Hypersensitivity in muscle pain syndromes

The aim of this review is to present research that has a bearing on the pathogenesis of hypersensitivity in muscle pain syndromes. Allodynia and hyperalgesia in these syndromes can be segmental or generalized and temporary or permanent. Hypersensitivity in muscle pain conditions in the clinic is best diagnosed by determining the pressure pain threshold. In a disorder such as fibromyalgia, decreased pain thresholds also are found at sites where there is no tenderness. Pathogenetic mechanisms for allodynia and hyperalgesia can be identified at several levels of the nociceptive system, from the nociceptors in the muscle to the cortex. Central sensitization of nociceptive neurons in the dorsal horn and a disturbed balance between inhibitory and facilitatory impulses in the descending tracts from the brain stem to the dorsal horn are the main mechanisms for pain hypersensitivity. Changes in function, biochemical make-up, and synaptic connections in the nociceptive neurons in the dorsal horn are considered to be caused by neuronal plasticity.     

Adaptation of human skeletal muscle to endurance training of long duration

Summary. The aim of this study was to examine the adaptive response of skeletal muscle to dynamic training of long duration and low intensity. The response of m. triceps brachii, (TB) and m. quadriceps femoris, vastus lateralis (VL) to training of long duration at an intensity corresponding to approximately 45% of V?O₂, max, has been studied in six subjects. Muscle specimens were taken during training (18.5 miles (30 km)), which involved skiing with a backpack, (6 daydweek, 8 weeks), as well as during a subsequent period of detraining (33 weeks). Increases in oxidative enzyme activities and capillarization during training were limited to the TB. There were parallel increases in citrate synthase (CS) and malate dehydrogenase (MDH) during the first 3 weeks of training (30%). CS then continued to rise (to 90% above pretraining level), while the increase in MDH levelled off. The activity of 3–hydroxyacyl-CoA-dehydrogenase (HAD) and the number of capillaries per fibre increased by 50 % and 40 % respectively. A selective decrease (12%) in area of fibre type IIA was noted during training after a 2-week period of energy deficiency. During the first 6 weeks of detraining, the decrease in CS and HAD (30%) was greater than the decrease in capillaries per fibre (14%). It is concluded that prolonged duration of training is not, in itself, sufficient to elicit an adaptive response in the leg muscles, while a modest training effect was seen for the arm muscles. The finding emphasizes the importance of adequate intensity in physical training programmes.     

From evoked potentials to cortical currents: Resolving V1 and V2 components using retinotopy constrained source estimation without fMRI

Despite evoked potentials' (EP) ubiquity in research and clinical medicine, insights are limited to gross brain dynamics as it remains challenging to map surface potentials to their sources in specific cortical regions. Multiple sources cancellation due to cortical folding and cross‐talk obscures close sources, e.g. between visual areas V1 and V2. Recently retinotopic functional magnetic resonance imaging (fMRI) responses were used to constrain source locations to assist separating close sources and to determine cortical current generators. However, an fMRI is largely infeasible for routine EP investigation. We developed a novel method that replaces the fMRI derived retinotopic layout (RL) by an approach where the retinotopy and current estimates are generated from EEG or MEG signals and a standard clinical T1‐weighted anatomical MRI. Using the EEG‐RL, sources were localized to within 2 mm of the fMRI‐RL constrained localized sources. The EEG‐RL also produced V1 and V2 current waveforms that closely matched the fMRI‐RL's (n = 2) r_(1,198) = 0.99, P < 0.0001. Applying the method to subjects without fMRI (n = 4) demonstrates it generates waveforms that agree closely with the literature. Our advance allows investigators with their current EEG or MEG systems to create a library of brain models tuned to individual subjects' cortical folding in retinotopic maps, and should be applicable to auditory and somatosensory maps. The novel method developed expands EP's ability to study specific brain areas, revitalizing this well‐worn technique. Hum Brain Mapp 37:1696–1709, 2016. © 2016 Wiley Periodicals, Inc.     

