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S Jani

Publications and source records attributed to S Jani.

At least 19 recordsLinked to original sources
PubMed2005

Particle analysis for the determination of UHMWPE wear.

Three types of ultrahigh molecular weight polyethylene (UHMWPE) acetabular liners were tested against cobalt-chrome (CoCr) femoral heads on a hip simulator to approximately 20 million cycles. The materials included (1) conventional, nonirradiated liners (C-PE); (2) 5 Mrad gamma-irradiated, remelted, and artificially aged liners (5-XPE); and (3) 10 Mrad gamma-irradiated, remelted, and artificially aged liners (10-XPE). Wear was quantified by gravimetric analysis and wear particle characterization. Particle number and morphology were quantified by scanning electron microscopy (SEM) and compared between groups. Atomic force microscopy (AFM) was used to measure particle height in an effort to improve the total wear volume estimation. The wear debris, as characterized by SEM, was predominantly submicron and round, with occasional fibrils documented in the C-PE material. AFM analysis showed that particle height was approximately one-third of the particle equivalent circular diameter for all three materials. This correlation was used to improve the estimation of volumetric wear rate through SEM particle analysis. This technique is particularly useful for high-dose crosslinked UHMWPE, such as 10-XPE, which show weight gain due to fluid absorption during wear testing. This study has shown that particle analysis provides additional particle morphology and quantity information that cannot be obtained through gravimetric analysis.

Biocompatible Materials↗
PubMed2001

Localized intracoronary gamma-radiation therapy to inhibit the recurrence of restenosis after stenting.

BACKGROUND: Although the frequency of restenosis after coronary angioplasty is reduced by stenting, when restenosis develops within a stent, the risk of subsequent restenosis is greater than 50 percent. We report on a multicenter, double-blind, randomized trial of intracoronary radiation therapy for the treatment of in-stent restenosis. METHODS: Of 252 eligible patients in whom in-stent restenosis had developed, 131 were randomly assigned to receive an indwelling intracoronary ribbon containing a sealed source of iridium-192, and 121 were assigned to receive a similar-appearing nonradioactive ribbon (placebo). RESULTS: The primary end point, a composite of death, myocardial infarction, and the need for repeated revascularization of the target lesion during nine months of follow-up, occurred in 53 patients assigned to placebo (43.8 percent) and 37 patients assigned to iridium-192 (28.2 percent, P=0.02). However, the reduction in the incidence of major adverse cardiac events was determined solely by a diminished need for revascularization of the target lesion, not by reductions in the incidence of death or myocardial infarction. Late thrombosis occurred in 5.3 percent of the iridium-192 group, as compared with 0.8 percent of the placebo group (P=0.07), resulting in more late myocardial infarctions in the iridium-192 group (9.9 percent vs. 4.1 percent, P=0.09). Late thrombosis occurred in irradiated patients only after the discontinuation of oral antiplatelet therapy (with ticlopidine or clopidogrel) and only in patients who had received new stents at the time of radiation treatment. CONCLUSIONS: Intracoronary irradiation with iridium-192 resulted in lower rates of clinical and angiographic restenosis, although it was also associated with a higher rate of late thrombosis, resulting in an increased risk of myocardial infarction. If the problem of late thrombosis within the stent can be overcome, intracoronary irradiation with iridium-192 may become a useful approach to the treatment of in-stent restenosis.

Angioplasty, Balloon, Coronary↗
PubMed2001

Comparison of three joint simulator wear debris isolation techniques: acid digestion, base digestion, and enzyme cleavage.

Quantification of ultrahigh molecular weight polyethylene (UHMWPE) wear debris remains a challenging task in orthopedic device analysis. Currently, the weight loss method is the only accepted practice for quantifying the amount of wear generated from a PE component. This technique utilizes loaded soak controls and weight differences to account for polymeric material lost through wear mechanisms. This method enables the determination of the amount of wear in the orthopedic device, but it provides no information about debris particulate size distribution. In order to shed light on wear mechanisms, information about the wear debris and its size distribution is necessary. To date, particulate isolation has been performed using the base digestion technique. The method uses a strong base, ultracentrifugation, and filtration to digest serum constituents and to isolate PE debris from sera. It should be noted that particulate isolation methods provide valuable information about particulate size distribution and may elucidate the mechanisms of wear associated with polymeric orthopedic implants; however, these techniques do not yet provide a direct measure of the amount of wear. The aim of this study is to present alternative approaches to wear particle isolation for analysis of polymer wear in total joint replacements without recourse to ultracentrifugation. Three polymer wear debris isolation techniques (the base method, an acid treatment, and an enzymatic digestion technique) are compared for effectiveness in simulator studies. A requirement of each technique is that the wear particulate must be completely devoid of serum proteins in order to effectively image and count these particles. In all methods the isolation is performed through filtration and chemical treatment. Subsequently, the isolated polymer particles are imaged using scanning electron microscopy and quantified with digital image analysis. The results from this study clearly show that isolation can be performed without the use of ultracentrifugation and that these methods provide a viable option for wear debris analysis.

