Opioid analgesic effects on subjective well-being in the operating theatre

Exposure to opioid analgesics due to surgery increases the risk of new persistent opioid use. A mechanistic hypothesis for opioids' abuse liability rests on the belief that, in addition to pain relief, acute opioid treatment improves well-being (e.g. via euphoria) and relieves anxiety. However, opioids do not consistently improve mood in laboratory studies of healthy non-opioid users. This observational study determined how two commonly used opioid analgesics affected patients' subjective well-being in standard clinical practice. Day surgery patients rated how good and how anxious they felt before and after an open-label infusion of remifentanil (n = 159) or oxycodone (n = 110) in the operating theatre before general anaesthesia. One minute after drug injection, patients reported feeling intoxicated (> 6/10 points). Anxiety was reduced after opioids, but this anxiolytic effect was modest (remifentanil Cohen's d = 0.21; oxycodone d = 0.31). There was moderate to strong evidence against a concurrent improvement in well-being (Bayes factors > 6). After remifentanil, ratings of 'feeling good' were significantly reduced from pre-drug ratings (d = 0.28). After oxycodone, one in three participants felt better than pre-drug. Exploratory ordered logistic regressions revealed a link between previous opioid exposure and opioid effects on well-being, as only 14 of the 80 opioid-naïve patients reported feeling better after opioid injection. The odds of improved well-being ratings after opioids were higher in patients with previous opioid exposure and highest in patients with > 2 weeks previous opioid use (adjusted OR = 4.4). These data suggest that opioid-induced improvement of well-being is infrequent in opioid-naïve patients. We speculate that peri-operative exposure could increase risk of persistent use by rendering subsequent positive opioid effects on well-being more likely.

DIY Flap Monitoring: The Glucose Index

Background

Flap loss is reduced by monitoring, which detects vascular compromise. Glucose levels vary in suffering flaps; therefore, we aimed to show that monitoring flaps with glucose pinprick test is a cheap, reliable, ubiquitous, and easy method.

Methods

We reviewed a prospectively kept database. A pinprick test was performed to measure systemic and flap glucose levels. A glucose index (GI; flap glucose/systemic glucose) was calculated. Comparison between the groups (with occlusive event, and without occlusive event) was done.

Results

In total, 32 flaps in 29 consecutive patients were included. Eleven (34%) were free flaps. Of these, one (9%) was explored twice. Initially, salvage was achieved. However, 36 hours later, a second exploration was needed but was unsuccessful. Of the 21 pedicled flaps (66%), one (5%) needed exploration (suture release), and three (14%) had partial losses that were not clinically relevant. On the ROC curve, we found a cut-off value for a GI of 0.49 or less with a sensitivity of 95% [95% confidence interval (CI): 75.1 to 99.9%] and a specificity of 100% (95% CI: 98.5 to 100%), with a positive predictive value of 100% (95% CI: 81.5 to 100%) and a negative predictive value of 99.6% (95% CI: 97.8 to 100%) for flap suffering.

Conclusions

The GI, as a complement, assists in defining treatment approach. It is an easy, reliable, accessible method that can be performed by nonmedical personnel. Its main drawback is the inability to monitor buried or hard to reach flaps.

Seminal vesicle fluid increases the efficacy of intravaginal HSV-2 vaccination

Once considered merely as a vehicle for spermatozoa, it is now clear that seminal plasma (SP) induces a variety of biological actions on the female reproductive tissues able to modulate the immune response against paternal antigens. To our knowledge, the influence of SP on the immune response against sexually transmitted pathogens has not been yet evaluated. We here analyzed whether the seminal vesicle fluid (SVF), which contributes almost 60% of the SP volume in mice, could modulate the immune response against herpes simplex virus type 2 (HSV-2). We found that SVF does not modify the course of primary infection, but markedly improved protection conferred by vaginal vaccination with inactivated HSV-2 against a lethal challenge. This protective effect was shown to be associated to a robust memory immune response mediated by CD4+ and CD8+ T cells in both the lymph nodes draining the vagina and the vaginal mucosa, the site of viral replication. In contrast with the widespread notion that SP acts as an immunosuppressive agent, our results suggest that SVF might improve the female immune response against sexually transmitted pathogens.

