Treatment of Chronic Pain with Buprenorphine in a Veteran with Traumatic Brain Injury

Case presentation:

We report a case of a 27-year-old Iraq War veteran with no previous psychiatric history who sustained severe traumatic brain injury (TBI) following a blast injury from an improvised explosive device. The patient subsequently suffered severe anxiety symptoms controlled only with combined therapy with benzodiazepines and venlafaxine. Even more disabling, the patient also experienced intractable headache and shoulder pain unresponsive to non-steroidal anti-inflammatory agents, tramadol, gabapentin, or NMDA-receptor antagonists. Given the risk of respiratory depression with his current medications, opioid analgesics were not favored for the management of his pain. The patient was started on sublingual buprenorphine at a dose of 8mg three times daily with significant improvement. This dose was maintained and the patient was able to function relatively pain-free.

Conclusion:

Chronic pain is a significant complication in patients with TBI and is reported by a majority of patients with TBI, regardless of the severity of the injury. The treatment of chronic pain among individuals can be challenging. Patients with TBI may be on other medications for impulse control, such as anticonvulsants and benzodiazepines. Further treatment with narcotic analgesics may therefore increase the risk of respiratory depression. Buprenorphine is a partial mu agonist whose effects plateau at higher doses, at which time it begins to act like an antagonist. It is this property at higher doses that limits its dose-dependent respiratory depression. Buprenorphine thus has the advantage of effective analgesia with minimal sedation and may be useful to treat chronic pain among TBI patients already taking benzodiazepines.

Gastroduodenal dysmotility in patients with gallbladder carcinoma: frequency of occurrence and clinical importance

BACKGROUND

Gastric stasis, common in patients with gall-bladder carcinoma (GBC), results from anatomical obstruction or motor abnormalities. We studied patients with GBC for antroduodenal motor dysfunction using manometry.

METHODS

Forty-one patients with GBC without endoscopic gastric outlet obstruction and 10 healthy controls were evaluated using a symptom scoring system for gastric stasis, saline load test and water perfusion antroduodenal manometry. Fasting, post-prandial and post-octreotide motility were recorded and analysed on a computer using GiPC manometry software.

RESULTS

Sixteen of 41 patients (39%) with GBC reported recurrent vomiting; patients with vomiting had a higher symptom score (13 [11-17] v. 6 [4-10], p<0.0001] and higher volume of aspirate on the saline load test (460 ml [210-650] v. 160 ml [70-260], p<0.0001) as compared with those without vomiting. Healthy subjects more often had spontaneous fasting migratory motor complex than patients with GBC (9/10 v. 13/41, p=0.002). The amplitudes of contractions in the antrum and duodenum were significantly lower in patients with GBC than in healthy subjects. Patients with GBC had lower fasting (157 [68-284] v. 190.5 [150-284], p=0.01) and post-prandial (200 [96-395] v. 284 [178-395], p<0.0001) antral motor indices than healthy subjects. Patients with GBC and vomiting had significantly lower contraction amplitude and motility indices than those without vomiting. Motility indices correlated inversely with the symptom score and volume of aspirate on the saline load test (Spearman correlation, p = 0.01 for all).

CONCLUSION

Antroduodenal motor abnormalities are common in patients with GBC. These may explain the symptoms of gastric stasis and abnormal results of the saline load test in the absence of anatomical obstruction in such patients.

Prevalence of dementia in an urban Indian population

This article reports the findings of a 3-year epidemiological survey for dementia in an urban community-resident population in Mumbai (Bombay), India, wherein the prevalence of all types of dementia was determined.

METHOD

The study was conducted in three stages. Stage 1: From a potential pool of 30,000 subjects aged 40 years or more, 24,488 (male = 11,875; female = 12,613) persons completed self-report or interviewer-rated protocols based on the Sandoz Clinical Assessment Geriatric Scale, but 5,512 (18.37%) persons refused to participate. Scores on the protocol had a possible range from 0 through 34. Stage 2: Persons with a score +2 SD above the mean were selected in this stage where the persons were screened for cognitive functioning using a modified and translated version of the Mini-Mental State Examination. Individuals who scored below the 5th percentile were included in Stage 3 and underwent a detailed neurological, psychiatric, and neuropsychological evaluation as well as hematological, radiological, electrocardiographic, and electroencephalographic investigations. Diagnoses were made jointly by a neurologist, psychiatrist, and psychologist using the DSM-IV diagnostic criteria. Subjects were also rated on the Clinical Dementia Rating (CDR) scale and assessed for activities of daily living.