Direct medical costs for patients with type 2 diabetes in Sweden

OBJECTIVES: To estimate the total direct medical costs to society for patients with type 2 diabetes in Sweden and to investigate how different factors, for example diabetic late complications, affect costs. DESIGN: Cross-sectional data regarding health care utilization, clinical characteristics and quality of life, were collected at a single time-point. Data on resource use cover the 6-month period prior to this time point. SETTING: Patient recruitment and data collection were performed in nine primary care centres in three main regions in Sweden. SUBJECTS: Only patients with an age at diabetes diagnosis >/= 30 years (type 2 diabetes) were included (n = 777). RESULTS: The total annual direct medical costs for the Swedish diabetes type 2 population were estimated at about 7 billion SEK (Swedish Kronor) in 1998 prices, which is about 6% of the total health care expenditures and more than four times higher than the former Swedish estimate obtained when using diabetes as main diagnosis for calculating costs. The annual per patient cost was about 25 000 SEK. The largest share of this cost was hospital inpatient care. Costs increased with diabetes duration and were higher for patients treated with insulin compared to those treated with oral hypoglycaemic drugs or with life style modification only. Patients with both macro- and microvascular complications had more than three times higher costs compared with patients without such complications. CONCLUSIONS: Type 2 diabetes is a serious and expensive disease and the key to reducing costs seems to be intensive management and control in order to prevent and delay the associated late complications.     

Mucin in gall bladder bile of gall stone patients: influence of treatment with chenodeoxycholic acid and ursodeoxycholic acid.

The concentration of hexosamine, a marker for mucin, was determined and related to the degree of cholesterol saturation and to the occurrence of cholesterol crystals in gall bladder bile of gall stone patients (n = 40) and gall stone free subjects (n = 25). Ten of the gall stone patients had been treated with chenodeoxycholic acid (CDCA) and eight with ursodeoxycholic acid (UDCA) three to four weeks before cholecystectomy. The hexosamine content was significantly higher in gall stone patients (137 (19) ng/ml, mean (SE) than in gall stone free subjects (83 (9) ng/ml, p less than 0.02). Treatment with CDCA or UDCA decreased cholesterol saturation, but did not significantly affect the hexosamine concentration. There was no difference in hexosamine concentration between gall stone patients with and without cholesterol crystals. The results do not support the hypothesis that the degree of cholesterol saturation is important for the mucin content of gall bladder bile in man. Neither do the data indicate that the formation and occurrence of cholesterol crystals in gall bladder bile from gall stone patients is caused by an increased concentration of mucin. As the studies were conducted on patients who had already had gall stones for several years, however, an effect of mucin in the very early stage of gall stone formation cannot be completely excluded.     

The experiences of pregnancy in women with SSA/Ro52 autoantibodies

Objective: Congenital heart block may develop in the foetus during pregnancy in SSA/Ro52 autoantibody‐positive women. The aim of this study was to investigate how women with SSA/Ro52 autoantibodies experience their pregnancy in terms of the risk of developing foetal heart block, and in undergoing serial ultrasound Doppler echocardiography to detect early signs of congenital heart block. Methods: Data were collected through individual semi‐structured interviews with SSA/Ro52‐positive women post‐pregnancy (n = 14). The interviews were audio‐taped, transcribed verbatim and analysed according to qualitative content analysis. Results: Three categories emerged from the responses: information, emotional response and support. The information received prior to and during early pregnancy was focused on the need for attending a specialized antenatal clinic, and information on the risk for congenital heart block was scarce or missing. During gestational weeks 18–24, when the ultrasound/Doppler examinations were performed, all women described increased stress. However, the interaction with the caregivers made the women feel more safe and secure. Several women also said that they did not emotionally acknowledge the pregnancy until after gestational week 24. None had been offered psychological support. Conclusion: There is a need for structured information and organized programmes for the surveillance of women who are SSA/Ro52 positive during their pregnancy. Further, offering psychological support to the women and their families to manage the stress and to facilitate the early attachment to the child should be considered. Copyright © 2010 John Wiley & Sons, Ltd.     

Treatment of Postoperative Esophagorespiratory Fistulas with Dual Self-Expanding Metal Stents

Background  Fistulas between the esophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after esophageal resection. The traditional therapeutic approach is to deviate the proximal portion of the esophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. Methods  One hundred sixty-seven consecutive esophageal resections were reviewed to address the outcome of a stent-based therapeutic strategy in cases with esophagorespiratory fistulas. The patency of each anastomosis was checked only at the time of clinical suspicion of leakage but then radiology, endoscopy, and bronchoscopy were used together. Results  Seven patients developed esophagorespiratory fistula. All of these fistulas were diagnosed more than 1 week after the operation. Two patients (27%) died due to the fistula. Four could be successfully treated but in two of these we were forced to change strategy and either perform a colonic interposition or externalize the esophagus. One of these patients subsequently developed total respiratory failure and required extracorporal membrane oxygenation (ECMO) to recover. Conclusions  When an esophagorespiratory fistula is diagnosed, an attempt to close the fistula tract by SEMS from both the esophageal and the respiratory side is a feasible treatment option. This strategy has to be prolonged and aggressive with a commitment to repeatedly change stents and modify sizes and designs. Thereby a majority of these patients can be managed conservatively with prospects of a successful outcome.     