Histidine-rich glycoprotein and idiopathic pulmonary fibrosis

Histidine-rich glycoprotein (HRG) is an enigmatic glycoprotein able to interact with a variety of ligands such as IgG, complement components, heparan sulfate, thrombospondin, fibrinogen and plasminogen. HRG is present at high concentrations in plasma and there is evidence indicating that it is able to modulate the course of biological processes such as angiogenesis, fibroblast proliferation, complement activation, coagulation and fibrinolysis. Because these processes are involved in the pathogeneses of lung fibrosis we here analyzed a possible link between HRG and idiopathic pulmonary fibrosis (IPF). We found that plasma concentrations of HRG are significantly diminished in IPF patients compared to healthy subjects. Moreover, we found a positive correlation between HRG plasma levels and forced vital capacity (FVC) values, suggesting that plasma concentration of HRG would be a useful indicator of disease activity in IPF. HRG has been described as a negative acute phase reactant able to accumulate at sites of tissue injury. Hence, we also measured the concentrations of HRG in BAL samples from IPF patients. We found that the concentrations of HRG in samples from IPF patients were significantly higher compared to controls, suggesting that the reduced concentration of HRG in plasma from IPF patients could be due, at least in part, to an enhanced uptake of this protein in the lung.

The search for the primary tumor in metastasized gastroenteropancreatic neuroendocrine neoplasm

Gastroenteropancreatic neuroendocrine tumors (NETs) often present as liver metastasis from a carcinoma of unknown primary. We recently showed that primary NETs from the pancreas, small intestine and stomach as well as their respective liver metastases differ from each other by the expression profile of the three genes CD302, PPWD1 and ABHB14B. The gene and protein expression of CD302, PPWD1, and ABHB14B was studied in abdominal NET metastases to identify the site of the respective primary tumors. Cryopreserved tissue from NET metastases collected in different institutions (group A: 29, group B: 50, group C: 132 specimens) were examined by comparative genomic hybridization (Agilent 105 K), gene expression analysis (Agilent 44 K) (groups A and B) and immunohistochemistry (group C). The data were blindly evaluated, i.e. without knowing the site of the primary. Gene expression analysis correctly revealed the primary in the ileum in 94 % of the cases of group A and in 58 % of group B. A pancreatic primary was predicted in 83 % (group A) and 20 % (group B), respectively. The combined sensitivity of group A and B was 75 % for ileal NETs and 38 % for pancreatic NETs. Immunohistochemical analysis of group C revealed an overall sensitivity of 80 %. Gene and protein expression analysis of CD302 and PPWD1 in NET metastases correctly identifies the primary in the pancreas or the ileum in 80 % of the cases, provided that the tissue is well preserved. Immunohistochemical profiling revealed CD302 as the best marker for ileal and PPWD1 for pancreatic detection.

Telomerase activity and telomere length in different areas of renal cell carcinoma

Telomerase activity and telomere length were analyzed in a total of 59 surgically removed primary renal cell carcinoma (RCC). The study includes tissue from the centre of the tumor, several different peripheral tumor areas, metastases and secondary tumors. None of the normal renal cortex tissues used as control exhibited telomerase activity. In contrast, telomerase activity was detected in 55 out df 59 (=93%) tested primary RCC. There was no case with intratumoral heterogeneity concerning the telomerase activity status. All metastases and secondary tumors were telomerase-positive. In the four telomerase deficient tumors all measured telomeric repeat fragments were shortened in comparison to the normal tissue. As these patients exhibit no metastases or secondary tumors a less malignant variant of RCC is supposed. There was no correlation between telomerase activity and specific histopathological subtypes of RCC or specific chromosomal aberrations. As telomerase activity is not associated with advanced stages of tumors it may be an important early event in the development of RCC. Thus, telomerase activity may be a prevalent marker for early and late stages of all subtypes of RCC.

[Fractionated inpatient rehabilitation of diabetes: results from a randomized controlled trial on rehabilitation aftercare]

BACKGROUND

Treating diabetes mellitus type 2 (DMT2) essentially involves long-term changes of health behaviour, especially diet and physical activity habits. Medical rehabilitation tries to support these changes by patient education and practical instructions. While short-term successes are frequently obtained, the main challenge lies in maintaining these results in the longer run. This study examines whether a fractionated inpatient rehabilitation programme of 3 weeks duration in combination with an additional week of inpatient rehabilitation after 6 months and a subsequent aftercare telephone service facilitates positive long-term effects for patients with DMT2.