Biocompatible Materials↗
PubMed2001

Early lumen loss after repeat coronary intervention for in-stent restenosis.

The purpose of this study was to compare the effects of balloon angioplasty versus repeat stenting on the early angiographic outcome in patients with in-stent restenosis. The treatment of in-stent restenosis using balloon angioplasty alone often yields excellent early results, but is associated with a high rate of late recurrence. In the SCRIPPS trial, patients with restenosis were treated either with balloon angioplasty alone or placement of additional stents to optimize angiographic results before randomization and exposure of the restenotic segment to gamma radiation or placebo. In patients undergoing repeat catheter based intervention for the treatment of in-stent restenosis, quantitative coronary angiography was used to compare the results of balloon angioplasty alone versus repeat stenting on early lumen loss. After a mean delay time interval of 71 min, the early loss was 0.35 +/- 0.34 mm in the balloon angioplasty alone group compared to 0.01 +/- 0.34 mm in the repeat-stenting group (P = 0.004). The early loss index in the balloon angioplasty alone group (12.8 +/- 12.9%) was significantly greater than in the repeat stenting group (0.7 +/- 12.1%; P = 0.003). Although balloon angioplasty for in-stent restenosis often provides excellent immediate angiographic results, luminal diameters are significantly reduced in the early time period after balloon dilatation. Repeat stenting nearly abolishes this early luminal loss.

Aged↗
PubMed2001

Relationship between gravimetric wear and particle generation in hip simulators: conventional compared with cross-linked polyethylene.

Hip-simulator studies have shown reduced gravimetric wear rates for inert-gas gamma-irradiated ultra-high molecular weight polyethylene when compared with conventional ethylene-oxide-sterilized ultra-high molecular weight polyethylene. Analysis shows a greater number of particles generated from inert-gas gamma-irradiated ultra-high molecular weight polyethylene. This study was undertaken to examine particle-generation rates of polyethylene with different levels of cross-linking and to correlate them with gravimetric wear data. Particle-generation rates did not correlate with gravimetric wear rates. Particle analysis should be performed to predict the in vivo behavior of bearing surface materials. Cross-linked ultra-high molecular weight polyethylene subjected to 10 Mrad (100,000 Gy) of gamma irradiation generated significantly fewer particles than ethylene-oxide-sterilized ultra-high molecular weight polyethylene; it also demonstrated a 96% reduction in the volume of particles.

Hip Prosthesis↗
PubMed2001

Radiation therapy to inhibit restenosis: early clinical results.

BACKGROUND: Although several early trials indicate that treatment of restenosis with radiation therapy is safe and effective, the long-term impact of this new technology has been questioned. The objective of this report is to document angiographic and clinical outcome 3 years after treatment of restenosis of stented coronary arteries with catheter-based iridium-192 (192Ir). METHODS: A double-blind, randomized trial compared 192Ir with placebo sources in patients with previous restenosis after coronary angioplasty. Over a 9-month period, 55 patients were enrolled; 26 were randomized to 192Ir and 29 to placebo. RESULTS: At 3-year follow-up, target-lesion revascularization was significantly lower in the 192Ir group (15.4% vs. 48.3%; p < 0.01). The dichotomous restenosis rate at 3-year follow-up was also significantly lower in 192Ir patients (33% vs. 64%; p < 0.05). In a subgroup of patients with 3-year angiographic follow-up not subjected to target-lesion revascularization by the 6-month angiogram, the mean minimal luminal diameter between 6 months and 3 years decreased from 2.49 +/- 0.81 mm to 2.12 +/- 0.73 mm in 192Ir patients, but was unchanged in placebo patients. CONCLUSIONS: The early clinical benefits observed after treatment of coronary restenosis with 192Ir appear durable at late follow-up. Angiographic restenosis continues to be significantly reduced in 192Ir-treated patients, but a small amount of late loss was observed between the 6-month and 3-year follow-up time points. No events occurred in the 192Ir group to suggest major untoward effects of vascular radiotherapy. At 3-year follow-up, vascular radiotherapy continues to be a promising new treatment for restenosis.

