Painful lesion in the forearm of a child traveller.

In this article, we intend to discuss a case of cutaneous myiasis in a British child traveller who recently travelled to Somaliland. A Cordylobia anthropophaga larva was identified as the species that caused the disease. The case report, which contains a video illustration of the causative agent, proved a diagnostic challenge at presentation.

Experimental Trypanosoma cruzi Infection Induces Pain in Mice Dependent on Early Spinal Cord Glial Cells and NFκB Activation and Cytokine Production.

The neglected tropical infirmity Chagas disease (CD) presents high mortality. Its etiological agent T. cruzi is transmitted by infected hematophagous insects. Symptoms of the acute phase of the infection include fever, fatigue, body aches, and headache, making diagnosis difficult as they are present in other illnesses as well. Thus, in endemic areas, individuals with undetermined pain may be considered for CD. Although pain is a characteristic symptom of CD, its cellular and molecular mechanisms are unknown except for demonstration of a role for peripheral TNF-α in CD pain. In this study, we evaluate the role of spinal cord glial cells in experimental T. cruzi infection in the context of pain using C57BL/6 mice. Pain, parasitemia, survival, and glial and neuronal function as well as NFκB activation and cytokine/chemokine production were assessed. T. cruzi infection induced chronic mechanical and thermal hyperalgesia. Systemic TNF-α and IL-1ß peaked 14 days postinfection (p.i.). Infected mice presented increased spinal gliosis and NFκB activation compared to uninfected mice at 7 days p.i. Glial and NFκB inhibitors limited T. cruzi-induced pain. Nuclear phosphorylated NFκB was detected surrounded by glia markers, and glial inhibitors reduced its detection. T. cruzi-induced spinal cord production of cytokines/chemokines was also diminished by glial inhibitors. Dorsal root ganglia (DRG) neurons presented increased activity in infected mice, and the production of inflammatory mediators was counteracted by glial/NFκB inhibitors. The present study unveils the contribution of DRG and spinal cord cellular and molecular events leading to pain in T. cruzi infection, contributing to a better understanding of CD pathology.

Effect of the Buzzy Application on Pain and Injection Satisfaction in Adult Patients Receiving Intramuscular Injections.

AIM: The aim of this study was to investigate the effect of the Buzzy application on pain and satisfaction during injections. BACKGROUND: Intramuscular injections usually cause some degree of pain at the injection site. Patients are often afraid of receiving injections because they perceive that it will be painful. DESIGN: The study was a single-blind, randomized controlled trial. METHOD: Patients (n = 65) who receive diclofenac sodium intramuscularly at a state hospital in a city in the western region of Turkey were included in the study. The study data were collected by The Patient Information Form and Visual Analog Scale (VAS). Pain intensity and injection satisfaction scores were evaluated using the VAS. RESULTS: According to the findings of this research, the post-injection pain intensity and injection satisfaction scores of patients in the application group were found to be higher than in the control group. CONCLUSION: In conclusion, the Buzzy device has the potential to reduce injection related pain in adult patients who may be fearful of receiving such injections.

Tungiasis-related life quality impairment in children living in rural Kenya.