METHOD

A prospective randomized controlled trial was conducted with 411 patients with DMT2 in order to compare the fractionated inpatient rehabilitation programme with aftercare to a 3-weeks standard rehabilitation programme without aftercare. The analysis included physiological (cardiovascular risk, HbA1c, BMI) and psychosocial (diabetes-specific coping, quality of life) parameters at baseline (beginning of the programme) and 1 year later.

RESULTS

After 12 months, no significant differences between the groups were found in the physiological parameters. At the same time, however, the aftercare group showed larger benefits in almost every psychosocial dimension (coping, quality of life, subjective health). Coping and quality of life had even improved when compared to baseline. In contrast, these parameters had decreased further in the standard-care control group when compared to baseline.

CONCLUSION

The intensive aftercare was successful in the long-term improvement of the patients' psychological well-being. Also, the high rate of participation in fractionated inpatient rehabilitation suggests both the acceptance of and the need for aftercare. However, positive long-term changes of physiological parameters probably will require more specific interventions or individual case management. The effectiveness of fractionated inpatient rehabilitation may be limited by the adverse social, psychological and financial situation of the patients.

[Development and validation of an inventory of ego functions and self regulation (Hannover Self-Regulation Inventory, HSRI)]

OBJECTIVE

The aim of this study was to construct and validate a short self-rating questionnaire for the assessment of ego functions and ability of self regulation.

MATERIAL AND METHODS

An item pool of 120 items covering 6 postulated dimensions was reduced by two steps in independent samples (n = 136 + 470) via factor and item analyses to the final version consisting of 35 items.

RESULTS

The 5 resulting questionnaire scales "interpersonal disturbances", "frustration tolerance and impulse control", "identity disturbances", "affect differentiation and affect tolerance" and "self-esteem" were well interpretable and showed in confirmatory factor analysis the best fit to the data (CHI²/df = 3.48; RMSEA = 0.73). Total scores were found to differentiate well between diagnostic groups of patients with more or less ego pathology (FANOVA = 9.8; df = 11; p < 0.001), thus proving good concurrent validity. Reliability was shown by testing internal consistency and test-retest correlations.

CONCLUSION

The "Hannover self-regulation questionnaire" (HSRQ) evidently is an appropriate and reliable screening instrument in order to assess ego functions and capacities of self regulation in an economic and user-friendly means. The scale structure allows differentiated diagnostics of weak vs. stable ego functions and may be used for detailed therapy planning.

[Pain therapy in addicted patients]

Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities. However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.

Pharmacological and nonpharmacological factors influencing hypothalamic-pituitary-adrenocortical axis reactivity in acutely depressed psychiatric in-patients, measured by the Dex-CRH test

The most consistent biological findings in patients with depression are abnormalities in the hypothalamic-pituitary-adrenal (HPA)-axis, which can be measured using the combined dexamethasone-suppression/CRH-stimulation (Dex-CRH) test. The reactivity of the HPA-axis in this test, however, ranges over several orders of magnitude in depressed patients with comparable severity of symptoms. In this present study, we investigate which factors influence the magnitude of the response in the Dex-CRH test in 235 acutely depressed in-patients. We first examined the effects of common confounders shown to influence the HPA-axis, such as caffeine and nicotine consumption, acute stressors during the test, weight, gender, and age. Of all these variables, only female sex and nicotine consumption were positively correlated with the cortisol or ACTH response, respectively. As for the effects of psychopharmacological treatment, only the intake of carbamazepine and the fact of having relapsed under an established pharmacotherapy significantly increased the response in the Dex-CRH test, whereas the presence or absence of antidepressant treatment, the type of antidepressant treatment, or the number of ineffective antidepressant treatment trials during the index episode up to admission did not have any effect. We also found a positive correlation of the number of previous episodes, the overall HAM-D score and the severity of somatic/vegetative symptoms with the results in the Dex-CRH test. These results underline that in depressed patients this test is not majorly influenced by disease-unrelated factors. In addition, current antidepressant treatment does not appear to affect test outcome in the absence of clinical response. The influence of the number of previous episodes and relapse under pharmacotherapy suggests that HPA-axis reactivity may be altered by repetitive states of hypercortisolemia or continuous antidepressant treatment. Finally, more severe vegetative symptoms are associated with an enhanced HPA-axis activity.