Coronary Angiography↗
PubMed2000

Effect of intracoronary gamma-radiation therapy on in-stent restenosis: An intravascular ultrasound analysis from the gamma-1 study.

BACKGROUND: The aim of this study was to use serial volumetric intravascular ultrasound to evaluate the effect of gamma-radiation on recurrent in-stent restenosis. METHODS AND RESULTS: After successful reintervention, patients were randomized to receive either (192)Ir or placebo. Intravascular ultrasound studies with motorized pullback (0.5 mm/s) were performed immediately after irradiation and at 8-month follow-up in 70 patients. Paired volumetric analysis of the stented segment and of 5-mm proximal and distal reference segments was performed; this included measurements of the external elastic membrane, lumen, plaque and media (external elastic membrane minus lumen), stent, and intimal hyperplasia (stent minus lumen). Baseline proximal reference, stent, and distal reference measurements were similar in both groups. The changes in proximal and distal reference measurements of the external elastic membrane, plaque and media, and lumen areas were similar in both groups. However, the decrease in stented segment lumen volume was less in the (192)Ir patients than the placebo patients (-25+/-34 mm(3) versus -48+/-42 mm(3); P:=0.0225), and the increase in the volume of intimal hyperplasia in the stented segment was less in the (192)Ir patients than in the placebo patients (28+/-37 mm(3) versus 50+/-40 mm(3); P:=0.0352). When averaged over the length of the stented segment (32+/-13 mm versus 33+/-14 mm; P:=0.9), the increase in mean area of intimal hyperplasia was 0.8+/-1.0 mm(2) in the (192)Ir group and 1.6+/-1.2 mm(2) in the control group (P:=0.0065). Late stent-vessel wall malapposition was noted in one placebo patient and no (192)Ir patients. CONCLUSIONS: gamma-Radiation therapy can effectively prevent recurrent in-stent restenosis by inhibiting neointimal formation within the stent. At the stent edge, there were no significant differences between (192)Ir and placebo patients.

Analysis of Variance↗
PubMed2000

Three-year clinical and angiographic follow-up after intracoronary radiation : results of a randomized clinical trial.

BACKGROUND: Although several early trials indicate treatment of restenosis with radiation therapy is safe and effective, the long-term impact of this new technology has been questioned. The objective of this report is to document angiographic and clinical outcome 3 years after treatment of restenotic stented coronary arteries with catheter-based (192)Ir. METHODS AND RESULTS: A double-blind, randomized trial compared (192)Ir with placebo sources in patients with previous restenosis after coronary angioplasty. Over a 9-month period, 55 patients were enrolled; 26 were randomized to (192)Ir and 29 to placebo. At 3-year follow-up, target-lesion revascularization was significantly lower in the (192)Ir group (15. 4% versus 48.3%; P<0.01). The dichotomous restenosis rate at 3-year follow-up was also significantly lower in (192)Ir patients (33% versus 64%; P<0.05). In a subgroup of patients with 3-year angiographic follow-up not subjected to target-lesion revascularization by the 6-month angiogram, the mean minimal luminal diameter between 6 months and 3 years decreased from 2.49+/-0.81 to 2.12+/-0.73 mm in (192)Ir patients but was unchanged in placebo patients. CONCLUSIONS: The early clinical benefits observed after treatment of coronary restenosis with (192)Ir appear durable at late follow-up. Angiographic restenosis continues to be significantly reduced in (192)Ir-treated patients, but a small amount of late loss was observed between the 6-month and 3-year follow-up time points. No events occurred in the (192)Ir group to suggest major untoward effects of vascular radiotherapy. At 3-year follow-up, vascular radiotherapy continues to be a promising new treatment for restenosis.

Aged↗
PubMed2000

How long is enough? Defining the treatment length in endovascular brachytherapy.

