Factors Associated with the Development of Chronic Pain after Surgery for Breast Cancer: A Prospective Cohort from a Tertiary Center in the United States

Chronic pain has been shown to affect up to 60% of patients undergoing surgery for breast cancer. Besides younger age, other risk factors for the development of chronic pain have not been consistent in previous studies. The objective of the current investigation was to detect the prevalence and risk factors for the development of chronic pain after breast cancer surgery by examining a patient population from a tertiary cancer center in the United States. The study was a prospective observational cohort study. Subjects were evaluated at least 6 months after the surgical procedure. Subjects responded to the modified short form Brief pain inventory and the short form McGill pain questionnaire to identify and characterize pain. Demographic, surgery, cancer treatment, and perioperative characteristics were recorded. Propensity matching regression analysis were used to examine risk factors associated with the development of chronic pain. 300 patients were included in the study. 110 reported the presence of chronic pain. Subjects with chronic pain reported median (interquartile range [IQR]) rating of worst pain in the last 24 hours of 4 (2–5) and a median (IQR) rating on average pain in the last 24 hours of 3 (1–4) on a 0–10 numeric rating scale. Independent risk factors associated with the development of chronic pain were age, OR (95% CI) of 0.95 (0.93–0.98) and axillary lymph node dissection, 7.7 (4.3–13.9) but not radiation therapy, 1.05(0.56–1.95). After propensity matching for confounding covariates, radiation was still not associated with the development of chronic pain. Chronic pain after mastectomy continues to have a high prevalence in breast cancer patients. Younger age and axillary lymph node dissection but not radiation therapy are risk factors for the development of chronic pain. Preventive strategies to minimize the development of chronic pain are highly desirable.     

Acute Sildenafil Use Reduces 24‐Hour Blood Pressure Levels in Patients With Resistant Hypertension: A Placebo‐Controlled,Crossover Trial

The authors previously demonstrated that acute administration of sildenafil—a phosphodiesterase 5 (PDE5) inhibitor—improves hemodynamic parameters in patients with resistant hypertensive (RH), but its effect on ambulatory blood pressure monitoring (ABPM) is unknown. This interventional, nonrandomized, single‐blinded, placebo‐controlled, crossover trial included 26 patients with RH. A dose of sildenafil (187.5mg) was given, and after a washout period of 14 days the patients received a single oral dose of placebo and the protocol was repeated. The patients underwent 24‐hour ABPM recordings the day before and immediately after the protocols. The reduction of systolic (−8.8±1.4 vs 1.3±1.2 mm Hg, P=.02), diastolic (−5.3±3.3 vs 1.8±1.1 mm Hg, P=.03), and mean (−7.9±3.6 vs 0.8±0.9 mm Hg, P=.01) 24‐hour BP were found after the use of sildenafil compared with placebo. Improvement in daytime BP levels was also observed (systolic −6.0±4.7 vs 4.4±1.5 mm Hg [P=.02] and mean −4.8±3.9 vs 3.5±1.4 mm Hg [P=.02] for sildenafil vs placebo, respectively). Considering its antihypertensive effect, sildenafil may represent a therapeutic option for RH treatment.

The pathogenesis of resistant hypertension (RH) is multifactorial,¹ impacting a worse prognosis when compared with controlled hypertension.² The mechanisms of resistance to antihypertensive therapy are not completely understood and can be modulated by several interrelated factors such as (1) hyperactivation of the sympathetic nervous and renin‐angiotensin‐aldosterone system,³, ⁴ (2) volume expansion,⁵ (3) endothelial dysfunction,⁶, ⁷ (4) inflammatory processes,⁸ and (5) increased peripheral vascular resistance.⁹ Although there is little evidence related to populations with RH, effective blood pressure (BP) control reduces the risk of cardiovascular events in general hypertensive patients and should be targeted.¹⁰ New drug therapies have been proposed, but BP control remains a challenge for patients with RH.¹¹ Phosphodiesterase type 5 (PDE5) inhibitors are safe and effective drugs presenting vasodilatory effects that provide office BP reductions in untreated¹² and resistant hypertensive patients.¹³ Recently, our group has shown an improvement in hemodynamic parameters after acute administration of sildenafil in patients with RH.¹⁴ Although ambulatory BP monitoring (ABPM) is superior to casual BP for predicting organ damage in hypertensive patients,¹⁵, ¹⁶ the influence of sildenafil on ABPM was never assessed in patients with RH.The present study sought to evaluate the effects of sildenafil on ABPM in patients with RH. We hypothesized that acute administration of sildenafil—a PDE5 inhibitor—compared with placebo improves 24‐hour BP levels in patients with resistance to antihypertensive therapy.     

