Beneficios de la sutura continua de la lesión perineal en la adaptación a la maternidad

ObjectiveTo assess the effect of the continuous suture technique of the perineal wound on the capacity and functional recovery of women when carrying out their self-care routine, the care of the newborn (NB), breastfeeding (BF) and Activities of Daily Living (ADLs), both basic (ABVD) and instrumental (IADL), during the postpartum period.MethodsNon-randomised clinical trial with blinding allocation to study groups, carried out at the Arnau de Vilanova tertiary hospital in Lérida. The intervention group received continuous suture for perineal repair and the control group discontinuous suture. The study population was women with eutocic delivery and second-degree perineal tears or episiotomy. Three postpartum assessment were performed (48 hours, 7-10 days and one month).Results126 women with eutocic delivery and second degree perineal tears or episiotomy participated (n = 126); 64 sutured with continuous technique (intervention group) and 62 with discontinuous technique (control group). At 48 hours postpartum, 85% of women from the continuous suture technique group were able to perform their self-care and 46,7% of them had recovered functionally. At 7-10 days, 96,7% of women with continuous suturing had acquired the ability to perform instrumental activities of daily living and 60% had recovered functionally compared to 68,3% and 15% respectively of women with discontinuous suturing (P<.001). At 7-10 days, 100% of women with continuous suturing achieved functional recovery for newborn care and 80% for breastfeeding and in the control group 81,7% and 30% respectively (P<.001 and P<.001).ConclusionsWomen who undergo the continuous suture technique restore their ability and functional recovery to perform activities of daily living earlier and with less pain than women with discontinuous suturing, adapting more quickly and satisfactorily way to motherhood.     

Les récepteurs des protons et de la capsa?cine: Contribution à la physiologie et la physiopathologie de la douleur

Les structures moléculaires de deux canaux ioniques activés par des ligands et présents dans les terminaisons nerveuses sensorielles nociceptives, le récepteur des protons ASIC et le récepteur de la capsaicine VR1, ont été récemment élucidées. Les canaux ASIC sont des canaux cationiques plut?t sélectifs pour le Na⁺ qui sont activés directement par une diminution du pH extracellulaire. Ils appartiennent à la superfamille des canaux Na⁺ sensibles à l’amiloride. Ils sont formés de plusieurs sous-unités homologues dont certaines sont aussi présentes dans le système nerveux central et qui peuvent s’assembler en homo- ou en hétéro-multiméres. Une combinaison particulière spécifique des neurones sensoriels (ASIC2b et ASIC3) a des propriétés proches de celles du cannal natif qui a été impliqué dans la perception de la douleur associée à une acidose tissulaire. VR1 est un canal cationique non sélectif très perméable au Ca²⁺ qui possède une structure différente de celle des canaux ASIC mais semblable à celle des canaux activés par la déplétion des stocks intracellulaires de Ca²⁺ VR1 est spécifiquement exprimé dans les neurones sensoriels et il est activé directement par les vanilliques comme la capsaicine. Il est surtout activé par la chaleur dans une gamme de températures douloureuses (à partir de 43°C). Ce seuil est considérablement abaissé par une diminution du pH extracellulaire et VR1 peut être activé à des températures physiologiques dans certaines conditions d’acidose. L’obtention de ces nouveaux outils moléculaires devrait permettre de mieux comprendre les mécanismes de la douleur associés à ces deux récepteurs et d’envisager le développement de nouveaux analgésiques capables de moduler leur activité.     

Physiologie de la douleur et de l’hyperalgésie ou de la nociception à la contagion émotionnelle de la douleur

The intensity of a pain does not simply reflect the severity of the injury that caused it, but also depends very much on the individual’s history. Therefore, clinical pain is also largely the expression of neural plasticity associated with peripheral and central sensitization leading to hyperalgesia, allodynia and persistent, spontaneous pain.Although opioids are recognized as unsurpassed analgesics for moderate to severe pain, for more than a century, experimental and clinical studies have reported that the administration of exogenous opioids not only produces analgesia but also induces long-term hypersensitivity to pain, in the form of prolonged hyperalgesia after an injury which is capable of facilitating the development of chronic pain. Like exogenous opioids, endogenous opioids released during situations of stress induce a latent hypersensitivity to pain that may emerge in the form of more severe pain on subsequent injuries. The hypersensitivity to pain induced by opioids is associated with a more general hypersensitivity affecting the emotional sphere, for example in terms of anxiety.The consequences of hypersensitivity to pain cannot be managed using analgesics alone but require specific antisensitisation strategies, such as NMDA receptor antagonists, nitrous oxide, nefopam and nutrition low in polyamines.     

Peut-on mesurer la souffrance liée à la douleur ?