RESULTS

One hundred five subjects with dementia (CDR > or = 0.5) were identified in this population of 24,488 persons. The prevalence rate for dementia in those aged 40 years and more was 0.43% and for persons aged 65 and above was 2.44%. Seventy-eight individuals had a CDR of > or = 1 yielding an overall prevalence rate of 0.32%, and a prevalence rate of 1.81% for those aged 65 years and older. The overall prevalence rate for Alzheimer's disease (AD) in the population was 0.25%, and 1.5% for those aged 65 years and above. AD (n = 62; 65%) was the most common cause of dementia followed byvascular dementia (n = 23; 22%). There were more women (n = 38) than men (n = 24) in the AD group. Increasing age was associated with a higher prevalence of the dementia syndrome in general as well as AD specifically.

CONCLUSION

In the population surveyed, the prevalence of AD and other dementias is less than that reported from developed countries but similar to results of other studies in India. Prevalence of the dementia syndrome increased with age and was not related to gender. AD was the most common dementia and the prevalence was higher in women than in men. Results are discussed with respect to shorter life expectancy, relocation of affected persons, and differences in the risk factors as compared to developed countries.

Characterization of a two-component system, devR-devS, of Mycobacterium tuberculosis

By subtractive hybridization, we isolated genes, differentially expressed in virulent strain (dev), that are expressed at higher levels in the virulent Mycobacterium tuberculosis H37Rv strain in comparison to its avirulent counterpart, H37Ra, and consequently may be associated with the virulence phenotype of M. tuberculosis. A two-component system, devR-devS, was identified by DNA sequencing of a dev clone. DevR, the predicted gene product of devR, is a response regulator (RR) in the NarL/ UhpA subfamily of two-component systems. The devS gene product displayed homology with histidine protein kinases (HPKs) including UhpB, NarX and NarQ. The devR-devS locus is preceded by gene Rv3134c that encodes a putative alanine-aline- rich protein. This locus was conserved in M. tuberculosis and M. bovis BCG but not in other mycobacteria. A devR -lacZ transcription fusion demonstrated beta-galactosidase activity in M. smegmatis and in M. tuberculosis. The devR and devS genes were cotranscribed and the levels of their transcripts were lower in two isolates of the avirulent H37Ra strain in comparison to the virulent H37Rv strain of M. tuberculosis. The level of DevR protein was also lower in one of the H37Ra strains in comparison to the H37Rv strain. However, in a third isolate of H37Ra, RNA and protein expression was equivalent to that in the H37Rv strain. Electron microscopic immunogold analysis of M. tuberculosis grown in laboratory medium and within human monocytes revealed specific labelling for DevR protein within the bacteria and the phagosomal lumen of infected monocytes. These findings collectively suggest a potential role for devR-devS in the regulation of genetic programmes unique to the tubercle bacillus.

Physiological analysis to quantify training load in badminton

OBJECTIVE

To estimate the training load of specific on court training regimens based on the magnitude of variation of heart rate-lactate response during specific training and to determine the magnitude of variation of biochemical parameters (urea, uric acid, and creatine phosphokinase (CPK)) 12 hours after the specific training programme so as to assess training stress.

METHODS

The study was conducted on six national male badminton players. Maximum oxygen consumption (VO2), ventilation (VE), heart rate, and respiratory quotient were measured by a protocol of graded treadmill exercise. Twelve training sessions and 35 singles matches were analysed. Heart rate and blood lactate were monitored during technical training routines and match play. Fasting blood samples collected on two occasions--that is, during off season and 12 hours after specific training--were analysed for serum urea, uric acid, and CPK.