BACKGROUND: Tungiasis (sand flea disease) is a neglected tropical skin disease caused by female sand fleas (Tunga spp.) embedded in the skin of the host. The disease is common in sub-Saharan Africa and predominantly affects children living in impoverished rural communities. In these settings tungiasis is associated with important morbidity. Whether tungiasis impairs life quality has never been studied. METHODS: The study was performed in 50 children with tungiasis, living in resource-poor communities in coastal Kenya. Based on the Dermatology Life Quality Index (DLQI) a tool was developed to determine life quality impairment associated with tungiasis in children, the tungiasis-related Dermatology of Life Quality Index (tungiasis-related-DLQI). Pain and itching were assessed using visual scales ranging from 0-3 points. The intensity of infection and the acute and chronic severity of tungiasis were determined using standard methods. RESULTS: Seventy eight percent of the patients reported a moderate to very large effect of tungiasis on life quality at the time of the diagnosis. The degree of impairment correlated with the number of viable sand fleas present in the skin (rho = 0.64, p < 0.001), the severity score of acute clinical pathology (rho = 0.74, p < 0.001), and the intensity of pain (rho = 0.82, p < 0.001). Disturbance of sleep and concentration difficulties were the most frequent restriction categories (86% and 84%, respectively). Four weeks after curative treatment, life quality had improved significantly. On the individual level the amelioration of life quality correlated closely with the regression of clinical pathology (rho = 0.61, p < 0.001). CONCLUSION: The parasitic skin disease tungiasis considerably impairs life quality in children in rural Kenya. After effective treatment, life quality improves rapidly.

Lys49 myotoxin from the Brazilian lancehead pit viper elicits pain through regulated ATP release.

Pain-producing animal venoms contain evolutionarily honed toxins that can be exploited to study and manipulate somatosensory and nociceptive signaling pathways. From a functional screen, we have identified a secreted phospholipase A2 (sPLA2)-like protein, BomoTx, from the Brazilian lancehead pit viper (Bothrops moojeni). BomoTx is closely related to a group of Lys49 myotoxins that have been shown to promote ATP release from myotubes through an unknown mechanism. Here we show that BomoTx excites a cohort of sensory neurons via ATP release and consequent activation of P2X2 and/or P2X3 purinergic receptors. We provide pharmacological and electrophysiological evidence to support pannexin hemichannels as downstream mediators of toxin-evoked ATP release. At the behavioral level, BomoTx elicits nonneurogenic inflammatory pain, thermal hyperalgesia, and mechanical allodynia, of which the latter is completely dependent on purinergic signaling. Thus, we reveal a role of regulated endogenous nucleotide release in nociception and provide a detailed mechanism of a pain-inducing Lys49 myotoxin from Bothrops species, which are responsible for the majority of snake-related deaths and injuries in Latin America.

Direct parasitologial diagnosis of infection with Hysterothylacium aduncum in a patient with epigastralgia.

Anisakis parasitization has been on the rise because some factors, like increased interest in dishes consisting of raw fish. We report a case of epigastralgia with direct diagnosis by endoscopy, which futher study pointed out H. Aduncum as causal agent, a anisakis which is rarely involved in human anisakiasis.

Evaluation of the efficacy of memantine in the treatment of fibromyalgia: study protocol for a doubled-blind randomized controlled trial with six-month follow-up.

BACKGROUND: Fibromyalgia is a prevalent chronic rheumatic disease of great clinical importance. Recent studies have found raised levels of glutamate in the insula, hippocampus and posterior cingulate cortex regions of the brains of fibromyalgia (FM) patients. This finding has led researchers to speculate about the usefulness of glutamate-blocking drugs such as memantine in the treatment of fibromyalgia. The hypothesis of this study is that the administration of memantine will reduce the glutamate levels, and futhermore, will decrease the perceived pain. The aim of this study is to evaluate the efficacy of memantine in the treatment of pain (pain perception). A secondary objective is to evaluate the efficacy of memantine in the treatment of other clinical symptoms of FM, and to evaluate the efficacy of memantine in reducing brain levels of glutamate, and its effects on the central nervous system as a whole. METHOD/DESIGN: A double-blind parallel randomized controlled trial. Participants, Seventy patients diagnosed with FM will be recruited from primary health care centers in Zaragoza, Spain. Intervention. The subjects will be randomized in two groups: A) A treatment group (n = 35), which will receive 20 mg of memantine daily; B) A control group (n = 35), to which will be administered a placebo. There will be a six-month follow-up period (including a titration period of one month). Outcomes. The main efficacy variable of this study is pain (pain perception). The secondary efficacy variables are clinical symptoms (pain threshold, cognitive function, health status, anxiety, depression, clinical impression and quality of life) and glutamate levels in different regions of the brain, which will be assessed by magnetic resonance spectroscopy. Randomization and blinding. Randomization has been computer-generated, and the random allocation sequence will be implemented by telephone. Subjects of the study and the research assistants will be blinded to group assignment. DISCUSSION: There is a need for the development of innovative and more effective treatments for fibromyalgia. This clinical trial will determine whether memantine can be an effective pharmacological treatment for fibromyalgia patients. TRIAL REGISTRATION: Current Controlled Trials http://ISRCTN45127327 EUDRACT 2011-006244-73.