The International Commission on Radiation Units and Measurement (IRCU) 50 has clearly defined treatment volumes in radiation therapy in the management of neoplasms. These concepts are applied to the field of endovascular brachytherapy (EVBT) for the prevention of postangioplasty restenosis. The following definitions are proposed: gross target length (GTL) is defined as the narrowed segment of the artery that requires intervention. Clinical target length (CTL) is defined as the intervened or injured length, which could be due to angioplasty, stent strut injury, stent deployment, or debulking procedures. Planning target length (PTL) is the CTL plus a margin to account for heart/catheter movement and uncertainty in target localization. The final treatment length (TL) is the PTL plus the effect of penumbra. The accurate specification of treatment length serves several important purposes. Based on an understanding of the different factors constituting the treatment length, adequate margins can be provided beyond the GTL; this will avoid geographic misses and minimize edge failures. These definitions of target length ensure treatment consistency and provide a standard terminology for communication among practitioners of EVBT, something of critical importance in the conduct of multi-institutional trials in this new and multidisciplinary therapy. Finally, since the efficacy of EVBT is critically dependent on the precision of radiation delivery, these guidelines ensure that the benefits of EVBT seen in prospective randomized trials can be translated into daily clinical practice at the community level.

Angioplasty, Balloon↗
PubMed1999

Quantitative angiographic analysis of stent restenosis in the Scripps Coronary Radiation to Inhibit Intimal Proliferation Post Stenting (SCRIPPS) Trial.

To identify luminal dimension changes occurring within the stent alone and within the stent + margin segment, we reviewed the quantitative angiographic results obtained from the Scripps Coronary Radiation to Inhibit Proliferation Post Stenting (SCRIPPS) trial, a prospective randomized trial assessing the effect of iridium-192 (Ir-192) on the prevention of stent restenosis. Fifty-five patients were randomly assigned to receive Ir-192 or placebo sources after successful intervention. Procedural and 6-month follow-up cineangiograms were quantitatively reviewed in 52 patients to identify changes within the stent and the stent + margin segment. The percent diameter stenosis was lower within the stent than within the stent + margin segment after the procedure (6 +/- 22% vs 21+/- 15%, p <0.0001) and at follow-up (28 +/- 29% vs 42 +/- 21%, p <0.0001). As a result, a lower restenosis rate was found within the stent than within the stent + margin (25% vs 37%, p <0.0001); isolated stent margin restenosis occurred in 11.5% of lesions. Treatment with Ir-192 reduced restenosis within the stent (8% vs 39%; p = 0.010) and within the stent + margin segment (17% vs 54%; p = 0.010); the reduction in restenosis at the margin only (8.3% vs 14.3%, p = 0.503) was not significant. The lowest relative risk for restenosis resulting from Ir-192 occurred within the stent (0.21; 95% confidence interval [CI] 0.05 to 0.86) compared with the stent + margin segment (0.31; 95% CI 0.12 to 0.81) or the stent margin (0.58; 95% CI 0.12 to 2.91). In the SCRIPPS trial, 32% of restenosis occurred at the stent margins. Treatment with Ir-192 reduced restenosis primarily within the stent rather than the margin. Whether extending the treatment length to fully include the stent margins will further reduce restenosis requires further study.

Brachytherapy↗
PubMed1999

Two-year follow-up after catheter-based radiotherapy to inhibit coronary restenosis.

BACKGROUND: Although early trials indicate the treatment of restenosis with radiation therapy is safe and effective, the long-term impact of this new technology has been questioned. The possibility of late untoward consequences, such as aneurysm formation, perforation, and accelerated vascular disease, is of significant concern. Furthermore, it is not known whether the beneficial effects of radiation therapy will be durable or whether radiation will only delay restenosis. METHODS AND RESULTS: A double-blind, randomized trial was undertaken to compare 192Ir with placebo sources in patients with previous restenosis after coronary angioplasty. Patients were randomly assigned to receive a 0.76-mm (0. 03-in) ribbon containing sealed sources of either 192Ir or placebo. All patients underwent repeat coronary angiography at 6 months. All living patients were contacted 24 months after their index study procedure. Patients were assessed with respect to the need for target-lesion revascularization or nontarget-lesion revascularization, occurrence of myocardial infarction, or death. Over a 9-month period, 55 patients were enrolled; 26 were randomized to 192Ir and 29 to placebo. Follow-up was obtained in 100% of living patients at a minimum of 24 months. Target-lesion revascularization was significantly lower in the 192Ir group (15.4% versus 44.8%; P<0. 01). Nontarget-lesion revascularization was similar in 192Ir and placebo patients (19.2% versus 20.7%; P=NS). There were 2 deaths in each group. The composite end point of death, myocardial infarction, or target-lesion revascularization was significantly lower in 192Ir-treated versus placebo-treated patients (23.1% versus 51.7%; P=0.03). No patient in the 192Ir group sustained a target-lesion revascularization later than 10 months. CONCLUSIONS: At 2-year clinical follow-up, treatment with 192Ir demonstrates significant clinical benefit. Although further follow-up (including late angiography) will be necessary, no clinical events have occurred to date in the 192Ir group to suggest major untoward effects of vascular radiotherapy. At the intermediate follow-up time point, vascular radiotherapy continues to be a promising new treatment for restenosis.