Incidence of adverse effects during acupuncture therapy-a multicentre survey

INTRODUCTION

Acupuncture is frequently used to treat chronic pain syndromes or other chronic diseases. Several hundred reports have been published of life-threatening adverse events after acupuncture. The aim of our study was to assess the adverse effects of acupuncture during a normal treatment routine.

METHODS

Thirteen general practitioners and outpatient clinics and 16 other practitioners were included in a questionnaire survey in Germany. Patient gender and age, indications for and method of treatment, and adverse effects were documented by the therapists.

RESULTS

Four hundred and nine patients receiving 3535 acupuncture treatment were included. Adverse effects were observed in 402 treatments (11.4%) in 153 different patients. The main side effects were slight haemorrhage (2.9%), haematoma (2.2%), dizziness (1%) and other systemic symptoms (2.7%). Other side effects mentioned (all below 1%) were fainting, nausea, prolonged DeQi effect (paraesthesia) and increase of pain. In one case, aphasia was reported lasting 1h after acupuncture.

CONCLUSION

Acupuncture has adverse effects, like any therapeutic approach. If it is used according to established safety rules and carefully at appropriate anatomic regions, it is a safe treatment method.

Left atrial appendage morphology: comparison of transesophageal images and postmortem casts

BACKGROUND

Aim of the study was to compare 1) transesophageal echocardiographic (TEE) measurements of the left atrial appendage (LAA) with postmortem casts and 2) the TEE with the postmortem diagnosis of LAA thrombi.

METHODS

From the TEE images and LAA casts length, orifice, diameter and number of branches were assessed. LAA area was measured by TEE and LAA volume from the cast.

RESULTS

In 12 patients who underwent TEE and autopsy, measurements of LAA length and area correlated well with the cast volume ( r=0.6 to r=0.93). The agreement between TEE and LAA casts, concerning the number of branches, was only moderate. In one patient, a false positive diagnosis of a LAA thrombus occurred.

CONCLUSIONS

LAA size and orifice diameter can be assessed reliably by TEE. The complex LAA morphology hampers measurements of LAA length, branches, course and diagnosis of thrombi.

Is left atrial appendage occlusion useful for prevention of stroke or embolism in atrial fibrillation?

Since in atrial fibrillation more than 90% of the thrombi are located in the left atrial appendage, an "elimination" of the left atrial appendage, either by resection or occlusion, seems an attractive alternative to oral anticoagulation. Although frequently regarded as an useless appendage, data from animal and human investigations show that the left atrial appendage may play an important role in the maintenance and regulation of the cardiac function, especially in arterial hypertension, atrial fibrillation, coronary heart disease, valvular heart disease and heart failure. Elimination of the left atrial appendage may impede thirst in hypovolemia, deteriorate hemodynamic responses to volume or pressure overload, decrease cardiac output and promote heart failure. Instead of preventing stroke, the consequences of left atrial appendage elimination may create new risk factors for stroke and thus might induce more harm than benefit to patients with atrial fibrillation. As long as the physiologic and pathophysiologic role of the left atrial appendage is not fully understood, left atrial appendage elimination should not be an alternative to oral anticoagulation.

Mass spectrometry meets chip technology: a new proteomic tool in cancer research?

DNA chip technologies are the most exiting genomic tools, which were developed within the last few years. It is, however, evident that knowledge of the gene sequence or the quantity of gene expression is not sufficient to predict the biological nature and function of a protein. This can be particularly important in cancer research where post-translational modifications of a protein can specifically contribute to the disease. To address this problem, several proteomic tools have been developed. Currently the most widely used proteomic tool is two-dimensional protein gel electrophoresis (2-DE), which can display protein expression patterns to a high degree of resolution. As an alternative to 2-DE, a preliminary study using a new technique was employed to generate protein expression patterns from whole tissue extracts. Surface-enhanced laser desorption/ionization (SELDI) allows the retention of proteins on a solid-phase chromatographic surface (ProteinChip Array) with direct detection of retained proteins by time of flight-mass spectrometry (TOF-MS). Using this system, we analyzed eight cases of renal cell carcinoma (RCC) including normal, peripheral and central tumor tissue as well as four microdissected cases of cervical intraepithelial neoplasia (CIN) and three microdissected cases of cervix uteri carcinoma. Differentially expressed proteins were found by comparing the protein expression patterns generated using SELDI-based TOF-MS of tumor tissue with normal and neoplastic tissue, respectively. By applying this fast and powerful ProteinChip array technology it becomes possible to investigate complex changes at the protein level in cancer associated with tumor development and progression.

