[With the Characteristics of Chronic Pain Patients, Can the Therapeutic Effect of Antidepressant Duloxetine be Predicted?].

BACKGROUND: Duloxetine, an antidepressant, is used for treatment of pain, but the factors related to its effectiveness are not well known, and therefore we have performed a retrospective study. METHODS: Over a 22-month period from June 2012 patients with pain lasting for 3 months or more, with an NRS of 4 or higher, and given duloxetine within 3 months from their first diagnosis, were extracted from the medical records. These patients were compared and studied regarding their scores of the HADS (hos- pital anxiety and depression scale) at the time of first visit, duration of the disease, type of patient, and treat- ment effect after 1 month. RESULTS: The subjects were 61 patients, and they were categorized based on the presence of anxiety, the presence of dysphoria whether from organic or inor- ganic condition, and the duration of the disease, and no significant difference in the effectiveness of duloxetine was found. CONCLUSIONS: Duloxetine had an overall effectiveness of 50.8%, regardless of the presence of anxiety or depression, the duration of the disease and the type of diseases.

[Usefulness of ultrasound sonography in performing posterior sacroiliac ligament injection in elderly patients].

BACKGROUND: The sacroiliac joint (SIJ) is recognized as a potential source for low back pain especially in elderly people. Previous studies indicated that in patients with SIJ pain, posterior sacroiliac ligament injections are more effective than intra articular injections. The aim of this study was to assess usefulness of ultrasound sonography (US) in performing posterior sacroiliac ligament injection. METHODS: We examined SIJ and ligaments, and injected local anesthetics using ultrasonography. US guided needle insertions were performed. We also examined the cadevar of a 74-year-old woman to examine SIJ anatomy. RESULTS: US was performed in 61 male and 97 female outpatients (N = 158) with a mean age of 72.8 ± 10.9. US examination of the SIJ is difficult to perform because of its complex anatomy, and wide range of normal variations, and relative inaccessibility by surface scanning. The long posterior sacroiliac ligament (LPSL) is visualized as a hyper echoic laminated linear structure. We were able to confirm needle placement and area affected by local anesthetics. CONCLUSIONS: Our study suggests that US can be useful in performing posterior sacroiliac ligament injections. Sufficient anatomical knowledge and extensive US experience are essential in performing these injections.

Clinical examination and necropsy findings of a mountain hawk-eagle (Nisaetus nipalensis) that died during rehabilitation.

We examined the clinical signs and necropsy findings of a mountain hawk-eagle (Nisaetus nipalensis) that died during rehabilitation. The bird was rescued and treated for open fracture of the right forearm. During rehabilitation, the bird could not stand up or fly. Part of the right secondary and left and right primary feathers were removed during rehabilitation; additional fracture was found in the right tibiotarsus and treated. However, the bird died 92 days after rescue and necropsy was performed. Severe hepatic lipidosis and capture myopathy were confirmed by histopathological examinations. These lesions may be associated with the cause of death of this animal. Accumulation of information is expected to contribute to the improvement of effective rehabilitation techniques for raptors.

Effects of mirtazapine on sleep disturbance under neuropathic pain-like state.

Sleep disturbance has been reported to be one of the most frequent symptoms in patients suffered from severe pain. Benzodiazepines are effective and reduce anxiety in the hours after use, but the induced sleep tends to be less than ideal in quality, with increased Stages I-II and reduces Stages III-IV sleep. In the present study, we investigated sleep disturbance under a neuropathic pain-like state in mice using electroencephalogram (EEG)/electromyogram (EMG). In a model of neuropathic pain, sciatic nerve ligation caused a marked decrease in the latency of paw withdrawal in response to a thermal stimulus only on the ipsilateral side. Under this condition, sciatic nerve-ligated animals showed a statistically significant increase in wakefulness and a decrease in non-rapid eye movement (NREM) sleep during the light phase. Mirtazapine (MTZ) is an antidepressant, which is considered to enhance noradrenergic and serotonergic neurotransmission via antagonistic action at central α2-adrenergic autoreceptors and heteroreceptors. In the present binding study, MTZ showed higher affinity for histamine H1 and serotonin 5-HT(2A/2C) receptors than other receptors, including α2-adrenergic receptor, in the mouse brain tissue. The thermal hyperalgesia and sleep disturbance following nerve ligation were almost completely alleviated by MTZ. These findings suggest that MTZ may improve the quality of sleep as well as control pain in patients with neuropathic pain mainly through histamine H1- and serotonin 5-HT2-receptor antagonistic actions.

Enhancement of glutamatergic transmission in the cingulate cortex in response to mild noxious stimuli under a neuropathic pain-like state.

Pain is evoked by noxious body stimulation or through negative emotional events and memories. There are several caveats to the simple proposition that pain and emotion are linked in the cingulate cortex (CG). In this study, we investigated whether mild noxious heat stimuli could affect the neuronal activity in the CG of rats with sciatic nerve ligation. We produced a partial sciatic nerve injury by tying a tight ligature in rats. Seven days after sciatic nerve ligation, rats received mild noxious heat stimuli. Mild noxious heat stimuli produced flinching behaviors in sciatic nerve-ligated rats, but not sham-operated rats. In addition, the mild noxious heat stimuli caused a significant increase in the release of glutamate in the CG of nerve-ligated rats compared with that of sham-operated rats. Furthermore, phosphorylated-NR1-positive cells in this area significantly increased after mild noxious heat stimuli under a neuropathic pain. Under this condition, there were no significant changes in the levels of immediate-early genes such as c-fos, c-jun, JunB, and Fra1 in the CG between nerve-ligated and sham-operated rats. However, mild noxious heat stimuli under a neuropathic pain-like state produced a marked increase in the phosphorylated-c-jun (p-c-jun) immunoreactivity, which is commonly used to map neurons in the brain that can be activated after N-methyl-D-aspartate receptor activation. These findings raise the possibility that mild noxious heat stimuli under a peripheral nerve injury may increase the release of glutamate and promote its related postneuronal activity in the CG.

