 años consecutivos intervenidos mediante cirugía cardiaca programada. Se analizaron 2grupos de pacientes establecidos por la aplicación o no de un programa de ahorro de sangre entre diciembre de 2012 y julio de 2013 (293 pacientes, grupo prep) y entre abril de 2015 y mayo de 2016 (311 pacientes, grupo posp). Resultados: Disminuyó la tasa transfusional global de componentes sanguíneos en el grupo posp (89,5 vs. 67,6%; p<0,001) y de manera individual: concentrados de hematíes (83,6 vs. 56,4%; p <0,001), plasma fresco congelado (36,2 vs. 21,2%; p <0,001), plaquetas (40,8 vs. 32,7%; p <0,001); por el contrario, aumentó el uso de fibrinógeno (16,4 vs. 49%; p <0,001). Las complicaciones postoperatorias fueron similares en ambos grupos, salvo las pulmonares, que disminuyeron (57,8 vs. 43,1%; p <0,001). La estancia hospitalaria fue similar en ambos grupos, excepto en la Unidad de Reanimación, con más días en el grupo prep (5,81±8,00 vs. 4,18±4,38; p=0,002). La mortalidad no presentó cambios. Conclusiones: La implantación de los programas de ahorro de sangre en el Área de Cirugía Cardiaca tiene consecuencias favorables como el ahorro de componentes sanguíneos y la disminución de complicaciones pulmonares, aunque sin consecuencias en la disminución de la mortalidad

Objective: The main objective of the study was to evaluate the effect of implementing a blood-saving programme in patients undergoing elective cardiac surgery with an analysis of the transfusion rate and complications. Materials and methods: A single-centre, observational, retrospective, comparative study which included 604 consecutive patients older than 15 years old undergoing elective cardiac surgery. Two groups of patients were created according to whether or not they were included in a blood-saving protocol, and analysed between December 2012 and July 2013 (293 patients, prep group) and April 2015 to May 2016 (311 patients, posp group). Results: The overall blood product transfusion rate was reduced in the posp group (89.5 vs. 67.6%; P<0.001), as well as individually: red blood cell concentrates (83.6%; P<0.001), fresh frozen plasma (36.2 vs. 21.2%; P<0.001), platelets (40.8 vs. 32.7; P<0.001). By contrast, fibrinogen use increased from 16.4 to 49% (P<0.001). Postoperative complications were similar in both groups, except for pulmonary complications (57.8 vs. 43.1%; P<0.001). Length of hospital stay was similar in both groups except in the Critical Care Unit with longer stay for the prep group (5.81±8.00 vs. 4.18±4.38; P=0.002). Mortality did not change. Conclusions: The implementation of a blood-saving programme in the cardiac surgery area has favourable consequences, such as a saving in blood product and a reduction of pulmonary complications, although without decreasing the mortality rate

Randomized double-blind controlled study of bedtime low-dose amitriptyline in chronic neck pain.

BACKGROUND: Amitriptyline has well-established efficacy in several chronic pain conditions. While optimal treatment for chronic neck pain (CNP) remains controversial, amitriptyline was not tested for CNP. We evaluated the effect of bedtime amitriptyline in the management of CNP. METHODS: A total of 220 patients suffering from idiopathic CNP were randomized to receive either placebo pill (n = 108) or 5 mg of amitriptyline (n = 112) at bedtime for 2 months. Primary outcome measure was visual analog scale (VAS) for pain. Secondary outcome measures were neck pain disability index (NPDI), Bergen Insomnia Score (BIS) and Hospital Anxiety and Depression Scale (HAD), measured before and at the end of 2 months of treatment, with the percentage of patient satisfaction measured at the end of follow-up only. RESULTS: Eight of 112 patients (7.14%) in the amitriptyline group withdrew from the study because of intolerance. Amitriptyline group showed significantly lower VAS scores than placebo group (3.34 ± 1.45 vs. 6.12 ± 0.92; p < 0.0001), which corresponds to a 53.06 ± 20.29% of improvement from baseline pain as compared to 14.41 ± 11.05%, respectively (p < 0.0001). Similar significant improvements were observed with lesser extents for secondary outcome measures: NPDI, BIS, HAD-A, HAD-D and percentage of patient satisfaction. CONCLUSION: Low-dose amitriptyline is effective for the management of idiopathic CNP with few side effects and high patients' satisfaction. SIGNIFICANCE: This randomized controlled trial is the first to show the effectiveness and tolerance of a medication, low-dose amitriptyline, in managing idiopathic chronic neck pain and its related comorbidities. The optimal treatment of this condition was still controversial in the literature. It extends the indication of low-dose amitriptyline to another chronic pain condition.

Patient blood management in cardiac surgery: Results. / Programa de ahorro de sangre en cirugía cardiaca: resultados.

OBJECTIVE: The main objective of the study was to evaluate the effect of implementing a blood-saving programme in patients undergoing elective cardiac surgery with an analysis of the transfusion rate and complications. MATERIALS AND METHODS: A single-centre, observational, retrospective, comparative study which included 604 consecutive patients older than 15 years old undergoing elective cardiac surgery. Two groups of patients were created according to whether or not they were included in a blood-saving protocol, and analysed between December 2012 and July 2013 (293 patients, prep group) and April 2015 to May 2016 (311 patients, posp group). RESULTS: The overall blood product transfusion rate was reduced in the posp group (89.5 vs. 67.6%; P<0.001), as well as individually: red blood cell concentrates (83.6%; P<0.001), fresh frozen plasma (36.2 vs. 21.2%; P<0.001), platelets (40.8 vs. 32.7; P<0.001). By contrast, fibrinogen use increased from 16.4 to 49% (P<0.001). Postoperative complications were similar in both groups, except for pulmonary complications (57.8 vs. 43.1%; P<0.001). Length of hospital stay was similar in both groups except in the Critical Care Unit with longer stay for the prep group (5.81±8.00 vs. 4.18±4.38; P=0.002). Mortality did not change. CONCLUSIONS: The implementation of a blood-saving programme in the cardiac surgery area has favourable consequences, such as a saving in blood product and a reduction of pulmonary complications, although without decreasing the mortality rate.