Chromosome studies of murine T-cell lymphoid leukemia and derived cell lines

Several cell lines were previously established from a spontaneous murine T-cell leukemia (LB). The aim of this study was to analyze the G- and C-banded karyotypes of the parental LB tumor cells and the derived cell lines. A sensitive cell line (LBL) from which two sublines originated, as well as Vincristine (LBR-V160) and Doxorubicin (LBR-D160) resistant cell lines, were used. Our results showed that LB cells had a pseudo-diploid karyotype with 40 acrocentric chromosomes in which trisomy of chromosome 14 was the most relevant alteration. The sensitive cell line showed this alteration in all metaphases studied; no changes in karyotypes were observed in either subline, despite their dissimilar morphology and growth patterns. In contrast, both resistant lines displayed a more heterogeneous karyotype with no common markers, except for the finding that chromosome 5 was involved in a trisomy in LBR-V160 and in a translocation with chromosome 12 in LBR-D160. Taking into account that the mdr genes are located in chromosome 5, these results suggest a possible association between such alterations and the acquisition of drug resistance.

Fluorescent dual colour 2D-protein gel electrophoresis for rapid detection of differences in protein pattern with standard image analysis software

The use of two different fluorescent dyes in two-dimensional (2D) polyacrylamide gel electrophoresis was recently described and termed difference gel electrophoresis (DIGE). Thereby differences between protein samples could be accomplished by fluorescently tagging the samples with different dyes as well as co-separation and visualisation in a single gel. We adapted this method to the ampholyte technique, using newly available fluorescent dyes and three common image software systems for analysis. Working with protein lysates from tumour cell lines with defined added proteins we found that the technique is reproducible, sensitive and fast, because it circumvents the necessity of matching several 2D gels. This is mainly due to the fact that the generated images from the two different fluorescent channels could be superimposed by standard image analysis, so that changes in the protein pattern could be easily detected either by a different colour or by comparing grey values of corresponding spots. This method will be especially helpful in comparing proteins from normal and tumour tissue to highlight changes in genesis and progression in cancer.

Mass spectrometry meets chip technology: a new proteomic tool in cancer research?

DNA chip technologies are the most exiting genomic tools, which were developed within the last few years. It is, however, evident that knowledge of the gene sequence or the quantity of gene expression is not sufficient to predict the biological nature and function of a protein. This can be particularly important in cancer research where post-translational modifications of a protein can specifically contribute to the disease. To address this problem, several proteomic tools have been developed. Currently the most widely used proteomic tool is two-dimensional protein gel electrophoresis (2-DE), which can display protein expression patterns to a high degree of resolution. As an alternative to 2-DE, a preliminary study using a new technique was employed to generate protein expression patterns from whole tissue extracts. Surface-enhanced laser desorption/ionization (SELDI) allows the retention of proteins on a solid-phase chromatographic surface (ProteinChip Array) with direct detection of retained proteins by time of flight-mass spectrometry (TOF-MS). Using this system, we analyzed eight cases of renal cell carcinoma (RCC) including normal, peripheral and central tumor tissue as well as four microdissected cases of cervical intraepithelial neoplasia (CIN) and three microdissected cases of cervix uteri carcinoma. Differentially expressed proteins were found by comparing the protein expression patterns generated using SELDI-based TOF-MS of tumor tissue with normal and neoplastic tissue, respectively. By applying this fast and powerful ProteinChip array technology it becomes possible to investigate complex changes at the protein level in cancer associated with tumor development and progression.

