European Pain Management Discussion Forum

ABSTRACT

Queries from European physicians about analgesic pharmacotherapy and responses from the author are presented. The topics addressed in this issue are unilateral continuous headache, serotonin syndrome, and myofascial trigger point injections.     

持续性先兆患者治疗前后发作间期SPECT和脑电图的变化

目的：探讨持续性先兆患者的临床特征、发作间期SPECT、长程EEG及CT／MRI特点及其治疗前后的变化。方法：对35例诊断为持续性先兆患者进行治疗前后发作间期SPECT、同步录像脑电图（V-EEG）检查。结果：本组病例发作间期SPECT治疗前正常灌注8例（23％）,异常27例（77％）,其中低灌注12例（34％）,高灌注15例（43％）。治疗后正常灌注增加6例（1Z％）,即正常14例（40％）,异常21例（60％）,异常者中低灌注8例（23％）,高灌注13例f37％）,V—EEG治疗前正常1例,异常（棘慢波发放）34例（97％）,异常者中局限性异常20例（57％）,广泛性异常14例（40％）;治疗后正常增加10例（29％）即正常11例（31％）,异常24例（69％）,其中局限性异常14例（40％）,广泛性异常10例（29％）。结论：持续性先兆以临床和EEG为依据,结合SPECT显像提供的辅助信息,以及CT／MRI等神经影像学结果作出诊断。本组病例经抗癫痴药与中药稳心颗粒联合治疗后,病灶修复率为22％,EEG转化为正常者为31％。     

丙泊酚对毒鼠强诱发大鼠癫痫的抑制作用及机理

目的：观察丙泊酚对毒鼠强诱发癫痫的抑制作用及其机理的实验研究。方法：64只大鼠分为对照组,癫痫发作组,脂肪乳组,安定组,丙泊酚25、50、75、100mg／kg剂量组,观察不同剂量的丙泊酚对惊厥的控制、24h的存活率及脑电图变化。以WesternBlot法观察麻醉剂量丙泊酚对癫痫大鼠皮层和海马GABAA受体α1亚单位表达的影响。结果：丙泊酚25～100mg／kg可剂量依赖性的控制癫痫大发作,增加24h的存活率。丙泊酚25mg／kg剂量组,脑电图仍见明显的高幅棘波;50—100mg／kg剂量组棘波明显减少,波幅显著降低。Western Blot结果：丙泊酚50mg/kg显著增加GABAA受体α1表达。结论：丙泊酚对毒鼠强诱发癫痫持续状态具有确切的治疗效果,其抗惊厥作用可能与其增加GABAA受体α1亚单位表达有关。     

天舒胶囊联合氟桂利嗪治疗偏头痛的meta分析*

目的：系统评价天舒胶囊联合氟桂利嗪治疗偏头痛的有效性与安全性,为临床应用提供一定的参考。方法：检索公开发表的有关天舒胶囊联合氟桂利嗪治疗偏头痛的随机临床对照试验研究的文献,通过Cochrane系统评价方法对所纳入文献进行质量评价,采用 Revman 5.3 软件进行统计分析。结果：共有17篇文献中有符合研究评价需要的RCT,均为中文文献,共计1423名患者。将天舒胶囊联合氟桂利嗪治疗偏头痛的总有效率作为结局指标,最终13个研究被纳入数据合成,各研究间差异无统计学异质性(P =0.96>0.10,I^2=0%),两组总有效率的差异有统计学意义[OR值为3.52,95%CI为[2.51,4.95],P <0.00001]。选取其中疗程在四周或一个月的RCT研究,纳入7篇研究[3.5,9.13],进行亚组分析,结果显示各研究间差异无统计学异质性(P =0.99>0.10,I^2=0%),且两组总有效率的差异有统计学意义[OR值为4.08,95%CI为[2.56,6.50],P <0.00001]。17个研究中,无严重不良反应,少量出现腹部不适、胃脘痛、嗜睡、头晕、体重增加等症状,但都基本改饭后服药或在继续用药后消失。结论：天舒胶囊联合氟桂利嗪治疗偏头痛的疗效要优于单纯使用氟桂利嗪,且不良反应较少。     

Epilepsia partialis continua with dystonic hand movement in a patient with a malformation of cortical development.

