Preinjury treatment with morphine or ketamine inhibits the development of experimentally induced secondary hyperalgesia in man

We examine the effect of morphine or ketamine (N-methyl-D-aspartate receptor antagonist; NMDA) treatment on secondary hyperalgesia. Drug treatment started preinjury and continued into the early postinjury period. Hyperalgesia was induced by a local 1 degrees burn injury covering 12.5 cm(2) on the medial side of the calf. In this double-blind, cross-over study, 12 healthy volunteers received, on 3 separate days and in randomized order: (1) placebo; (2) morphine, bolus 150 microg/kg + infusion 1 microg/kg per min and 0.5 microg/kg per min; and (3) ketamine, bolus 60 microg/kg + infusion 6 microg/kg per min and 3 microg/kg per min. Bolus + infusion started 30 min before injury and ended 50 min after it. The area of secondary hyperalgesia was quantitated using punctate (von Frey filaments) and brush stimuli (electric brush). On the day of placebo, all subjects developed an area of hyperalgesia to punctate and brush stimuli outside the thermal injury (secondary hyperalgesia). We show that ketamine or morphine treatment starting preinjury significantly reduces this development (P<0.01, both). In a previous study, we found that postinjury treatment alone with morphine did not affect secondary hyperalgesia, whereas ketamine did so significantly. The differential response to morphine administered pre- or postinjury may be relevant to the recently shown NMDA receptor mediated interaction of central hyperexcitability and morphine antinociception. The effect of ketamine supports the hypothesis of the role of NMDA receptor mediation in central hyperexcitability.     

Urgent surgery for ulcerative colitis: Early colectomy in 132 patients

In accordance with a policy of early colectomy for severe ulcerative colitis, urgent/emergency surgery was performed in 132 patients during the last decade. The indication for surgery was toxic megacolon (45 cases), massive hemorrhage (6 cases), and fulminating colitis not responding to medical treatment within 4 days (81 cases). The operations performed were proctocolectomy (9 cases, mostly of hemorrhage), colectomy plus ileorectal anastomosis (3 cases), and abdominal colectomy plus ileostomy plus proctostomy (CIP) (120 cases, including 45 of toxic megacolon). Secondary proctectomy (SP) was later performed in 113 CIP cases. A major distinction of this series is a colonic perforation rate of only 3% (9% in toxic megacolon). Mortality after urgent/emergency colectomy was 5.3%. Total mortality within 2 years (including SP) was 6.8%. Two of 4 patients with colonic perforation died, as did 1 patient with colonic cancer. Postoperative complications occurred in 40% of the patients after urgent/emergency colectomy, and in 52% after all surgery combined (including SP). Mortality and morbidity were higher in toxic megacolon and in patients older than 60 years. Late complications, mostly persisting perineal sinuses, were seen in 31%. We believe that the low colonic perforation rate, and the subsequent favorable mortality and morbidity, are the results of our policy of early colectomy. Also, this study lends support to the choice of abdominal colectomy plus ileostomy plus proctostomy (and subsequent secondary elective proctectomy) when urgent/emergency surgery is indicated for severe ulcerative colitis.

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Résumé Suivant une politique de colectomie précoce en cas de colite ulcéreuse grave, nous avons, au cours des 10 dernières années, opéré en urgence ou semiurgence 132 malades. Les indications opératoires ont été le mégacÔlon toxique (45 cas), l'hémorragie massive (6 cas) et la colite fulminante n'ayant pas répondu en 4 jours au traitement médical (81 cas). Les opérations réalisées ont été la proctocolectomie (9 cas, surtout pour hémorragie), la colectomie avec iléorectostomie (3 cas) et la colectomie par voie abdominale avec iléostomie et proctostomie (120 cas, y compris les 45 mégacÔlons toxiques). Une amputation ultérieure du rectum fut réalisée dans 113 de ces cas.Une première remarque s'impose pour cette série: elle ne comporte que 3% de perforations (9% pour les mégacÔlons toxiques). La mortalité après chirurgie d'urgence a été de 5.3%. La mortalité après 2 ans, y compris les amputations secondaires du rectum, a été de 6.8%. Sur 4 malades avec perforation colique, 2 sont décédés, ainsi qu'un malade atteint de cancer colique. Des complications postopératoires sont survenues chez 40% des malades après colectomie d'urgence, et chez 52% pour toute la chirurgie, y compris les amputations secondaires du rectum. La mortalité et la morbidité sont plus élevées dans le mégacÔlon toxique et chez les malades de plus de 60 ans. Nous avons eu 31% de complications tardives, surtout des fistules périnéales peristantes.Nous estimons que la rareté des perforations coliques et, en conséquence, la mortalité et la morbidité favorables résultent de notre politique de colectomie précoce. Les résultats de cette étude sont également en faveur de la colectomie abdominale avec iléostomie et proctostomie (et amputation secondaire du rectum) lorsqu'une chirurgie d'ursecondaire du rectum) lorsqu'une chirurgie d'urgence est indiquée en cas de colite ulcéreuse grave.