Angioplasty, Balloon, Coronary↗
PubMed1999

Endovascular brachytherapy for peripheral vascular disease.

The most common cause of morbidity and mortality in the United States is vascular disease, which afflicts a wide spectrum of organs such as the heart (cardiovascular system), brain (cerebrovascular system), kidney (renal system), liver (hepatic system), and extremities (peripheral vascular system). The most common pathology of vascular diseases is occlusion. Percutaneous Transluminal Angioplasty (PTA) is currently the most common nonsurgical treatment for obstructive arteries. Unfortunately, the long-term effectiveness of PTA is limited by a high restenosis rate. Efforts to reduce post-PTA restenosis, including laser, mechanical atherectomy, intravascular stenting, and pharmacologic agents, have not been successful. With recent advances in the pathogenesis of restenosis, we have learned that the major problem is the intimal hyperplastic reaction in response to vessel injury. Encouraging animal data in the use of various radiotherapeutic approaches to prevent restenosis has led to a large number of multi-national, multicenter, randomized trials on coronary vascular systems. Because early results have been in favor of radiation therapy, and because the basic process of restenosis is similar for coronary and noncoronary vascular systems, many investigators extend the application of radiotherapy to the prevention of restenosis in peripheral vascular systems. However, the clinical scenarios are much different for peripheral vascular systems than for the coronary vascular system. This article discusses the current views of the pathophysiology of restenosis, major clinical trials, and perspectives on future studies. Experimental studies on animal models have documented the profound effects of endovascular brachytherapy in reducing restenosis caused by angioplasty and stenting. Early results of clinical trials are encouraging and confirm these positive results. Long-term follow-up data are needed to show that radiation does prevent, not merely delay, restenosis; Several areas of opportunity exist for both basic science research and clinical studies to enhance our knowledge of the pathophysiology. This would optimize the treatment strategy, maximizing the benefits and minimizing late complications.

Angioplasty, Balloon↗
PubMed1999

Intravascular brachytherapy physics: report of the AAPM Radiation Therapy Committee Task Group no. 60. American Association of Physicists in Medicine.

Recent preclinical and clinical studies indicate that irradiation using ionizing radiation in the dose range of 15 to 30 Gy may reduce the occurrence of restenosis in patients who have undergone an angioplasty. Several delivery systems of intravascular brachytherapy have been developed to deliver radiation doses in this range with minimal normal tissue toxicity. In late 1995 the American Association of Physicists in Medicine (AAPM) formed a task group to investigate these issues and to report the current state of the art of intravascular brachytherapy physics. The report of this task group is presented here.

Angioplasty, Balloon, Coronary↗
PubMed1998

A subgroup analysis of the Scripps Coronary Radiation to Inhibit Proliferation Poststenting Trial.