Diurnal time course of heat pain perception in healthy humans.

Rapid skin heating by infrared lasers can be used to investigate the integrity of the nociceptive system by activating A-delta and C fibers. The aim of our study was to analyze if healthy humans exhibit any clinically relevant diurnal variations in their heat pain sensitivity. Circadian A-delta fiber function was analyzed by studying N2 and P2 components of laser-evoked potentials (LEP) and pain thresholds evoked by laser stimulation of the foot every 2h from 8a.m. to 10p.m. in 15 healthy subjects. Heat stimuli were generated by an infrared Tm-YAG laser and were delivered to an area of 4 cm × 4.5 cm on the dorsum of the right or left foot in 3 runs of incremental and decremental intensities. After each stimulus subjects were asked to classify the intensity of pain with a numeric rating scale (NRS). LEPs were recorded with fixed stimulus intensities that were 1.5× of the pain threshold. Data were collected with the SynAmps System (Neuroscan, El Paso, USA) and averaged across 35-40 trials. Laser-induced heat pain thresholds and circadian latencies of LEP did not significantly vary during the day. Our results correspond with previous studies that did not detect any consistent significant diurnal variations in perception of heat pain perception using contact thermodes. The intensity of pain perception did not demonstrate any correlation with mood or sleep parameters as measured with the Beck Depression Inventory (BDI), the subjective sleep scales Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS).

Depression among injured workers receiving vocational rehabilitation: contributions of work values, pain, and stress.

INTRODUCTION: Work-related injuries or disabilities result in significant negative consequences to physical, economic, social, and psychological well-being. Depression has been shown to increase post-injury and to contribute to poor return to work outcomes. The primary goals of the study were to test known correlates of depression in a sample of injured workers receiving vocational rehabilitation and to assess the unique contribution of work values in injured worker depression. METHOD: Scores on depression, stress, pain, work values, and demographic information were obtained from an archived sample of 253 injured workers receiving vocational rehabilitation. RESULTS: Hierarchical multiple linear regression was used for analyses, resulting in a final model with a "large" effect size (R (2) = 0.42). The accepting vs. investigative work value dimension accounted for variance in depression scores beyond that accounted for by covariates and other significant correlates. Of the study variables, significant regression coefficients were found for pain, psychosocial stress, an interaction between pain and stress, and having an accepting work value. CONCLUSIONS: Injured workers experiencing higher levels of pain and stress and who prefer to avoid workplace challenges may be vulnerable to experiencing depression. Results suggest that the presence of pain, stress, and the accepting work value dimension should be monitored in injured workers, and that the role of work values in injured worker depression may be a fruitful area for further research.

Role of enhanced noradrenergic transmission within the ventral bed nucleus of the stria terminalis in visceral pain-induced aversion in rats.

Pain is an unpleasant sensory and emotional experience. We demonstrated the crucial role of the bed nucleus of the stria terminalis (BNST) in the negative affective component of somatic and visceral pain induced by intraplantar formalin and intraperitoneal acetic acid injections, respectively, in rats. Recently, we reported the involvement of enhanced noradrenergic transmission via beta-adrenoceptors within the ventral BNST (vBNST) in formalin-induced aversion. Here, we examined the role of intra-vBNST noradrenergic transmission in the negative affective component of visceral pain induced by intraperitoneal acetic acid injection. In vivo microdialysis showed that extracellular noradrenaline levels within the vBNST significantly increased after intraperitoneal acetic acid injection. Using a conditioned place aversion (CPA) test, we found that intra-vBNST injection of timolol, a beta-adrenoceptor antagonist, dose-dependently attenuated the acetic acid-induced CPA without reducing nociceptive behaviors. These results suggest that enhanced noradrenergic transmission via beta-adrenoceptors within the vBNST plays a pivotal role in the negative affective, but not sensory, component of visceral pain.