     

Intra-articular morphine 5 mg after knee arthroscopy does not produce significant pain relief when administered to patients with moderate to severe pain via an intra-articular catheter

BACKGROUND AND OBJECTIVES: Intra-articular (IA) morphine for postoperative analgesia after knee arthroscopy is controversial. The IA catheter technique for test drug administration allows baseline pain assessment before inclusion. Results from one such randomized controlled trial (RCT) in patients with moderate to severe pain have shown equal effects of IA saline with or without morphine 2 mg. However, the IA catheter technique may have an unintended placebo effect. The aims of this placebo-controlled RCT were (1) to compare the analgesic effect of IA saline 1 mL (placebo) with morphine 5 mg given through an IA catheter and (2) to analyze the impact on pain of immediate or delayed removal of the IA catheter. METHODS: Sixty patients operated under general anesthesia had an IA catheter inserted at the end of arthroscopy. Patients who reported moderate or severe postoperative pain during the following hour were randomized to IA saline 1 mL (placebo) or IA morphine 5 mg and to immediate or delayed removal of IA catheter. RESULTS: Forty of 60 patients (67%) developed moderate to severe pain within 1 hour. In addition, 5 patients experienced intolerable pain and were excluded. Significantly more women (24/26) than men (26/39) reported at least moderate pain (P = .018) during the first hour after surgery. There were no differences between IA morphine 5 mg and placebo in pain intensity or pain relief at any time during the 48-hour observation period. There was no detectable effect on pain intensity of early compared with late removal of the IA catheter. CONCLUSIONS: IA morphine 5 mg does not produce clinically significant pain relief in patients with moderate or severe pain after knee arthroscopy.     

Gastroduodenal intussusception due to gastrointestinal stromal tumor (GIST) treated by laparoscopic billroth II distal gastrectomy

Gastrointestinal stromal tumors are rare tumors of the gastrointestinal tract. They, however, occur most commonly in the stomach where they present with abdominal pain, bleeding, and obstruction. Many are asymptomatic and are discovered incidentally or at postmortem. We present a case-report of a rare complication of gastrointestinal stromal tumors of the stomach causing gastroduodenal intussusception and how patient was successfully managed by laparoscopic Billroth II distal gastrectomy.     

No altered dorsal anterior cingulate activation in bipolar II disorder patients during a Go/No-go task: an fMRI study

Objectives:  It has been reported that one of the core features in patients with bipolar disorder II (BD II) is increased impulsivity. The aim of this study was to investigate whether patients with BD II showed decreased activation in the dorsal anterior cingulate cortex (dACC) as compared to healthy controls when performing a task sensitive to impulsivity.
Methods:  Twenty-seven BD II patients and 28 healthy controls performed a Go/No-go task during a functional magnetic resonance imaging (fMRI) session. Eleven of the patients were unmedicated, and possible group differences between medicated and unmedicated patients were also assessed.
Results:  The groups did not differ in behavioral performance on the Go/No-go task.
Both BD II subjects and healthy controls demonstrated dACC activity during the task, and analyses revealed no statistically significant group differences. Medicated and unmedicated patients also did not differ in the degree of fMRI activation.
Conclusions:  These findings do not support the hypothesis of abnormal dACC activity during a Go/No-go task in BD II patients.     

A DNA vaccine directed against a rainbow trout rhabdovirus induces early protection against a nodavirus challenge in turbot

A DNA vaccine encoding the envelope glycoprotein from a fish rhabdovirus, viral hemorrhagic septicemia virus (VHSV), has previously been shown to induce both early and long time protection against the virus in rainbow trout. Challenge experiments have revealed that the immunity established shortly after vaccination is cross-protective against heterologous fish rhabdoviruses. In this study, we show that the DNA vaccine encoding the VHSV glycoprotein also induces early protection against a non-enveloped, positive-sense RNA virus belonging to the Nodavirus family, the Atlantic halibut nodavirus (AHNV). In a vaccine efficacy test using juvenile turbot as model fish, the fish injected with the VHSV vaccine were completely protected against a nodavirus challenge performed 8 days post vaccination, while the cumulative mortality in the control group reached 54%. A DNA vaccine carrying the gene encoding the capsid protein of AHNV revealed no protective properties against the nodavirus challenge. Histological examination of muscle tissue sections from the vaccine injection site showed that the DNA vaccine against VHSV triggered a pronounced inflammatory response in turbot similar to what has earlier been observed in rainbow trout.     