Training-induced cortical representation of a hemianopic hemifield

Background

Patients with homonymous hemianopia often have some residual sensitivity for visual stimuli in their blind hemifield. Previous imaging studies suggest an important role for extrastriate cortical areas in such residual vision, but results of training to improve vision in patients with hemianopia are conflicting.

Objective

To show that intensive training with flicker stimulation in the chronic stage of stroke can reorganise visual cortices of an adult patient.

Methods

A 61‐year‐old patient with homonymous hemianopia was trained with flicker stimulation, starting 22 months after stroke. Changes in functioning during training were documented with magnetoencephalography, and the cortical organisation after training was examined with functional magnetic resonance imaging (fMRI).

Results

Both imaging methods showed that, after training, visual information from both hemifields was processed mainly in the intact hemisphere. The fMRI mapping results showed the representations of both the blind and the normal hemifield in the same set of cortical areas in the intact hemisphere, more specifically in the visual motion‐sensitive area V5, in a region around the superior temporal sulcus and in retinotopic visual areas V1 (primary visual cortex), V2, V3 and V3a.

Conclusions

Intensive training of a blind hemifield can induce cortical reorganisation in an adult patient, and this case shows an ipsilateral representation of the trained visual hemifield in several cortical areas, including the primary visual cortex.Homonymous hemianopia refers to blindness of a visual hemifield, a common symptom after a lesion in the occipital cortex or in the retinocortical pathway behind the optical chiasm. Neuroimaging studies have indicated residual responsiveness to blind hemifield stimulation in the extrastriate^1,2,3,4,5,6 and spared calcarine cortex,⁷ but studies on improvements of residual vision using training have reported conflicting results. Training of visual functions is not a standard procedure after a local cerebral damage, whereas benefits of motor rehabilitation and reorganisation of the motor cortex are widely accepted.⁸ Plasticity in the primary visual cortex (V1) has been described in primate studies,⁹ but there is an ongoing debate on the capacity of adult V1 for major long‐term reorganisation.^10,11 Overall, there is no previous report on a patient whose hemianopia had been intensively trained and the cortical effects of this training studied with functional imaging.This report describes cortical reorganisation of an adult male patient with homonymous hemianopia. His visual functions in the blind hemifield were trained using difficult detection tasks of flickering discs and recognition of flickering letters. The training procedure and follow‐up findings of psychophysical and neuromagnetic results for this and another patient are described in detail by Raninen et al.¹² Spontaneous recovery during training in this patient was unlikely, because training began in the chronic stage of the stroke. We were careful not to let eye movements or stable eccentric fixation contaminate the results.     

A specialist nurse as a resource for family members to patients with brain tumors: an action research study

There are few scientific publications available with a focus on the value of supportive care services for patients with brain tumors and their families. The present study is part of a project where a specialist nurse (SN) function was implemented for patients with malignant glioma and their next-of-kin. The purpose of the present study was to identify how next-of-kin made use of the SN function. To identify what they asked for when they contacted the nurse is a way of understanding the vulnerability of family members and thus to learn how to provide better support to the benefit of the family. In accordance to a design inspired by action research, the SN approached patients and next-of-kin during diagnosis at the Departments of Oncology/Neurosurgery and informed them that they could use her as a resource when they wanted. The SN documented all contacts with the next-of-kin of 16 consecutive patients in field notes during the course of the disease: telephone calls and personal meetings-who contacted whom, about what, and with what outcome. In addition, summarizing interviews were conducted. The study is based on the field notes and complemented with the interview data. Different needs were expressed throughout the relationship between the next-of-kin and the SN: initially, conversation about the sick family member was paramount, but as time passed, talk about oneself came to the forefront, and thereafter, they also commented on the relationship to the SN in a more personal tone. The relationship to the SN per se is important-the SN function can be far more than a provider of information. Altogether, the platform provided by the SN easily lends itself to the conceptualization of "a secure base" in attachment theory.