The demand made to physicians to be more attentive to assessing the suffering of their patients was introduced by Eric Cassell as one of the fundamental goals of medicine. This call was indeed taken into account by health professionals but remained difficult to satisfy in the absence of appropriate measures. In addition, the focus on end-of-life suffering in palliative care has excluded in the vast majority of cases patients with chronic medical conditions and in particular those suffering from chronic pain whose on-going suffering is part of everyday life. To fill this gap, my integrative research proposes an interdisciplinary approach that relies on both philosophical, psychobiological and clinical concepts seeking to provide a measure accompanied by an interpretation of the person’s suffering. The practical goal is to provide a simple and effective clinical tool to assess the degree of suffering related to pain and to characterize its specific nature in each patient, allowing a more precise diagnosis and more individualized management of chronic pain patients. In answering the question « Can we measure Painrelated Suffering? » this paper addresses the main issues, both conceptual and methodological, attached to the evaluation of suffering in order to instruct the development of its assessment tool.     

Place de la chirurgie dans la névralgie du trijumeau

Trigeminal neuralgia is a potentially disturbing disease and may be resistant to classical medications such as anti-epileptic drugs. The first step is to check out the clear assessment of an essential trigeminal neuralgia so as to rule out specific etiologies of the trigeminal pain. There are mainly three kinds of surgical strategies: microsurgical neurovascular decompression, percutaneous gasserian lesioning and radiosurgery with Gamma knife. Microsurgical neurovascular decompression is an open surgery and the goal is to take away a vessel (mainly an artery) from the trigeminal nerve as it has been assumed that this conflit was the pathophysiological reason for the ??epileptic-like?? pain. This surgery has been around for at least 40 years. The results are very good, with 90% of the patients being satisfied and relieved from pain. Moreover, the results are long lasting with a 70% rate of satisfaction for the longest follow-up published. The morbidity is low even for elderly people in good health condition. There are several percutaneous techniques. The principle is doing a lesion on the retrogasserian part of the nerve, either by radiofrequency (thermic lesion), or by compression with a balloon (compressive lesion). The results are also good, with 90% of the patients being immediately relieved from pain, but there is a higher risk of recurrence and some potential morbidity (trigeminal numbness or trigeminal dysfunction mainly with radiofrequency lesion). The Gamma knife procedure is a radiosurgical procedure using cobalt radiation, in one shot, at a 80 Gy dosage, with a single 4 mm isocenter located at the entry zone. There is a delay in getting relief from pain. The results are good, with 80% of the patients being relieved. Somehow, there is a tendency of pain recurrence at mid-term follow-up and a 50% rate of patients being satisfied at a 5 year follow-up. The respective indications of each technique depend on the patient, the surgeon and their experience and the avaibility of the techniques. Altogether, it has been assumed that microvascular decompression is the first option for patients with neuralgia resistant to anti-convulsivant medications. Patient in poor medical conditions, or with MS lesion or refusing surgery, can be relieved by radiosurgery or percutaneous techniques.     

Approches cognitivo-comportementales dans la gestion de l'insomnie secondaire à la douleur chronique

Résumé  Les plaintes de sommeil font partie intégrante du tableau clinique chez une proportion considérable de patients aux prises avec de la douleur chronique. Ces dernieers rapportent des difficultés à initier et à maintenir, le sommeil ainsi que des plaintes de sommeil non réparateur. L'évaluation polysomnographique confirme la présence de perturbations dans la continuité et l'architecture du sommeil. La relation entre douleur et insomnie est souvent bidirectionnelle: I'intensité de la douleur semble prédire la sévérité des difficultés de sommeil, et les difficultés de sommeil peuvent intensifier la perception de la sévérité de la douleur. Même si la douleur est souvent la source principale de l'insomnie, plusieurs facteurs comportementaux et psychologiques peuvent contribuer à exacerber et maintenir les difficultés de sommeil. Le traitement cognitivo-comportemental de l'insomnie vise à modifier ou éliminer ces facteurs. Les méthodes utilisées sont le contr?le par le stimulus, la restriction du sommeil, la relaxation, la restructuration cognitive et l'hygiène du sommeil. L'efficacité de ces traitements est bien établie pour l'insomnie primaire. Même si les données disponibles relatives à l'insomnie secondaire à la douleur chronique sont peu nombreuses, elles indiquent que l'approche cognitivo-comportementale représente une option thérapeutique très utile chez les patients aux prises avec de telles difficultés.      

Angiogenèse: de la physiologie à la thérapeutique

• •- Vasculogenesis, angiongenesis and arteriogenesis

• •• Angiogenesis in embryonic development vasculogenesis
• •• Angiogenesis

• •- Vessel formation
• •- Mechanical hypothesis
• •- Biological hypothesis: role of the angiogenic growth factors FGF and VEGF
• •• Combined hypothesis: angiogenesis and vascular remodelling

• •- Therapeutic angiogenesis in cardiovascular diseases
• •• Critical limb ischemia
• •• Myocardial ischemia

• •- Gene therapy
• •- Angiogenic growth factor therapy
• •- Tumour angiogenesis
• •- Angiogenesis in healing wounds