A long distance-PCR derived FISH probe detects a deletion between p15 and p16 in CML and T-ALL patients

The tumor suppressor genes p15INK4B and p16INK4A, located in the chromosomal region 9p21, are frequently inactivated by homo- or hemizygous deletions, point mutation or promotor methylation in various types of cancer. No commercial probe is yet available that allows the detection of such deletions by FISH. Long distance (LD)-PCR was successfully used to generate a FISH probe, that covers a sequence stretch of 11.68 kb, located between the tumor suppressor genes p15 and p16. The LD-PCR amplicon was cloned and biotinylated by DOP-PCR (degenerated oligonucleotide primed-PCR) or nick translation. The FISH probe was hybridized on different samples of 16 patients with leukemia (3 T-ALL, 13 CML) and normal controls. Loss of at least one FISH-signal was found in 2/3 (67%) of the T-ALL- and 2/13 (15%) of the CML-cases. The new FISH probe presented here was proven to be advantageous for the detection of deletions in chromosomal region 9p21, especially between p15 and p16.

Paediatric fluoroscopy--a survey of children's hospitals in Europe. I. Staffing, frequency of fluoroscopic procedures and investigation technique

BACKGROUND

Fluoroscopy is an important, sometimes vital radiological procedure in paediatric patients with high variability in frequency and technique.

OBJECTIVE

To obtain data on paediatric fluoroscopy practice in Europe using a simple questionnaire mailed to 191 children's hospitals.

RESULTS

Eighty-eight radiology departments in 21 European countries participated in the survey. There was great variation in the size of paediatric hospitals in Europe and, consequently, the numbers of staff members (radiographers and radiologists). The total number of fluoroscopy procedures varied widely; the mean value was 1,073 examinations per year. The most frequent fluoroscopic examination was the micturating cystourethrogram, comprising 40% of total fluoroscopies. For all types of investigations there were enormous differences in the number of spot film images routinely obtained. Only a few departments have prepared protocols for junior doctors or radiographers.

CONCLUSIONS

Although the number of fluoroscopic investigations per radiologist does not reflect real workload (the difficulty of the investigation was not requested), it can be stated that a considerable percentage of children's hospitals are understaffed. These results also clearly demonstrate that fluoroscopy guidelines for the most common investigations in paediatric patients are needed to improve the quality of examinations and limit radiation exposure to the patients.

Tissue-specific microdissection coupled with ProteinChip array technologies: applications in cancer research

Analysis of whole genomes to monitor specific changes in gene activation or changes in gene copy number due to perturbation has recently become possible using DNA chip technologies. It is now becoming apparent, however, that knowing the genetic sequence encoding a protein is not sufficient to predict the size or biological nature of a protein. This can be particularly important in cancer research where posttranslational modifications of a protein can specifically lead to the disease. To address this area, several proteomic tools have been developed. Currently the most widely used proteomics tool is two-dimensional polyacrylamide gel electrophoresis (2D-PAGE), which can display protein expression patterns to a high degree of resolution. However, 2D-PAGE can be time consuming; the analysis is complicated and, compared with DNA techniques, is not very sensitive. Although some of these problems can be alleviated by using high-quality homogeneous samples, such as those generated using microdissection techniques, the quantity of sample is often limited and may take several days to generate sufficient material for a single 2D-PAGE analysis. As an alternative to 2D-PAGE, a preliminary study using a new technique was used to generate protein expression patterns from either whole tissue extracts or microdissected material. Surface-enhanced laser desorption and ionization allows the retention of proteins on a solid-phase chromatographic surface or ProteinChip Array with direct detection of retained proteins by time-of-flight mass spectrometry. Using this system, we analyzed tumor and normal tissue from head and neck cancer and microdissected melanoma to determine differentially expressed proteins. In particular, comparisons of the protein expression patterns from microdissected normal and tumor tissues indicated several differences, highlighting the importance of extremely defined tissue lysates for protein profiling.

The myth of the 'Mediterranean syndrome': do immigrants feel different pain?

There is a long tradition of assuming other way of pain perception in immigrants than in natives. This article discusses profound methodological problems to assess pain perception and behaviour between people of different cultural background, existing epidemiological data are reviewed and results of an own study regarding chronic pain syndromes are included. There is no clear evidence for existing differences in pain syndromes between natives and immigrants of any kind. In difference, there is some evidence, that clinicians and health workers frequently have other impressions about pain intensities as the patients themselves.

