Therapeutic potential of silymarin as a natural iron‐chelating agent in β‐thalassemia intermedia

Abnormal iron accumulation in vital organs is one of the major complications of β‐thalassemia intermedia (β‐TI). Silymarin, a flavonolignan isolated from Silybum marianum, significantly decreases the serum ferritin levels of β‐TI patients. This finding suggests silymarin as a safe and effective natural iron‐chelating agent for the treatment of iron‐overloaded conditions.     

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BackgroundAbscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.ObjectiveThis review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.DiscussionUltrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.ConclusionsThis review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.     

The Dorsolateral Prefrontal Cortex in Acute and Chronic Pain

The dorsolateral prefrontal cortex (DLPFC) is a functionally and structurally heterogeneous region and a key node of several brain networks, implicated in cognitive, affective, and sensory processing. As such, the DLPFC is commonly activated in experimental pain studies, and shows abnormally increased function in chronic pain populations. Furthermore, several studies have shown that some chronic pains are associated with decreased left DLPFC gray matter and that successful interventions can reverse this structural abnormality. In addition, studies have indicated that noninvasive stimulation of the left DLPFC effectively treats some chronic pains. In this article, we review the neuroimaging literature regarding the role of the DLPFC and its potential as a therapeutic target for chronic pain conditions, including studies showing the involvement of the DLPFC in encoding and modulating acute pain and studies demonstrating the reversal of DLPFC functional and structural abnormalities after successful interventions for chronic pain. We also review studies of noninvasive brain stimulation of the DLPFC showing acute pain modulation and some effectiveness as a treatment for certain chronic pain conditions. We further discuss the network architecture of the DLPFC, and postulate mechanisms by which DLPFC stimulation alleviates chronic pain. Future work testing these mechanisms will allow for more effective therapies.

Evaluation of the acutely dyspneic elderly patient

Dyspnea is among the most frequent complaints in the elderly. The prevalence of comorbid medical conditions and the physiologic changes of aging present significant challenges in determining the cause. The initial approach to the elderly dyspneic patient mandates consideration of a broad range of diagnoses. Failure to diagnose life-threatening medical conditions presenting with dyspnea such as pulmonary embolus, acute coronary syndromes, congestive heart failure, asthma, obstructive pulmonary disease, pneumothorax, and pneumonia can lead significant morbidity and mortality. This article focuses on the rapid assessment and approach to the acutely dyspneic elderly patient.     

Contribution of chronic pain and neuroticism to abnormal forebrain gray matter in patients with temporomandibular disorder

Cortical plasticity is thought to occur following continuous barrage of nociceptive afferent signals to the brain. Hence, chronic pain is presumed to induce anatomical and physiological changes in the brain over time. Inherent factors, some pre-dating the onset of chronic pain, may also contribute to brain abnormalities present in patients. In this study we used structural MRI to examine whether patients with chronic temporomandibular (TMD) pain have abnormalities in gray matter (GM) within brain areas implicated in pain, modulation and sensorimotor function. We found that patients with TMD have cortical thickening in the primary somatosensory cortex (S1), frontal polar and the ventrolateral prefrontal cortex (PFC). These findings provide a structural basis for previous findings of TMD pain and cognitive sluggishness in TMD. We then examined the contribution of TMD characteristics to GM abnormalities. We found that 1) GM in the sensory thalamus positively correlated to TMD duration, 2) cortical thickness in the primary motor (M1) and the anterior mid-cingulate cortices (aMCC) were negatively correlated to pain intensity, and 3) pain unpleasantness was negatively correlated to cortical thickness in the orbitofrontal cortex (OFC). These findings suggest that an individual's TMD pain history contributes to GM in the brain. Lastly, we examined the contribution of a potential pre-existing vulnerability due to neuroticism. In the TMD patients, we found that there was an abnormal positive correlation between neuroticism and OFC thickness, in contrast to the negative correlation found in the healthy controls. Therefore, neuroticism may contribute to TMD pathophysiology. In sum, our data suggest that GM in the brain of patients with chronic TMD pain can be shaped by both personality and pain characteristics.     

Abnormal cortical activity in patients with temporomandibular disorder evoked by cognitive and emotional tasks

Patients with temporomandibular disorder (TMD) perform poorly in neuropsychological tests of cognitive function. These deficits might be related to dysfunction in brain networks that support pain and cognition, due to the impact of chronic pain and its related emotional processes on cognitive ability. We therefore tested whether patients with TMD perform poorly in cognitive and emotion tasks and whether they had abnormal task-evoked brain activity. Seventeen female subjects with nontraumatic TMD and 17 age-matched healthy female subjects underwent functional magnetic resonance imaging while performing counting Stroop tasks comprising neutral words, incongruent numbers, or emotional words, including TMD-specific words. Group differences in task-related brain responses were assessed. Connectivity between 2 pairs of coupled brain regions during the cognitive and emotional tasks (prefrontal-cingulate and amygdala-cingulate) was also examined. The patients had sluggish Stroop reaction times for all Stroop tasks. Furthermore, compared to controls, patients showed increased task-evoked responses in brain areas implicated in attention (eg, lateral prefrontal, inferior parietal), emotional processes (eg, amygdala, pregenual anterior cingulate), motor planning and performance (eg, supplementary and primary motor areas), and activation of the default-mode network (medial prefrontal and posterior cingulate). The patients also exhibited decoupling of the normally correlated activity between the prefrontal and cingulate cortices and between the amygdala and cingulate cortex. These findings suggest that the slow behavioral responses in idiopathic TMD may be due to attenuated, slower, and/or unsynchronized recruitment of attention/cognition processing areas. These abnormalities may be due to the salience of chronic pain, which inherently requires attention.     

Effects of one-year storage in water on bond strength of self-etching adhesives to enamel and dentin

The aim of this study was to compare the bond strengths of three self-etching materials during one year of storage. Clearfil SE Bond (SE), Clearfil Protect Bond (PB), and Clearfil Tri-S Bond (TS) were used for bonding to dentin and enamel according to manufacturer's instructions. Microshear bond strength values were measured after 24 hours, six months, and one year. Two-way ANOVA showed that the interaction of material type and storage time was significant for dentin. At baseline, SE had the highest bond strength to dentin. There were no significant changes in bond strength for each material during the storage period, except for PB which showed increased bond strength to dentin after one year. All materials performed reliably after one year. However, the antibacterial and fluoride-releasing effects of PB would further contribute to the long-term clinical benefits of this material.