RESULTS

Analysis of the on court training regimens showed lactate values of 8-10.5 mmol/l in different phases. The percentage of maximum heart rate ranged from 82% to 100%. Urea, uric acid, and CPK activity showed significant changes from (mean (SD)) 4.93 (0.75) mmol/l to 5.49 (0.84) mmol/l, 0.23 (0.04) to 0.33 (0.06) mmol/l, and 312 (211.8) to 363 (216.4) IU/l respectively.

CONCLUSION

Maximum lactate reported in the literature ranges from 3-6 mmol/l. Comparatively high lactate values and high percentage of maximum heart rate found in on court training show a considerable stress on muscular and cardiovascular system. The training load needs appropriate monitoring to avoid over-training. Workouts that are too intensive may interfere with coordination, a factor that is important in sports requiring highly technical skill such as badminton.

Altered fetal growth: antenatal diagnosis by symphysis-fundal height in India and comparison with western charts

Antenatal identification of altered fetal growth is a significant problem in spite of the availability of sophisticated technology. The present study was undertaken to generate symphysis-fundal height curves locally for an Indian population and to assess their value in predicting altered fetal growth. The measurements were found to have a high sensitivity of 80.8% and specificity of 93.5% in detection of small for date babies and a sensitivity and specificity of 72.2% and 95.2%, respectively in detection of fetal macrosomia. The locally generated symphysis-fundal height charts have been compared with the western charts and the differences stressed. It is concluded that symphysis-fundal height curves should be locally generated for best results.

Immunohistochemical characterisation of Aschoff nodules and endomyocardial inflammatory infiltrates in left atrial appendages from patients with chronic rheumatic heart disease

Fifty left atrial appendages collected fresh during closed mitral valvotomy in patients with chronic rheumatic heart disease, were analysed to determine the frequency of Aschoff nodules and characteristics of mononuclear inflammatory infiltration. Fifty-six percent of specimens demonstrated Aschoff nodules with no clinical or laboratory evidence of acute rheumatic activity in the patients undergoing surgery. Endomyocardial infiltration contained predominantly T cells and occasionally B cells. The relative proportions of T helper-inducer, T suppressor-cytotoxic lymphocytes and macrophages were 45.1 +/- 7.6, 23.5 +/- 4.8 and 29.3 +/- 9.6%, respectively. Frequent presence of Aschoff nodules and heavy mononuclear infiltrates in chronic rheumatic heart disease suggests a possibility of subclinical ongoing carditis.

High progesterone/estradiol ratio in follicular fluid at oocyte aspiration for in vitro fertilization as a predictor of possible pregnancy

Eighteen women undergoing in vitro fertilization (IVF) procedures were studied. All had optimal (900 to 1600 pg/ml) peak serum estradiol (E2) response to the same stimulation regimen with clomiphene citrate and menotropins; fertilization rate was above 64%; and two to four embryos in two to eight cell stages were replaced in each patient. All were considered to have optimal chances for conception. The authors compared progesterone (P), E2, and P/E2 ratio in serum and follicular fluid (FF) at the time of oocyte aspiration in eight patients who conceived (group I) and ten who did not (group II). Mean serum P and E2 levels and serum P/E2 ratio were not significantly different between the groups. In contrast, mean FF P concentrations (ng/ml) were significantly (P less than 0.05) higher in group I (9721 versus 5385), as was FF P/E2 ratio (19.0 versus 11.8; P less than 0.02). There was no significant difference in mean FF E2 concentrations between the groups. These data indicate that in IVF cycles with optimal serum E2 response to the stimulation protocol, FF P and P/E2 ratio at the time of oocyte aspiration may be predictive of subsequent implantation and pregnancy.

Salivary and gastric secretions in patients with tropical sprue

Salivary secretions on mechanical stimulation with forced spitting method and on chemical simulation with 10% citric acid and gastric acid secretions on maximal histamine stimulation were studied in 20 adults with tropical sprue and 20 adult control subjects. It was observed that the chemical method provided a better stimulus than the mechanical one in both groups. The salivary flow rates as well as salivary amylase, pH, sodium and potassium were similar in both groups. Tropical sprue patients, however, had significantly lower maximal acid output as compared to normals. It was concluded that, although tropical sprue patients are known to have widespread damage to alimentary tract mucosa, salivary glands do not seem to be involved.