Somatotopic effects of rTMS in neuropathic pain? A comparison between stimulation over hand and face motor areas.

BACKGROUND: The therapeutic influence of somatotopic matching between pain topography and motor cortex stimulation site for neuropathic pain (NP) remains controversial. METHODS: Thirty-two patients suffering from NP involving the upper limb (n = 20) or the face (n = 12) received two high-frequency rTMS neuronavigated sessions targeting hand and face motor cortical areas, versus placebo. The cortical target was defined by anatomical MRI and EMG responses in all patients, completed in 19 of them by functional MRI. Sessions were separated by at least 2 weeks and applied in random order. Pain relief was assessed using numerical rating scale (NRS). RESULTS: In terms of percentage of pain relief, rTMS over the hand motor area was significantly superior to both face rTMS and placebo. When comparing pre- and post-NRS scores, a significant decrease in pain was observed after hand area rTMS for the two pain localizations, while stimulation of the face area induced a slight but nonsignificant effect on upper limb pain after correction. Sham-rTMS did not exert any effect. The percentage of patients with clinically significant (>30%) or mild (15-30%) pain relief did not differ, however, between rTMS addressed to the hand or face area. CONCLUSIONS: The results do not support a somatotopic effect of motor rTMS for NP. Lack of clinically relevant somatotopic effects in upper limb or face pain suggests that much of the rTMS analgesic effect may depend on high-order mechanisms involving cognitive and affective appraisal of pain, rather than on a sensory effect related to the specific motor area stimulated. SIGNIFICANCE: Strict somatotopic targeting of rTMS does not appear warranted for the treatment of upper limb or face NP. Since the hand motor area is easier to target and provides better results, it might be privileged for both types of pain.

Does an observer's empathy influence my pain? Effect of perceived empathetic or unempathetic support on a pain test.

The physiological and behavioural effects of empathy for other's pain have been widely investigated, while the opposite situation, i.e. the influence on one's pain of empathetic feedback from others, remains largely unexplored. Here, we assessed whether and how empathetic and unempathetic comments from observers modulate pain and associated vegetative reactions. In Study 1, conversations between observers of a pain study were recorded by professional actors. Comments were prepared to be perceived as empathetic, unempathetic or neutral, and were validated in 40 subjects. In a subsequent pain experiment (Study 2), changes in subjective pain and heart rate were investigated in 30 naïve participants who could overhear the empathetic or unempathetic conversations pre-recorded in study 1. Subjective pain was significantly attenuated when hearing empathetic comments, as compared to both unempathetic and neutral conditions, while unempathetic comments failed to significantly modulate pain. Heart rate increased when hearing unempathetic remarks and when receiving pain stimuli, but heart acceleration to nociceptive stimulation was not correlated with pain ratings. These results suggest that empathetic feedback from observers has a positive influence on pain appraisal and that this effect may surpass the negative effect of unempathetic remarks. Negative remarks can either trigger feelings of guilt or induce irritation/anger, with antagonistic effects on pain that might explain inter-individual variation. As in basal conditions heart rate and pain perception are positively correlated, their dissociation here suggests that changes in subjective pain were linked to a cognitive bias rather than changes in sensory input.

EAN guidelines on central neurostimulation therapy in chronic pain conditions.

BACKGROUND AND PURPOSE: Our aim was to update previous European Federation of Neurological Societies guidelines on neurostimulation for neuropathic pain, expanding the search to new techniques and to chronic pain conditions other than neuropathic pain, and assessing the evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. METHODS: A systematic review and meta-analysis of trials published between 2006 and December 2014 was conducted. Pain conditions included neuropathic pain, fibromyalgia, complex regional pain syndrome (CRPS) type I and post-surgical chronic back and leg pain (CBLP). Spinal cord stimulation (SCS), deep brain stimulation (DBS), epidural motor cortex stimulation (MCS), repetitive transcranial magnetic stimulation (rTMS) and transcranial direct electrical stimulation (tDCS) of the primary motor cortex (M1) or dorsolateral prefrontal cortex (DLPFC) were assessed. The GRADE system was used to assess quality of evidence and propose recommendations. RESULTS: The following recommendations were reached: 'weak' for SCS added to conventional medical management in diabetic painful neuropathy, CBLP and CRPS, for SCS versus reoperation in CBLP, for MCS in neuropathic pain, for rTMS of M1 in neuropathic pain and fibromyalgia and for tDCS of M1 in neuropathic pain; 'inconclusive' for DBS in neuropathic pain, rTMS and tDCS of the DLPFC, and for motor cortex tDCS in fibromyalgia and spinal cord injury pain. CONCLUSIONS: Given the poor to moderate quality of evidence identified by this review, future large-scale multicentre studies of non-invasive and invasive neurostimulation are encouraged. The collection of higher quality evidence of the predictive factors for the efficacy of these techniques, such as the duration, quality and severity of pain, is also recommended.