International EMS Systems: the Nordic countries

Emergency medicine service (EMS) systems in the five Nordic countries have more similarities than differences. One similarity is the involvement of anaesthesiologists as pre-hospital physicians and their strong participation for all critically ill and injured patients in-hospital. Discrepancies do exist, however, especially within the ground and air ambulance service, and the EMS systems face several challenges. Main problems and challenges emphasized by the authors are: (1) Denmark: the dispatch centres are presently not under medical control and are without a national criteria based system. Access to on-line medical advice of a physician is not available; (2) Finland: the autonomy of the individual municipalities and their responsibility to cover for primary and specialised health care, as well as the EMS, and the lack of supporting or demanding legislation regarding the EMS; (3) Iceland is the only country that has emergency medicine (EM) as a recognised speciality but there is a need for more fully trained specialists in EM; (4) Norway: the ordinary ground ambulance is pointed out as the weakest link in the EM chain and a health reform demands extensive co-operation between the new health enterprises to re-establish a nation-wide air ambulance service; (5) Sweden: to create evidence based medicine standards for treatment in emergency medicine, a better integration of all part of the chain of survival, a formalised education in EM and a nation wide physician staffed helicopter EMS (HEMS) cover.     

Individual differences in pain sensitivity: genetic and environmental contributions

Large individual differences in pain sensitivity present a challenge for medical diagnosis and may be of importance for the development of chronic pain. Variance in pain sensitivity is partially mediated by genetic factors, but the extent of this contribution is uncertain. We examined cold-pressor pain and contact heat pain in 53 identical (MZ) and 39 fraternal (DZ) twin pairs, and 4 single twins to determine the heritability of the two phenotypes, and the extent to which the same genetic and environmental factors affect both pain modalities. An estimated 60% of the variance in cold-pressor pain and 26% of the variance in heat pain was genetically mediated. Genetic and environmental factors were only moderately correlated across pain modalities. Genetic factors common to both modalities explained 7% of the variance in cold-pressor and 3% of the variance in heat pain. Environmental factors common to both modalities explained 5% of variance in cold-pressor and 8% of the variance in heat pain. The remaining variance was due to factors that were specific to each pain modality. These findings demonstrate that cold-pressor pain and contact heat pain are mainly distinct phenomena from both a genetic and an environmental standpoint. This may partly explain disparate results in genetic association studies and argues for caution in generalizing genetic findings from one pain modality to another. It also indicates that differences in pain scale usage account for a minor portion of the variance, providing strong support for the validity of subjective pain ratings as measures of experienced pain.     

Pain and quality of life in hospitalized patients with heart failure

The pain experience of patients with heart failure (HF) and its impact on their quality of life (QOL) has not been described in sufficient detail. This study sampled patients hospitalized with HF to describe the prevalence and severity of bodily pain; evaluate differences in bodily pain related to selected demographic and disease-specific characteristics; and evaluate the effect of selected demographic, disease-specific characteristics, bodily pain, and mental health on QOL. Two items from the Medical Outcomes Study--Short Form (SF-36) were used to measure pain, and one subscale of the SF-36 was used to evaluate mental health. The Minnesota Living With Heart Failure Questionnaire was used to measure QOL. Patients with HF (n=93) had a mean age of 75 years, were predominantly male (65%), and lived alone (47.3%). Lung diseases and diabetes were the most common comorbidities; 58% were categorized as New York Heart Association (NYHA) Class III, whereas 58% of the sample was diagnosed with HF in the past four years. Of note, 85% of the patients reported pain and 42.5% said that it was in the severe or very severe range. No demographic variables were associated with pain, whereas a higher number of chronic conditions were associated with pain. SF-36 mental health and pain scores, as well as NYHA class, explained 34.1% of the variance in QOL in patients with HF. These data suggest that pain is highly prevalent and has a significant impact on the QOL of patients with HF. However, additional research is warranted to determine the specific causes and characteristics of pain in these patients.     

Gender is a confounding factor in pain trials: women report more pain than men after arthroscopic surgery

A gender difference in the incidence of acute pain may be a confounder in analgesic trials. We have tested the hypothesis that the incidence of acute pain after knee arthroscopic procedures is greater in women than men. We performed three RCTs on intra-articular analgesics in which no postoperative analgesia was given until the need for such treatment was documented by scoring moderate-to-severe pain on a verbal rating scale (VRS 0-4; n=219), and a 0-100 mm visual analogue pain scale (VAS) within 2 h postoperatively. All trials were performed with an intra-articular catheter technique. The design allowed us to study the natural course of pain after arthroscopic surgery until analgesia was required. Women reported more pain of at least moderate intensity than men (84 vs 57%; P<0.0001), indicating that being female is a risk factor for early postoperative pain (RR 1.47, 95% confidence interval from 1.23 to 1.74). The VAS score corresponding to moderate and severe pain is similar in men and women. Only short acting anaesthetics were given in order to minimise carry-over effects. Since previous trials on arthroscopic analgesics neither measured baseline pain nor stratified for gender, a difference between treatment groups could result from an uneven distribution regarding these factors. Our findings have major implications for the interpretation of previously published trials on intra-articular analgesia.