[Anesthetic management for electroconvulsive therapy using rocuronium bromide and sugammadex sodium in a patient with suspected malignant syndrome].

A 62-year-old woman was treated for schizophrenia for 40 years. When the symptoms had deteriorated and new medications had to be added, CPK rose and she malignant syndrome was suspected. The electroconvulsive therapy (ECT) was proposed because of no improvement of the symptoms. We employed rocuronium bromide instead of suxamethonium considering malignant syndrome. The maintenance of anesthesia was necessary, because the duration of rocuronium bromide is longer than that of suxamethonium chloride. Anesthesia was induced and maintained using target controlled infusion (TCI) of propofol. After ECT was performed, sugammadex sodium 4 mg . kg-1 was administered at 2 post-tetanic counts (PTC) and the patient could come out the operating room safely and speedy. ECT using rocuronium bromide and sugammadex sodium can be performed safely and speedily, when suxamethonium chloride cannot be used.

[Successful anesthetic management of a postpartum patient with amniotic fluid embolism].

We report a case of amniotic fluid embolism (AFE) after cesarean section (C/S). A 35-year-old primigravida with placenta previa and myoma underwent C/S because of nonreassuring fetal status caused by medical induction of labor. C/S was performed smoothly under general anesthesia and the baby had no problems. Immediately after the end of C/S, she went into sudden cardiovascular collapse and massive postpartum hemorrhage (PPH) became apparent. The mechanical ventilation with 100% oxygen was continued. Cardiovascular stabilization was attained with immediate administration of noradrenaline and blood transfusion. As her clinical course indicated coagulopathy due to disseminated intravascular coagulation (DIC), we gave transfusion of fresh frozen plasma and red cell concentrate before the diagnosis of DIC was established by laboratory tests. Since we thought that manual pressure and uterotonics were not adequate to stop PPH, we performed uterine artery embolization additionally. The PPH with DIC was stopped by these measures seven hours after C/S. The patient and her baby left the hospital with no complications. AFE is a rare and often fatal obstetric condition, characterized by sudden cardiovascular collapse, and massive bleeding with DIC. The prompt awareness and initiation of appropriate measures are mandatory for patient's survival.

Sex-Specific Impact of Pain Severity, Insomnia, and Psychosocial Factors on Disability due to Spinal Degenerative Disease.

Purpose: Pain experience due to spinal degenerative disease decreases activity of daily living and quality of life. The present cross-sectional study was aimed at examining the sex-specific impact of pain severity, psychosocial factors, and insomnia on the disability due to chronic pain arising from spinal degenerative disease. Methods: In total, 111 outpatients with chronic spinal degenerative on initial diagnosis were analyzed. The definition of chronic spinal degenerative disease was (1) pain duration ≥3 months, (2) findings of nerve root compression on neurological examination and imaging, and (3) localized neck or lower back pain (not widespread, upper or lower limb pain). We used Numerical Rating Scale (NRS), Pain Disability Assessment Scale (PDAS), Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), and Athens Insomnia Scale (AIS) to assess patients. Univariate regression analysis was performed to investigate whether sex influences the PDAS score, and sex-stratified multivariate regression analysis was conducted to identify the variables associated with the PDAS score. Results: Sex was identified as a predictor of the PDAS score (standardized coefficient (ß) = 0.28; 95% confidence interval (CI), 0.10-0.46; p=0.003). In men, the AIS score was associated with PDAS (ß = 0.36, 95% CI 0.09-0.63). Age (ß = 0.31, 95% CI 0.06-0.55) and NRS (ß = 0.40, 95% CI 0.14-0.67) were associated with PDAS in women. HADS-A, HADS-D, and PCS were not associated with PDAS in both sexes. Conclusion: Insomnia was associated with disability in men, whereas aging and pain severity were associated with disability in women. Catastrophic thinking was not associated with disability in both sexes.

Insomnia and caregiver burden in chronic pain patients: A cross-sectional clinical study.

Insomnia is a major comorbid symptom of chronic pain and is likely to affect caregiver burden. This cross-sectional study investigated the association between insomnia in chronic pain patients and family caregiver burden. Participants were 60 patients with chronic pain of ≥3 months duration. Demographic and clinical information were collected using the Athens Insomnia Scale (AIS), the Pain Disability Assessment Scale (PDAS), the Hospital Anxiety and Depression Scale (HADS), and a pain intensity numerical rating scale (NRS). Family members who accompanied chronic pain patients to hospital completed the Zarit Burden Interview (ZBI). Univariate regression analysis and multiple regression analysis were conducted to clarify the associations between ZBI scores and total/subscale AIS scores. Covariates were age; sex; pain duration; and scores on the PDAS, HADS anxiety subscale, HADS depression subscale, and NRS. Insomnia was independently associated with ZBI scores [ß: 0.27, 95% confidence interval (CI): 0.07-0.52, p = 0.001]. Scores on the AIS subscale of physical and mental functioning during the day were significantly associated with ZBI scores (ß: 0.32, 95% CI: 0.05-0.59, p = 0.007). In conclusion, the findings suggest that in chronic pain patients, comorbid insomnia and physical and mental daytime functioning is associated with family caregiver burden independently of pain duration, pain-related disability, and pain intensity.