[Drug-induced headache--pathomechanisms of addiction]

The pathogenesis of drug abuse in patients suffering from drug-induced headache is not known in detail. It is unclear whether drug abuse in chronic daily headache should be classified as a form of drug dependence. Current findings concerning the neurobiological correlates of addictive behavior and affective disorders point to the importance of monoaminergic dysregulation, especially a dysfunction of central serotonergic neurotransmission. We reviewed the literature on drug-induced headache and examined hypothetical pathomechanisms of addiction. Drugs causing drug-induced headache such as paracetamol, coffein and ergotamine interfere with behavior patterns or neurotransmitter systems that are also affected by drugs of abuse. Several drugs that ameliorate acute headache interact with central serotonergic neurotransmission and may affect anxiety and depression in patients with chronic daily headache. Non human primate and human studies revealed mechanisms of serotonergic dysfunction in drug dependence, which may also be relevant for drug-abuse in medication-induced headache. Medication-induced dysfunction of monoaminergic, especially serotonergic neurotransmission, may affect drug dependence by exacerbating mood disorders. Further studies are necessary to assess serotonergic neurotransmission in patients with drug-induced headache and abuse of medication.

Determination of telomerase activity for differential analysis of multifocal renal cell carcinomas

Secondary tumors are found in approximately 12 to 22% of all renal cell carcinoma, and their origin is currently unknown. To determine their potential for malignancy, we examined the telomerase activity of primary tumors and secondary lesions, and found that 86% of the lesions had an identical telomerase status as the related primary tumors, and thus probably share their malignancy potential.

P53 genotyping - an effective concept for molecular testing of head and neck cancer?

P53 mutations are currently recognized as the most common genetic alteration in human tumors. The purpose of our study was to evaluate the significance and reliability of p53 genotyping in head and neck cancer as a possible marker permitting the prediction of tumor behavior and clinical outcome. P53 genotyping in our study refers to highly sensitive molecular screening in order to detect structural alterations in the nucleic acid sequence of the gene. Exons 2-11 and adjacent intronic regions were screened for mutations by direct genomic sequencing or by bi-directional dideoxyfingerprinting in 66 primary tumors of the larynx, pharynx and oral cavity. Alterations in the <hot spot region> of the p53 gene were detected in 36% (24 of 66) of the analyzed tumors, no mutation was found in our cohort outside exons 5-8. The frequency of p53 mutation had no correlation to the tumor stage or tumor site. The recurrence rate in patients with a p53 alteration was not significantly higher compared to patients without a p53 mutation in their primary tumors. Summarizing the results of our study only limited reliability of p53 genotyping as an effective concept for molecular testing of head and neck cancer was found.

Tumor suppressor gene p16 (CDKN2A) mutation status and promoter inactivation in head and neck cancer

The p16INK4A (CDKN2A/MTS1) putative tumor suppressor gene encodes a cyclin dependent kinase inhibitor which plays an important role in the regulation of the G1/S phase cell cycle checkpoint. A high frequency of various p16 gene alterations were consequently observed in many primary tumors. P16 can be inactivated by different mechanisms: i) homozygous deletion, ii) methylation of the promoter region or iii) point mutation. In order to investigate p16 alterations in head and neck cancer (HNC) we analyzed 70 primary tumors of the larynx, pharynx and oral cavity including their corresponding normal mucosa for mutation inactivation by direct sequencing exon 2. We detected only one so far undescribed transversion G to T at position 322 (Asp108Tyr) and a known polymorphism (Ala148Thr) in five cases. The methylation status of the p16 promoter region was analyzed by an improved highly sensitive methylation-specific PCR protocol. P16 methylation inactivation was found in 16 of 55 cases (29%). Our data indicate that p16 point mutations in HNC are less frequent, but inactivation by methylation of the promoter region could be involved in genesis and progression of HNC.

[The prognostic value of dobutamine stress echocardiography. A long-term follow-up study]

BACKGROUND AND OBJECTIVE

The prognostic value of dobutamine stress echocardiography in patients with suspected or known coronary heart disease has not exactly been assessed. Purpose of the study was the assessment of the prognostic value of DSE regarding cardiac events, especially in patients with a normal DSE finding.