INTRODUCTION: In the Scripps Coronary Radiation to Inhibit Proliferation Poststenting (SCRIPPS) Trial, 192Ir significantly reduced angiographic, ultrasonographic, and clinical endpoints of restenosis. The objective of this analysis was to quantitate the impact of patient, lesion and technical characteristics on late angiographic outcome. METHODS: Patients with restenotic, stented coronary lesions were randomized to receive either 192Ir or placebo sources. Late luminal loss and loss index were calculated for several patient subgroups, including patients with diabetes, in-stent restenosis, multiple previous percutaneous transluminal coronary angioplasty (PTCA) procedures, longer lesion lengths, saphenous vein grafts, small vessel diameters, and minimum dose exposures < 8.00 Gy. Two-factor analysis of variance was used to test for an interaction between patient characteristics and treatment effect. RESULTS: In the treated group, late loss was particularly low in patients with diabetes (0.19 mm), in-stent restenosis (0.17 mm), reference vessel diameters < 3.0 mm (0.07 mm), and patients who received a minimum radiation dose to the entire adventitial border of at least 8.00 Gy. The loss index in each of these subgroups was similarly low at -0.02, 0.03, -0.02, and 0.03, respectively. By 2-factor analysis of variance, a significant interaction between subgroup characteristic and treatment effect (late loss) was found in patients with in-stent restenosis (p = 0.035), and patients receiving a minimum dose of 8.00 Gy to the adventitial border (p = 0.009). CONCLUSION: In this pilot study, patient characteristics associated with a more aggressive proliferative response to injury appeared to confer an enhanced response to radiotherapy. Furthermore, a dose threshold response to 192Ir was found with an enhanced response occurring when the entire circumference of the adventitial border was exposed to at least 8.00 Gy.

Analysis of Variance↗
PubMed1997

Catheter-based radiotherapy to inhibit restenosis after coronary stenting.

BACKGROUND: In animal models of coronary restenosis, intracoronary radiotherapy has been shown to reduce the intimal hyperplasia that is a part of restenosis. We studied the safety and efficacy of catheter-based intracoronary gamma radiation plus stenting to reduce coronary restenosis in patients with previous restenosis. METHODS: Patients with restenosis underwent coronary stenting, as required, and balloon dilation and were then randomly assigned to receive catheter-based irradiation with iridium-192 or placebo. Clinical follow-up was performed, with quantitative coronary angiographic and intravascular ultrasonographic measurements at six months. RESULTS: Fifty-five patients were enrolled; 26 were assigned to the iridium-192 group and 29 to the placebo group. Angiographic studies were performed in 53 patients (96 percent) at a mean (+/-SD) of 6.7+/-2.2 months. The mean minimal luminal diameter at follow-up was larger in the iridium-192 group than in the placebo group (2.43+/-0.78 mm vs. 1.85+/-0.89 mm, P=0.02). Late luminal loss was significantly lower in the iridium-192 group than in the placebo group (0.38+/-1.06 mm vs. 1.03+/-0.97 mm, P=0.03). Angiographically identified restenosis (stenosis of 50 percent or more of the luminal diameter at follow-up) occurred in 17 percent of the patients in the iridium-192 group, as compared with 54 percent of those in the placebo group (P= 0.01). There were no apparent complications of the treatment. CONCLUSIONS: In this preliminary, short-term study of patients with previous coronary restenosis, coronary stenting followed by catheter-based intracoronary radiotherapy substantially reduced the rate of subsequent restenosis.

Aged↗
PubMed1995

Cross-cultural studies with the Conners rating scales.

The teacher and parent forms of the Conners Rating Scales were completed by the parents and teachers of 863 children who were living in an area of Bombay, India. Two socioeconomic strata were sampled. The results were compared to American norms for ratings done by parents and teachers. The teacher ratings demonstrated some clear differences from American norms. Correlational analysis suggested that the Conners scales showed greater overlap, and, hence, less independence, than has been reported in the American research literature.

Child↗
PubMed1994

Illness beliefs and alexithymia in headache patients.

Research regarding psychological factors in head pain have generally focused upon personality traits and psychopathology. The role of illness beliefs offers another method of elucidating perceptions, attitudes and convictions towards a somatic complaint. One hundred patients, evaluated for head pain at a neurology clinic, were administered the illness Behavior Questionnaire (IBQ) to delineate illness beliefs; the illness Effects Questionnaire (IEQ) to quantify the disruptive aspects of head pain; and the Toronto Alexithymia Scale (TAS) to assess the subjects propensity to somatize as well as the ability to identify and report emotions. The data found no difference between subjects diagnosed with migraine syndrome and those with tension head pain in the IBQ dimensions, the TAS or in reported levels of anxiety or depression. However, chronicity of symptoms was associated with increased irritability. The clinical implications of the findings suggest that patients with head pain are psychologically distressed but often possess alexithymic characteristics that make insightful associations difficult.

Adult↗