Malformations of cortical development (MCD) with polymicrogyria and schizencephaly are due to abnormal cortical organization and usually manifest by intractable epilepsy and mental retardation. Epileptical activity is often hard to register and focal dystonia associated with such MCD has previously been described but without any metabolic imaging. We report here a 46-year-old man presenting with late-onset atypical abnormal movements of his left hand associated with right central region MCD. To demonstrate the involvement of an epileptical focus, we performed [(18)F]FDG-PET and fMRI both before and after a single dose of clobazam and diazepam, respectively. Characteristics of the abnormal hand movements, clinical response to the medication, and the result of the [(18)F]FDG-PET and fMRI investigations all favor the diagnosis of epilepsia partialis continua. We conclude that the dystonic movement is part of the partial seizure.     

'Side locked' migraine and trigeminal autonomic cephalgias: evidence for clinical overlap

This paper will discuss evidence which supports a link between 'side locked' migraine (SLM) and the trigeminal autonomic cephalgias (TACs). Recent papers brought strictly unilateral primary headaches into focus, proposing new classification and discussing pathophysiological mechanisms. We reviewed those proposals and present evidence that SLM falls in between the well-defined TACs and side shifting migraine (SSM). It is difficult to differentiate SLM from the recently proposed headache subtype called hemicrania generis incerti (i.e. hemicrania continua unresponsive to indomethacin). We also present cases that may exemplify the considerations made in the paper.     

儿童持续性部分性癫痫诊治进展

持续性部分性癫痫(EPC)是一种由于大脑皮层神经元异常放电导致的局限性、持续性肌肉收缩(间隔时间不超过10 s,持续时间不小于1 h)的局灶性癫痫持续状态。EPC的病因决定了其临床特征、治疗和预后。文章从病因的角度综述EPC的诊治进展,以提高对EPC的认识。     

Development and Validation of the OSA-CPAP Perceived Competence Evaluation Interview

IntroductionContinuous positive airway pressure (CPAP) is one of the most common therapies for Obstructive Sleep Apnea (OSA). We present a brief, patient-reported outcome measure used to assess patients’ levels of adherence with CPAP treatment.MethodsA questionnaire was developed based on academic literature. We qualitatively tested a pool of 18 items. It was tested in a sample of 174 patients from the Hospital La Princesa. Next, 1021 patients from Catalonia were evaluated.Results5 items were removed. Nominal groups referred to three areas: general knowledge about OSA and its risks; CPAP treatment information and expectations; CPAP use, monitoring, and confidence with its use. The 13 retained items maintained the same meaning as the original questionnaire (r = .986; p < .001) and the three proposed dimensions detected a significant increase in general knowledge of OSA (t[173] = 8.097, p < .001); CPAP treatment information (t[173] = 15.170, p < .001); and CPAP use (t[173] = 14.642, p < .001). The final 12-item version was reliable (CRI = .793) and its internal structure was adequate (χ²[51] = 72.073; p = .027, CFI = .967, RMSEA = .020 [.000, .030]). Women had a better general knowledge of OSA (t[1,018] = 2.190, p = .029), CPAP treatment information (t[1,018] = 2.920, p = .004), and higher overall OSA-CPAP scores (t[1,018] = 3.093, p = .002). Scores were positively related to quality of life and motivation, adherence was positively related to CPAP use and monitoring, and the total score was negatively related to daytime sleepiness.ConclusionsThe interview could help clinicians prevent some dropouts by targeting patients with lower adherence. It's a tool for assessing patient adherence to CPAP and to promote strategies through education and external motivational stimuli.     

Adult-Onset Rasmussen's Encephalitis: Anatomical-Electrographic-Clinical Features of 7 Italian Cases

Summary:  Purpose: A limited number of cases of adult-onset Rasmussen's encephalitis (A-RE) have been reported, but the features of the syndrome are still unclear. The aim of this study was to verify the clinical features of A-RE, and outline a noninvasive approach that may allow its early diagnosis and treatment.
Methods: Retrospective evaluation of extensive noninvasive work-up of seven patients with A-RE, including repeat clinical, neurophysiological, and neuroimaging investigations.
Results: The study identified two distinct patterns of disease presentation, one characterized by focal motor epilepsy (the "epileptic" phenotype), and the other by focal cortical myoclonus (the "myoclonic" phenotype). Unilateral neurological deficits and brain atrophy were progressive in both phenotypes, but they were more prominent and were detected earlier in the "epileptic" phenotype.
Conclusions: The anatomo-electroclinical features of these patients allowed a noninvasive diagnosis of A-RE and identification of two distinct disease phenotypes. Early noninvasive diagnosis can allow faster initiation of treatment.