Increased visceral sensitivity in Giardia-induced postinfectious irritable bowel syndrome and functional dyspepsia. Effect of the 5HT3-antagonist ondansetron.

In an outbreak of waterborne giardiasis where 1300 subjects were diagnosed, with Giardia lamblia, 139 continued to have abdominal symptoms of whom two of three had negative stool culture and microscopy. These were considered to have a postinfectious functional gastrointestinal disorder. We investigated visceral hypersensitivity in patients with persisting abdominal symptoms after Giardia infection and assessed the effect of 5HT(3)-antagonist ondansetron. Twenty-two patients with Giardia negative stools and 19 controls were included. A subset of patients (n = 15) had both irritable bowel syndrome (IBS) and functional dyspepsia (FD). All subjects underwent a satiety test with a soup combined with three-dimensional ultrasound. Fifteen of 22 patients underwent double-blind, randomized, placebo-controlled study with the 5-HT(3) antagonist ondansetron given orally. Drinking capacity was lower in patients than in controls (P < 0.01) and gastric emptying was reduced (P < 0.05). Patients had more symptoms both fasting and postprandially (P < 0.001) compared to controls. Ondansetron had no effect on these parameters except from less nausea postprandially (P < 0.05). In conclusion, patients with Giardia-induced gastrointestinal symptoms developed both IBS and FD. They exhibited gastric hypersensitivity with lower drinking capacity and delayed gastric emptying. The 5-HT(3) antagonist ondansetron did not improve drinking capacity, gastric emptying or symptoms except nausea.

Conceptualizing and testing random indirect effects and moderated mediation in multilevel models: new procedures and recommendations.

The authors propose new procedures for evaluating direct, indirect, and total effects in multilevel models when all relevant variables are measured at Level 1 and all effects are random. Formulas are provided for the mean and variance of the indirect and total effects and for the sampling variances of the average indirect and total effects. Simulations show that the estimates are unbiased under most conditions. Confidence intervals based on a normal approximation or a simulated sampling distribution perform well when the random effects are normally distributed but less so when they are nonnormally distributed. These methods are further developed to address hypotheses of moderated mediation in the multilevel context. An example demonstrates the feasibility and usefulness of the proposed methods.

Extraocular muscle cysticercosis - a clinical challenge to the ophthalmologists.

PURPOSE: To report our experience with extraocular myocysticercosis, to highlight the role of ultrasound and orbital computerized tomography (CT) scan in these cases and to discuss the management. METHODS: This is retrospective study of 35 cases of orbital myocysticercosis confirmed on ultrasound and CT scan of the orbit. RESULTS: There were 18 males and 17 females. The average age of these patients was 19.6 years. The most common presenting feature was restricted ocular motility with diplopia and recurrent pain and redness. Ultrasound examination and CT scan of the orbit done for all these patients identified the cyst and the affected muscle. All extraocular muscles were noted to be involved in myocysticercosis. However the lateral rectus, medial rectus and the superior oblique were affected to a greater extent. All cases dramatically improved on treatment with albendazole and oral steroids. Surgical excision of cyst was done in 6 cases. CONCLUSION: A high index of suspicion should be entertained for extraocular muscle cysticercosis, especially in cases of acquired ocular motility disorder with recurrent ocular congestion. Ultrasound and CT scans of orbit play a vital role in diagnosis. Medical therapy with albendazole under cover of steroids is effective in most of the cases.