Cytomegalovirus infection and disease after liver transplantation

Cytomegalovirus is the single most important pathogen in clinical transplantation. Although much progress has been made in our understanding of the molecular biology and epidemiology of CMV infection and in our ability to diagnosis and treat CMV disease, it remains a major cause of morbidity but is no longer a major cause of mortality after liver transplantation. Risk factors for CMV disease after liver transplantation include donor and recipient serologic status, the use of antilymphocyte therapy, and retransplantation. CMV disease occurs early after transplantation, and the most frequent site of disease is the hepatic allograft. We have treated 79 patients with intravenous ganciclovir, with ultimate control of disease achieved in 69 patients (87.3%). Preliminary results using intravenous immunoglobulin and oral acyclovir for CMV prophylaxis in high-risk patients have been encouraging. In addition to producing clinical syndromes, CMV may have direct immunologic effects and is a marker of the net state of immunosuppression.     

Effects of androgens on bone in men and women

Although the beneficial effects of estrogen on bone have been proven in multiple well-designed clinical trials, with respect to testosterone and androgens, the data are less definitive. Testosterone appears to have a role in the development and maintenance of bone mass; however, the mechanism by which androgens exert their effects on bone is still not clearly understood. Despite the increasing use of testosterone supplementation in men and women for the prevention and treatment of osteoporosis, in sufficient evidence exists to support the widespread use of these agents for this indication at this time. The data supporting the beneficial effects of testosterone on bone mineral density are more convincing in hypogonadal men than in men with normal testosterone levels, or in women. The transdermal route of administration is often preferred for testosterone therapy because it avoids the first-pass metabolism associated with oral formulations and the pain experienced with intramuscular injections. Other androgens, including an abolic steroids and dihydroepiandrosterone, have also been used. In addition to monitoring for therapeutic response on initiation of androgen therapy, assessment for potential adverse events should be implemented. This should include assessment for adverse effects on the liver and alterations in the lipid profile in both men and women. Men should also be monitored for prostate growth, gynecomastia, priapism, decreased libido, and erythrocytosis, whereas women should be monitored for virilizing effects. Ongoing research into the pathophysiology and clinical effects of testosterone on bone will provide more insights regarding the utility of androgens in these populations.     

Prevalence of hepatitis C virus infection in asymptomatic anti-HIV1 negative pregnant women and their children

The prevalence of hepatitis C virus (HCV) infection was studied prospectively in pregnant women in France and their children by detection of anti-HCV with second-generation ELISA (ELISA2). In ELISA2-positive women, anti-HCV was detected with second- and third-generation RIBA (RIBA2 and RIBA3) and serum HCV RNA was detected with PCR. Among 670 women, anti-HIV1-negative, 26 (3.9%) were positive with ELISA2. RIBA2 was positive in 13 and HCV RNA was found in 10. Ten ELISA2-positive women had a further evaluation with assessment of HCV infection in their children. Among the 10 children born to the index pregnancy, only one was positive with ELISA2 and RIBA2 but negative with RIBA3 and PCR; the nine other children were ELISA2, RIBA2, RIBA3, and PCR negative. All 26 siblings (2–16 years old), of whom 14 were born to PCR-positive mothers, were ELISA2 and RIBA2 negative. We conclude that among anti-HIV1-negative pregnant women with normal serum ALT levels, the prevalence of HCV infection is relatively high but the risk for mother-to-infant transmission of HCV seems to be low.