PATIENTS AND METHODS

316 patients (168 men, 148 women, mean age 61 +/- 10 years), included in this follow-up study, underwent DSE between January 1994 and December 1996 to evaluate clinically suspected or known coronary heart disease. DSE was classified according to resting and stress echocardiography as either "normal-normal (NN)", "normal-ischemic (NI)", "abnormal-normal (AN)", "abnormal-ischemic (AI)" or "inconclusive (C)". Follow-up by telephone took place between June 1997 and April 1998. "Events" were survived myocardial infarction and death. "Interventions" were revascularisation procedures, either percutaneous transluminal coronary angioplasty (PTCA) with or without stenting or aortocoronary bypass surgery.

RESULTS

In 161 patients, DSE was NN, NI in 27 patients, AN in 55 patients, AI in 54 patients and C in 19 patients. Mean follow-up duration was 28 months. Events occurred in 23 patients: survived myocardial infarction in 10, death in 13 persons. Interventions were carried out in 50 patients: PTCA with or without stenting in 19, aortocoronary bypass surgery in 31 persons. The event rate was significantly lower in patients with DSE classified as NN (P = 0.03 by log-rank) than in other groups. The intervention rate was significantly lower in the NN-group (P = 0.0001 by log-rank) than in the other groups, too.

CONCLUSION

Patients with a normal rest echocardiography and DSE had a good prognosis in a long-term follow-up study.

Open and closed kinetic chain exercises improve shoulder joint reposition sense equally in healthy subjects

OBJECTIVE

To compare the effects of open and closed kinetic chain exercise on shoulder joint reposition sense.

DESIGN AND SETTING

Subjects with no previous upper extremity injury participated in a 6-week exercise program consisting of 3 sessions per week.

SUBJECTS

Thirty-nine healthy male military cadets: 13 each in the open, closed, and control groups.

MEASUREMENTS

Each subject was pretested and posttested for both active and passive joint reposition sense at 30 degrees external rotation, 30 degrees internal rotation, and 10 degrees from full external rotation.

RESULTS

The open and closed kinetic chain groups de- creased in reposition sense error scores in comparison with the control group, but no difference was found between the 2 training groups.

CONCLUSION

Our findings suggest that shoulder joint reposition sense can be enhanced with training in healthy subjects. Also, open and closed kinetic chain exercises appear to be equally effective in improving shoulder joint reposition sense.

Chest pain in cardiac syndrome X--caused by neuromuscular disorders?

We wanted to find out if chest pain in cardiac syndrome X can be a manifestation of neuromuscular disorders. Five patients with cardiac syndrome X (3 women, 2 men), aged 34 to 70 years, consented with a clinical neurological examination, muscle enzyme testing, electroneurography of the right median and peroneal nerves and electromyography of the right brachial biceps and anterior tibial muscles. A neuromuscular disorder was found in 1 of the 5 investigated patients. The 60-year-old man presented with a monoparesis of the left leg and sensory dysfunction of the left upper and lower limb. He was diagnosed as having either posttraumatic myelopathy or radiculopathy. Since chest pain in cardiac syndrome X can be caused by neuromuscular disorders, a comprehensive neurological examination is recommended in patients with this disorder.

[Effect on morphine and other opioids on immune function]

PROBLEM

Already 1898 first clinical observations of a possible immune suppression after morphine intake were published. Today there are many reports describing opioid effects on nearly all parameters of the immune system. The question arises, whether there exists any evidence for clinical (harming) effects on patients.

METHOD

Recent experimental and clinical publications are reviewed. Results are summarized, pathophysiological mechanisms and clinical conclusions discussed.

RESULTS

Morphine and other opioids have immunomodulating effects on nearly all measurable parts of the immune system (macrophages, granulocytes, nk-cells; mediators like Interleukin 1, 2 and 6, TNF). However, most studies did not include pain models, and in addition, high morphine doses were used. First studies using a combined pain/morphine-approach report immune stimulating effects. There are three pathophysiological mechanisms under discussion, including opioid receptors on immune competent cells, central opioid receptors activating the adrenergic system and opioid-induced steroid release with consecutive immunosuppression. It is completely unclear, if there is any relevance of these findings for clinical settings.

CONCLUSIONS

The question whether use of opioids can harm chronic pain patients is unsolved. There is an urgent need for studies in clinical settings with clinical relevant parameters.